Like many countries in the Global North, Canada has an ageing population. Currently, its medical system is not equipped to ensure that seniors can age healthily and within the community. Healthy ageing, defined as the maintenance of functional ability in older age, is a key priority for the World Health Organization. Those who don’t age healthily become frail, with reduced function and health.

Currently, Canadian medical practitioners evaluate elderly patients using antiquated assessment methods which tend to focus solely on frailty, medical conditions, weaknesses, risks and loss. Anne Summach, Titus Chan and Tammy O’Rourke argue that an alternative approach is needed.

Firstly, they explain that more attention should be paid to strengths, capacities, and resilience, rather than focusing entirely on deficits. It is also imperative to highlight the factors that lead to frailty. If these factors are neglected, healthy ageing can be impeded, increasing the risk that seniors will need to be moved to long-term care.

Assessments should also identify complex comorbidities, which are a key factor in increased healthcare use for older people, who require targeted interventions from a range of services. Addressing this complexity and risk can help to improve people’s quality of life. Finally, the assessment should facilitate an integrated, holistic approach, incorporating community organisations as well as primary care practitioners.

To fulfil these needs, Summach, Chan and O’Rourke have developed the Healthy Ageing Asset Index. This can be used to assess seniors’ risk factors for functional decline, which may worsen their frailty. It can also be used to suggest interventions for improving resilience and for meeting their social and medical needs.

In developing the index, it was important for the researchers to consider a range of factors. The team conducted a study to identify issues particularly relevant for older people, such as chronic conditions, last medical appointment, substance use, and attachment to a primary provider. As pre-existing assessment tools tended to lack social assessment indicators, highlight weaknesses, and focus on hospital discharge, the researchers adjusted these tools before using them as the basis for the Healthy Ageing Asset Index.

Summach, Chan and O’Rourke released a first draft of the index in a senior-serving community organisation in Western Canada, which was based on a new, community-based model for social care.

Within this organisation, primary care is codeveloped by seniors and staff and the clinic director is a nurse practitioner. The clinical staff are embedded, providing care within the social service organisation, partnered with social workers, community navigators, and volunteers. On site, seniors are able to complete financial resource and housing applications requirements, and access referrals to community-based organisations. This type of support has never been experienced by older adults in the city.

The Healthy Ageing Asset Index was implemented as a component of all new-client visits to a primary care centre on the site. Nurses, nurse practitioners, and student nurse practitioners conducted the assessments. The research team then made changes to the index in response to feedback from users.

For example, feedback from students highlighted the need for standardised questions to ensure clarity for both the assessor and patient. Furthermore, due to a lack of NPs, the researchers adjusted the index to make it accessible to a range of assessors, including alternative clinical team members, social workers, and non-medical personnel. This ultimately led to a greater breadth of perspectives and more robust community and social services approach to implementation.

The final product needed to be usable by a range of community organisations, not just medical professionals. It had to take a strength-based approach, which concentrated on optimising patient capacity through support. Because of the COVID-19 pandemic, it was vital that the tool could be used both in-person and via telehealth. Finally, it had to foster inclusion, validation and empowerment.

The final version of the Healthy Ageing Asset Index incorporates seven categories, which align with the Healthy Ageing Framework and the World Health Organization’s determinants of healthy ageing.

Each section is scored from one to three, with zero indicating low complexity. Scores one and above in a subcategory suggest vulnerability factors and trigger clinical and social prescriptions. Clinical prescribing focuses on traditional medical needs, such as referrals to specialists and prescription optimisation, while social prescribing refers to programs that address diet, exercise, housing, transport, community engagement, and financial and substance use supports.

The use and results of the Healthy Ageing Asset Index are promising. Seventy-three seniors identified as moderately frail completed the index with a Community Connector in Social Work, leading to an intervention planning exercise. They were then reassessed at three, six, and twelve months of the intervention. This allowed for scores to be tracked over time, and for the index’s effectiveness to be assessed.

Summach, Chan and O’Rourke noticed a significant reduction in index scores for seniors at the twelve-month assessment when compared to their intake score. This occurred over a longer period of time than anticipated, potentially due to the time it takes for a relationship to build between the patient and medical professional. However, the index generally succeeded in expanding the capacity to assess and address complex needs relating to frailty.

These index scores were used to individualise interventions, which were optimised to align with the seniors’ capacities and goals. The scores were also integrated into electronic medical records for easy data extraction and reporting.

Enhancing our capacity to screen seniors and address their complex medical needs is important given Canada’s changing demographics. Summach, Chan and O’Rourke have created a tool that has the potential to improve wellbeing, reduce costs, improve workforce stability, reduce institutionalisation, and lessen pressure on facilities that provide higher levels of care. The Healthy Ageing Asset Index could help to shift Canadian healthcare away from reactionary medical care and towards a programme of long-term wellness and prevention.