Over the past several decades, Ontario has made meaningful progress in helping people receive palliative care at home.
Working closely with partners across the health system, physician leaders have helped shift the dynamic: palliative care is no longer a service offered only at the very end of life, but an earlier, more integrated approach with a focus on planning, quality improvement, measurement and system-level coordination of palliative care services.
This progress matters because well-organized home palliative care is not only compassionate; it is also a thoughtful and intentional health system strategy. Yet this framework has not extended to other populations with similar needs. Older adults living with frailty often experience challenges closely resembling those of palliative patients yet lack access to comparable home-based support.
Frailty is not simply “getting older.” The Seniors Care Network and Geriatrics Ontario defines frailty as “increased vulnerability caused by reduced reserve and loss of function across multiple body systems,” and links it to outcomes such as death, institutionalization and poorer quality of life. Yet when frailty is identified, care remains inconsistent and poorly integrated.
In Ontario, frailty is far more common than we often acknowledge. Provincial analyses suggest that more than 644,000 Ontarians aged 65+ and older were living with frailty in 2021, representing about 22 per cent of the older adult population. Canadian data show that frail older adults are more than three times more likely to die within a few years than their non-frail counterparts, underscoring that frailty carries a mortality risk comparable to many chronic diseases traditionally recognized as life-limiting.
This gap is evident in everyday clinical care. Ontario’s older adult population is on track to rise from about 2.9 million in 2023 to 4.4 million by 2046. At current prevalence rates, this growth would translate into hundreds of thousands more people living with frailty. If the health system continues to respond reactively rather than proactively, the strain on emergency departments, inpatient units and community services will only intensify, underscoring the need for deliberate system redesign now.
Consider an 87-year-old with frailty who is no longer able to safely bathe and needs help to get to appointments; every time they are hospitalized, they come home more anxious and disoriented. At the same time, their caregiver is afraid to leave them alone, worn down and unsure how long they can keep going. If this person had a clearly identified terminal diagnosis, the clinical response would be different. A palliative pathway would be activated, bringing coordinated home care, clinical support, help for the caregiver and conversations about goals and priorities. When someone is described as “just” frail, however, support often arrives late, piecemeal or not at all. According to the Canadian Institute for Health Information, among long-stay home care individuals more than two in five unpaid caregivers experience distress, defined as feelings of distress, anger or depression and an inability to continue in the caregiving role due to the lack of supports at home outside of the palliative pathway.
The difference is not that frailty is less serious. The difference is that palliative care has a label that triggers a clear pathway. Frailty is complex, and its trajectory is often uncertain – and that uncertainty works against access. Unfortunately, eligibility for enhanced, coordinated services depends on prognosis or diagnosis, not symptom burden or dysfunction, and the result is that profoundly vulnerable people are deemed “not palliative enough.” The consequence of this is that frail patients end up cycling through emergency departments and hospital beds rather than receiving proactive, team-based care at home.
These gaps are especially apparent in hospitals. Discharges proceed despite unresolved needs, not due to clinical readiness. Appropriate community supports are often unavailable. Without a palliative designation, access to enhanced home-based care is typically out of reach. Frail older adults are also at substantially higher risk of readmission within 30 days of discharge: in one Canadian cohort, nearly one in four frail older patients were readmitted or died within 30 days compared with about one in seven non-frail adults, reflecting unresolved needs and inadequate transitional support.
The result is predictable: repeated hospital admissions, fragmented care and vague labels such as “failure to cope” that mask systemic failure. Acute care is ill-suited to meet the ongoing needs of frail older adults who fall outside palliative criteria. At the same time, the primary care where responsibility is often redirected remains inaccessible for many due to homebound status. Frailty remains poorly recognized, poorly coded and poorly supported – until preventable decline leads back to hospital. The financial implications are just as important as the clinical ones. Hospital care, particularly acute admissions and alternate level of care days, is among the most expensive parts of Ontario’s health system. In comparison, long-term care and well-organized home-based programs cost significantly less per day. When frail older adults remain in hospital because appropriate community supports are not in place, the system ends up paying far more than it would to provide coordinated, interdisciplinary care at home. As Ontario’s population ages, continuing to rely on hospital beds as a default solution will drive up costs and prolong unnecessary stays.
Canadian experts have raised concerns about this disparity in care for many years.
Canadian experts have raised concerns about this disparity in care for many years. A consensus paper from the Canadian Frailty Network notes that end-of-life care systems in Canada have historically been designed around cancer rather than frailty. It calls for better identification of frail older adults who would benefit from a palliative approach, alongside organizational change and innovative funding models. Studies underscore that frail individuals often experience significant physical and emotional distress, indicating that a broader application of palliative principles could improve quality of life and care experiences for this population. This evidence supports the call for systemic reform to ensure frailty is recognized and acted on earlier in care trajectories rather than treated as an afterthought.
