Life in Long Term Care

SeeME® – Understanding frailty with Perley Health

Incorporating frailty considerations into care plans

Location: Perley Health, Ottawa 

Perley Health, a long-term care home and campus of care in Ottawa, Ontario, follows an innovative approach to developing, implementing and updating resident care plans. SeeMe®: Understanding Frailty Together is a comprehensive framework that considers frailty and prioritizes each resident’s values, preferences and desired lifestyle. Under SeeMe®, residents collaborate with their families and care teams to make informed decisions about treatment and intervention options.

“Most families with a loved one admitted to long-term care are unaware of frailty and its effects,” says Dr. Benoit Robert, Chief Medical Officer at the Perley Health since 2011 and attending physician there for more than two decades.

Frailty, a medical condition of reduced function and health, is increasingly recognized and studied. A person who is frail is less able to cope with minor stresses and more likely to suffer rapid and dramatic changes in health. The risk of frailty increases with age, although not all older people are frail.

“I compare a frail person to someone in an overloaded canoe,” says Dr. Robert. “While the water’s calm, it’s easy to stay afloat. But when conditions get tougher – say the resident gets a urinary tract infection or a chest cold – the canoe can sink quite quickly, even with interventions that are typically effective in an emptier boat.”

Developed at Perley Health and the subject of ongoing evaluation, SeeME® engages residents, families and care teams in often-challenging conversations about the relationship between frailty, medical intervention and the quality of life. The process begins soon after admission with a Comprehensive Frailty Assessment, a standardized and holistic consideration of the resident’s physical, functional, cognitive and psychosocial status. Part of the Assessment involved the Clinical Frailty Scale, a validated, evidence-based tool developed in 2005 that broadly stratifies degrees of fitness and frailty among people aged 65 and older. The results are discussed during a care conference involving the resident, family 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 family are unique; there are no right or wrong choices.”

After Diane Eddy developed Alzheimer’s, her husband Laird Eddy cared for her at home for eight years. In June 2021, Diane moved into a secure unit at Perley Health, where staff used SeeMe® to develop her original care plan and to update it a year later.

“I still feel responsible for her care,” says husband Laird Eddy, “and recognize that she’s getting the best of care at Perley Health. Sitting down with Diane and her care team to discuss who she is and what she likes, as well as her current health status – and then using this information to develop a care plan – helps to put my mind at ease.”

In March 2022, the Canadian Geriatrics Journal published a study of SeeMe® completed by Perley Health’s Centre of Excellence in Frailty-Informed Care. The study demonstrates that SeeMe® resulted in high satisfaction levels among nurses, physicians and the families of long-term care residents. SeeMe® residents and their families were more likely to choose less-invasive interventions to preserve both health and quality of life. This included decisions to decline cardiopulmonary resuscitation (CPR) and transfers to hospital.

“Frail patients present an existential challenge to medicine’s traditional approach of treating one disease or condition at a time,” says Dr. Kenneth Rockwood, who led the development of the Clinical Frailty Scale in 2005 and is widely considered one of Canada’s top experts in geriatrics. A Professor of Geriatric Medicine at Dalhousie University, Dr. Rockwood is also a Canadian Institute of Health Research Investigator, a Staff Physician at Halifax’s QEII Health Sciences Centre and the Nova Scotia Health Authority Senior Medical Director (Acute Medicine).

“Today’s long-term care residents tend to be more clinically complex and to have more chronic illness than in the past,” he says. “The higher the degree of frailty, the harder it is to recover and return to baseline – and by baseline, we mean what a resident was like two weeks earlier. And some may never get back to baseline.”

Dr. Rockwood believes that identifying and tracking frailty enables care teams to deliver individualized, person-centred care informed by a resident’s strengths and weaknesses. He encourages clinicians and policymakers alike to reconsider what it means to “get better.”

“We have to frame the care of frail patients in a morally neutral way,” he says. “Terms such as ‘bed blockers’ and ‘hallway medicine’ can serve to shift blame onto patients and away from the fundamental problems of the acute-care approach.”

Since 2019, all Perley Health residents participate in SeeMe®. To support its implementation, Perley Health has developed a range of resources, including a training program for staff, and continue to conduct further evaluations.

“A deeper understanding of frailty helps everyone – residents, families and caregivers – communicate more effectively and make better decisions,” says Dr. Robert. “One of the tragedies of medicine is that it over-medicalizes end-of-life care and death. In many cases, I think we’re better off focusing on caring rather than curing. To improve long-term care, we need to develop, implement and validate more innovations like SeeMe®.

To learn more, or to request SeeMe® resources visit

Perley Health

Home to 450 seniors and veterans in long-term care and another 150 in independent apartments, Perley Health provides a full range of clinical, therapeutic and recreational services. It is also a centre of research, education and clinical innovation. The Centre of Excellence in Frailty-Informed CareTM, established in 2019, conducts and shares the practical research needed to improve care. Caregivers come to Perley Health to study and to acquire hands-on skills and experience.

This article was originally published in the Long Term Care Today magazine