As our population continues to age and life expectancy grows, it can become increasingly important to maintain the quality of life (QoL) in older patients. A patient’s desire to prioritize their functional status and QoL may change the objectives and options for their care. A patient-centred Team-Based Care (TBC) strategy offers a preventative approach and ongoing management of frail patients.

Coding for health conditions in an EMR (Electronic Medical Record) is essential for ensuring accurate and comprehensive documentation, improving communication and care coordination, managing population health, and tracking quality metrics and reporting. With BC’s continued rollout of Primary Care Networks (PCNs) and TBC, the use of accurately coded health conditions can validate our intuitions and provide insights to primary care providers and their communities. Better information about patients leads to better care for patients.

The Kootenay Boundary (KB) region has a comparatively higher proportion of citizens aged 60 to 100+ as illustrated in HDC Discover’s Population Pyramid below. According to BC Guidelines, “…the prevalence of frailty increases with advanced age (from 16% at ages 65 to 74, to 52% at age 85 and older)…”. This prompted some KB physicians to explore strategies for better identification and proactive management of patients with frailty.

Frailty Management and Team-Based Care (TBC)
When David Chan, Clinical Services Manager at the HDC, met with Dr Janet Fisher and Dr Erin Love from the Riverside Family Medicine Clinic in Trail BC, they discussed their frailty coding habits in their EMR. Their first objective was to identify the Population of Focus, with the goal that specific patient subgroups can be managed and followed by members of their PCN team, thereby adding capacity, and benefiting the patient experience. As clinics in BC work towards more integrated TBC, the ability to identify specific patient subgroups will enable superior coordination resulting in improved outcomes and care.

As can be seen in HDC Discover’s Frailty Prevalence Measure shown above, Drs. Fisher and Love updated their coding practices in Q3 of 2022. When a patient is identified as “Frail”, the ‘V15’ diagnostic code is added to the patient’s problem list. While they previously had only included the diagnostic that caused the frailty for treatment purposes (e.g. “Parkinson’s”, “Dementia”, etc.), the ‘Frail’ diagnosis is now an essential part that is integral to their TBC processes.

Our Primary Care Network (PCN) Occupational Therapist (OT) or Physical Therapist (PT) can now identify a list of “Frail” patients and meet with them as a preventative appointment, assessing their needs and offering resources to prevent injury, falls, and other frailty-related outcomes,” states Dr. Erin Love.

Frailty Management in the Community
As more physicians in BC embrace these improved coding behaviours, the aggregate datasets in HDC Discover will enable systems that can be organized to serve identified patient groups. These can be managed by a team of community health professionals to enhance the patient experience, improve population health, and reduce health care costs, otherwise known as the triple aim.

With the PCN resources, identifying frail or potentially frail patients allows us to allocate resources and prioritize evaluations (for example OT assessments),” says Dr. Janet Fisher. “In turn, this may help us prevent acute admissions and work more effectively with the community to transition patients to increased levels of care.

With Divisions of Family Practice, PCNs and clinicians working together, there’s a great opportunity for EMR data to support the identification and prioritization of services needed within each unique community. Providing data as supporting evidence can reinforce and create a strong foundation for funding proposals.

On a larger scale, if certain regions are identified as having a higher number of “Frail” patients, this may help to encourage more funding to be put into preventative and supportive measures in those communities (more OTs, PTs, geriatric supports, etc.), to help our more frail patients live more safely and with a higher quality of life,” explains Dr. Erin Love.

Your Aging Patient Population
Discover how your coding behaviours can help manage your patients with frailty and contribute to improved patient resources. Contact an HDC Clinical Services Manager at

Bright Spots (PDF copy) – Frailty Dr. Love Dr. Fisher