ORIGINAL ARTICLE Developing an integrated system of care for frail seniors George A. Heckman, MD, MSc, FRCPC; Loretta Hillier, MA; Brooke Manderson, MSc; Jane McKinnon-Wilson, MSc, HB; Selena M. Santi, MA; Paul Stolee, PhD Abstract—A consultation process was undertaken with healthcare providers in the Waterloo Wellington region of southern Ontario to assess current system strengths, challenges and gaps in providing care to frail seniors. The findings were used to implement strategies for improving system integration. T he Canadian healthcare system has been described as fragmented and uncoordinated, with challenges including multiple entry points, care delivery driven by available services rather than patient need, piece-meal care planning, costly services with long waiting lists, limited information sharing, and standardized tools which lead to redundant assessments. 1,2 Such fragmentation can be particularly problematic for frail seniors. Frailty—a state of inherent vulnerability— leads to poor health outcomes when an affected person is challenged by a health stressor. Frailty usually affects older individuals and results from the accumulation of deficits across multiple physiological systems. 1,2 As a chronic state, 1 frailty requires approaches to care that not only include the identification and management of these deficits, but also the anticipation, management, and prevention of stressors that lead to poor outcomes—this includes promoting greater healthcare system integration. 3,4 A systematic review of clinical trials of community-based integrated systems of care suggests that these can improve quality, coordination, and continuity of care for frail seniors, leading to better health outcomes while potentially reducing overall healthcare costs. Integration is defined as a system-wide process of combining social and health services to meet the needs of seniors through the alignment of financial and administrative incentives 5 and modalities across care settings, standardized and comprehensive assessment, and support by clinical inter- professional teams. 6-8 The implementation of integrated models of care constitutes a significant opportunity to improve healthcare delivery. 9-11 The purpose of this paper is to describe how the Waterloo Wellington (WW) Local Health Integration Net- work (LHIN) used a structured approach to regional consultation to formulate recommendations promoting greater system integration that reflect regional needs and target frail seniors. The key objectives were to identify the following: (1) unmet needs and challenges in the WWLHIN; (2) changes required for existing services; (3) key new services required; and (4) priorities for an integrated clinical services plan that is rooted in primary care. There are 14 LHINs in Ontario that oversee regional funding and health- care priorities. 12 The WWLHIN covers approximately 4800 km 2 in Southern Ontario. METHODS This was a secondary analysis of focus group interviews, as described by Krueger and Casey. 13 Sampling and participant characteristics A purposeful sample of 186 individuals was recruited through the WW Geriatric Services Network (GSN), which represents various organizations, agencies, and professio- nal groups providing regional services to frail seniors. The WWGSN assisted in recruitment through the dissemination of project information. Attempts were made to ensure that there was representation across all communities of inter- est, including service providers and healthcare professio- nals from acute care, long-term care, primary care, community support services, seniors’ housing services, specialized geriatric services, the Regional Geriatric Pro- gram, 14 mental health services, the Community Care Access Centre (CCAC), 15 and public health. Potential parti- cipants were invited to engage in a consultation process that identified opportunities for improved healthcare services for seniors. Participation was voluntary and con- sent was implied through attendance at a public consulta- tion exercise. A total of 20 focus groups were conducted; these included 29 patients and informal caregivers (see Appendix A in the Supplementary Information). From the Research Institute for Aging University of Waterloo, Ontario, Canada, N2L 3G1 (Heckman); and School of Public Health and Health Systems, University of Waterloo, Ontario, Canada (Manderson, Santi and Stolee); St Joseph’s Health Care London, Specialized Geriatrics Services: Research and Evaluation, Ontario, Canada (Hillier); Canadian Mental Health Association-Waterloo Wellington Dufferin, Ontario, Canada (McKinnon- Wilson). Corresponding author: George A. Heckman, MD, MSC, FRCPC, Research Institute for Aging, Schlegel Research Chair for Geriatric Medicine, and Associate Professor, School of Public Health and Health Systems, University of Waterloo, 200 University Avenue West, Waterloo, Ontario, Canada, N2L 3G1. (e-mail: ggheckman@uwaterloo.ca) The content of this paper is based on a larger report submitted to the WWLHIN in December 2011. Healthcare Management Forum 2013 26:200–208 0840-4704/$ - see front matter & 2013 Canadian College of Health Leaders. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.hcmf.2013.09.003