Ontario already has strong evidence that well-designed home-based palliative models improve outcomes. Studies evaluating regionally organized home-based palliative care have shown a higher likelihood of dying at home, longer time to first hospital admission, reduced number of hospital visits and length of stay and reduced health-care costs. Research has demonstrated similar results for home care programs for frail homebound older adults. There is evidence that such programs also improve patient satisfaction and quality of life, as well as caregiver satisfaction. Evaluation of team members of care programs for frail older adults demonstrate that they are supportive of this type of model. Practitioners find it rewarding and feel that it improves patient care.
If structured home-based care can improve patient centred, provider-specific and systems outcomes for people with serious illness, the question is obvious: Why has Ontario not built an equally deliberate pathway for home-based frailty care when frailty is common and growing?
Guidance for strengthening frailty care already exists. A University of Waterloo implementation guide, developed with support from the Canadian Frailty Network, frames frailty care as an urgent primary care and system issue, calling for proactive identification, engagement of patients and caregivers and coordination with community-based services before crises occur.
Local models offer a glimpse of what could be scaled more broadly. The CARE (Coordinated, Accessible, Respectful, and Equitable) Program within the Central West Ontario Health Team delivers team-based, home-centred care for frail older adults, bringing together family physicians, nurses, home care coordinators and other disciplines as needed. The model is explicitly patient centred, prioritizing care in the home, continuity of relationships and responsiveness to patient and caregiver goals rather than diagnosis or prognosis.
The CARE Program’s objectives closely parallel those of high-quality home palliative care, including supporting aging in place, reducing avoidable emergency department visits, and easing caregiver burden. The program also embeds an equity-oriented approach, intentionally serving patients who face barriers to accessing traditional clinic-based care and tailoring supports to the social, cultural and structural contexts shaping their health.
Early patient and caregiver feedback suggests high overall satisfaction. Participants report improved sense of support, better coordination and greater confidence managing complex health needs at home. In its first year, CARE Program data demonstrated a significant reduction in emergency department visits, highlighting the impact of early, upstream intervention. What CARE lacks is not thoughtful design or alignment with patient needs, but sufficient reach and resourcing. Similar programs across Canada further demonstrate both the feasibility and the impact of this approach, while underscoring the need for broader scale and system-level support.
Ontario Health’s frailty quality standard work began November 2025, signaling growing recognition of frailty as a province-wide quality issue. But older adults and caregivers cannot wait through a multi-year standards process before the service gap is addressed.
If Ontario wants to help more people age at home, it should apply two lessons from home palliative care to frailty right now. First, eligibility for enhanced home supports should be based on need rather than diagnostic labels. Second, frailty care should be organized around accountable interdisciplinary teams, not a patchwork of time-limited services that families must coordinate themselves. To accomplish this, Ontario should consider investing in scaling and evaluating frailty-focused home programs through Ontario Health Teams, using models like CARE as a blueprint. The next step is clear: Providing stable resourcing and formal provincial integration will allow programs such as CARE to grow, deepen their impact and become a durable part of Ontario’s health system.
Ontario does not need to choose between palliative care and frailty care. It needs to stop treating frailty as an administrative afterthought, and act on what it already knows works.
Outstanding article. The palliative philosophy and approach to care for frail elders in the community is key. Unfortunately the term palliative is associated with end of life care in many peoples minds thereby limiting application to other populations. When we built the CARE program a partnership approach was also a key part of the secret sauce. This program required 3 things: the dedication and commitment of physicians committed to providing quality care for frail elders in their home with a primary care organization committed to supporting those physicians in practical ways; the coordinated resources and commitment from home care coordination & services; and finally leadership with an uncompromising vision and willingness to to roll up their sleeves and keep the momentum going despite challenges and setbacks along the way. Seeing the real impact on frail elderly patients ( and their families) who are unable to access care in the traditional “doctors office”scenario due to the very issues defining their frailty in the first place, is the motivator driving the whole initiative. .
This is a great initiative! There is so much need in the community. As an Emergency physician this is exactly the kind of program that helps patients get safely home, and maintains capacity in acute care hospitals
Great article Joyce et al.
Exemplars are a great way to demonstrate what is possible and promote spread and scale.
Agreed. There’s a lot of challenges to scale high-quality home palliative care though.
Scaling the CARE program means moving funding away from hospital care. Historically, shifting budgets away from hospitals has faced immense political and administrative friction.