b'UNDERSTANDING FRAILTYfamily members and staff, including a physician, nurse and personal support worker (PSW). Together, they create a customized care plan, which is updated annually or as needed. During the conference, the resident and family get the information they need to make informed choices about the care plan, says Andrea Liu, Manager of Interprofessional Care at Perley Health. They learn about what we can do to manage pain, provide comfort and enable the resident to live life to the fullest in the time they have left. The wishes of each resident and LTC resident Diane Eddy benefited from the SeeMeframework, which enabled herfamily are unique; there are no right or husband Laird to incorporate her personal wishes and preferences into her care wrong choices.Incorporating frailtyAfter Diane Eddy developed Alzheimers, her husband Laird Eddy cared for her at home for eight years. considerations intoIn June 2021, Diane moved into a secure unit at Perley Health, where staff used SeeMe to develop her original care plans care plan and to update it a year later. I still feel responsible for her care, says husband Laird Eddy, and recognize SeeMe: Understanding Frailty Together that shes getting the best of care at P erley Health, a long-term careI compare a frail person to someonePerley Health. Sitting down with Diane and her care team to discuss who she home and campus of care inin an overloaded canoe, says Dr.is and what she likes, as well as her Ottawa, Ontario, follows anRobert. While the waters calm,current health statusand then using innovative approach to developing,its easy to stay afloat. But whenthis information to develop a care plan implementing and updating residentconditions get toughersay the helps to put my mind at ease. care plans. SeeMe: Understandingresident gets a urinary tract infection Frailty Together is a comprehensiveor a chest coldthe canoe can sinkIn March 2022, the Canadian Geriatrics framework that considers frailty andquite quickly, even with interventionsJournal published a study of SeeMe prioritizes each residents values,that are typically effective in ancompleted by Perley Healths Centre preferences and desired lifestyle.emptier boat. of Excellence in Frailty-Informed Care. Under SeeMe, residents collaborateThe study demonstrates that SeeMe with their families and care teamsDeveloped at Perley Health andresulted in high satisfaction levels to make informed decisions aboutthe subject of ongoing evaluation,among nurses, physicians and the treatment and intervention options. SeeMe engages residents,families of long-term care residents. families and care teams in often- SeeMe residents and their families Most families with a loved onechallenging conversations aboutwere more likely to choose less-admitted to long-term care arethe relationship between frailty,invasive interventions to preserve both unaware of frailty and its effects,medical intervention and quality ofhealth and quality of life. This included says Dr. Benot Robert, Chief Medicallife. The process begins soon afterdecisions to decline cardiopulmonary Officer at Perley Health since 2011 andadmission with a Comprehensiveresuscitation (CPR) and transfersattending physician there for moreFrailty Assessment, a standardized andto hospital. than two decades.holistic consideration of the residents physical, functional, cognitive andFrail patients present an existential Frailty, a medical condition of reducedpsychosocial status. Part of thechallenge to medicines traditional function and health, is increasinglyAssessment involves the Clinical Frailtyapproach of treating one disease or recognized and studied. A person whoScale, a validated, evidence-basedcondition at a time, says Dr. Kenneth is frail is less able to cope with minortool developed in 2005 that broadlyRockwood, who led the development stresses and more likely to sufferstratifies degrees of fitness and frailtyof the Clinical Frailty Scale in 2005 and rapid and dramatic changes in health.among people aged 65 and older. Theis widely considered one of Canadas The risk of frailty increases with age,results are discussed during a caretop experts in geriatrics. A Professor although not all older people are frail.conference involving the resident,of Geriatric Medicine at Dalhousie 36 LONG TERM CARE TODAY Spring/Summer 2023'