Table 4.

Examples of recommended management strategies for those screening positive on C5-75 program components.

Positive Screening Results	Management Recommendations
Chronic Obstructive Pulmonary Disease	Spirometry conducted by a trained respiratory therapist and diagnosis by a family physician with special training through the Spirometry in Primary Care Program, a program which has been endorsed by the Ontario Thoracic Society and Ontario Respiratory Care Society. Medical management and monitoring consistent with Canadian Thoracic Society guidelines [58]. Smoking cessation program recommended for smokers. Patient education on self-management and exercise and a COPD action plan through our respiratory therapist, who is a Certified Respiratory Educator, and a nurse and family physician who will ensure appropriate use of bronchodilators and corticosteroids as well as updated vaccinations. Based on degree of symptoms and severity, patients will be appropriately referred when necessary to local pulmonary rehabilitation programs and to respirologists for shared care.
Cognitive impairment	Referral to the Primary Care Collaborative Memory Clinic for comprehensive assessment and management using a shared care approach [74]. This includes assessment of caregiver burden, home and driving safety, future planning, exclusion of depression, delirium and other reversible causes, elimination of medications known to adversely affect cognition, introduction of cognitive enhancing medication if appropriate, and integration of community support services. Cases identified as most complex are referred to a geriatrician.
Falls risk	Referral to Mobility Clinic [75] for further assessment and management. The Mobility Clinic conducts evidence-based interprofessional assessments to determine extent of mobility and balance dysfunction, addresses reversible or modifiable factors, and initiates appropriate investigations and management. The multi-faceted approach includes sensory evaluation (vision, hearing), neurological and musculoskeletal assessment, assessment for orthostatic hypotension, analysis of footwear and gait aids, home environment review, and reduction of medications that contribute to falls risk and osteoporosis. Recommendations may include the prescription of a gait aid, alteration to home environment for safety, and individualized exercise program to improve strength and balance [76].
Low physical activity	Prescription for exercise, which includes various exercise options and a list of exercise programs available in the community.
Fracture risk	Assessment for orthostatic hypotension [77]. Management consistent with 2010 Clinical Practice Guidelines for the Diagnosis and Management of Osteoporosis in Canada for monitoring of bone mineral density [61]. Vitamin D use and regular visual assessment of cataracts as recommended by the 2011 American Geriatrics Society/British Geriatrics Society Clinical Practice Guideline for Prevention of Falls in Older Persons [60]. Assessment for correct cane or walker height, lower limb muscle weakness through chair stand test [78]; referral to the Mobility Clinic for more detailed assessment and management as necessary.
Depression, anxiety, and social isolation	Further assessment using validated tools such as the Patient Health Questionnaire (PHQ-2 and PHQ-9) [65,79], Short Anxiety Screening Test (SAST) [80], Lubben Social Network Scale (LSNS-6) [67], and Short Michigan Alcoholism Screening Test (S-MAST-G) [81], as needed. Patients identified with potential depression or anxiety are referred to their family physician for appropriate medication management and to social work counselling. For those identified as socially isolated, referral will also be made for social work assessment and possible Integrated Geriatric Service Worker support to facilitate community linkages [82].
Urinary incontinence	Further investigation for hematuria; those with hematuria are referred to a urologist. Lifestyle interventions are recommended as well as a program of pelvic floor training exercises consistent with guidelines for urinary incontinence [62,63].
Caregiver burden	Caregivers suffering from high degree of caregiver stress will be referred to a social worker with expertise in geriatrics for counselling, integration of appropriate home care supports, and future planning.
Assessment Urgency Algorithm	A function-based screening tool for assessment of risk of adverse outcome; those identified as scoring at highest risk are recommended for referral to a geriatrician [71].