Mary Fox

How do we keep older people functioning while we treat their illnesses or injuries?

Mary Fox researches how to help older people in hospital stay functioning as much as possible while their acute episodes are being treated so that they can get back to their former lives. While she began her research career in long-term and complex continuing care environments, the results of these early studies led her to the acute care setting. Her research focuses on preventing functional decline – one of the most disabling and life-altering risks related to hospital stays for older people.


My whole realm of research was inspired by my practice as a nurse and my patients’ experiences. Now that I’m no longer practicing, my inspiration comes from other healthcare practitioners who share their issues and their experiences with me. I need to know what experiences in the healthcare system are good and not so good, and think about how we can make the ones that aren’t so good, better. For example, we just finished a very large survey of more than 2000 nurses from 148 hospitals across Ontario, trying to understand nurses’ opinions about whether their hospital work environment supports them or fails to support them in providing care to older people. We know that the environment in which somebody works influences the kind of care they provide. I want to understand nurses’ experiences so that we can improve patients’ experiences.


Around 40-60% of older people lose their functioning when they’re hospitalized because hospitals weren’t originally designed to take care of older people. What I’m really trying to do is redesign the healthcare system for the aging population.

Through my research I try to provide healthcare practitioners with practical guidance: what exactly do we need to do, when do we start it, how often should we do it and for how long for different types of patients. People in hospitals are busy and can’t do everything, so we aim to identify the absolutely essential things that are necessary to see better outcomes for older people. Ideally, this information will be used as a tool to help hospitals measure how they are doing in meeting the needs of older people, and develop performance improvement initiatives.


My biggest breakthrough has been my research on a particular model of care called Acute Care for Elders (ACE). ACE is a pre-habilitation approach to the care of older people who have an acute illness or injury. In rehabilitation we restore lost functioning; pre-habilitation is going back a step and trying to preserve functional abilities alongside treating the acute event. This model has been around for about 20 years but traditionally it has only been used by the very few specialized ACE Units that exist in Canada. I found that there were a lot of barriers, such as costs, to adopting this model more widely. And yet my research showed that this model improves outcomes while cutting costs. I led a team that conducted a large systematic review, and we showed that the ACE model reduced functional decline, falls, delirium, length of hospital stay, and costs, compared to usual care. ACE was less expensive by more than $200 per patient per length of hospital stay. This is a big potential future source of cost savings for the healthcare system. Another important finding is that ACE can be provided outside the confines of an ACE-dedicated unit. It’s not so much the physical environment but what the care providers actually do that seems to make a difference.

What’s next?

Now that we know ACE is the Cadillac of gerontological care models, that it is cost-effective, and that it can be used hospital-wide, my next project will look at how we can incorporate it as broadly as possible into our healthcare system so that it has far-reaching impact.