CARES Early Frailty Identification and Prevention Strategy

The FRAILTY MATTERS Innovation Showcase received 80 applications from across the country. From these, the TOP FIVE INNOVATIONS were selected by a panel of leading experts. These five initiatives presented on the stage at the FRAILTY MATTERS Innovation Showcase on Thursday, September 20 in Toronto at the CFN National Conference.

Click here to see the storyboard presented at the Conference.

CARES Early Frailty Identification and Prevention Strategy

Frailty threatens the quality of life for seniors as well as the sustainability of the health care system. Evidence suggests a collaborative approach in the primary care setting involving early geriatric assessment of “at risk” seniors combined with a community-based health coaching intervention can prevent or delay frailty. Based on this knowledge Fraser Health developed the CARES model designed as an upstream approach to address preventable frailty.

CARES (Community Action and Resources Empowering Seniors) is an evidenced based model that supports General Practitioners (GPs) working within a multidisciplinary team framework to identify seniors “at risk” for frailty early by using an electronic comprehensive geriatric assessment tool which generates a frailty index (eFI-CGA) at point of service. The Frailty Index (FI) is a reliable and sensitive measure of frailty generated from the CGA.

Targeting seniors with Clinical Frailty Scores between 3 and 6 CARES uses the results of eFI-CGA to develop individualized care plans and then supports seniors to connect with free health coaches through the UVIC’s Self-Management Health Coaching program to support and develop the senior’s self-management capacity. Telephone based health coaches help seniors to improve their exercise, nutrition and socialization within their local community. Over a period of 3 to 6 months health coaches support seniors to adopt health protective behaviours which reduce their risk for frailty while improving their functional capacity. After a period of a year the eFI-CGA is repeated in the GP’s office to measure the senior’s progression toward or movement away from frailty.

Presenting at the Showcase:

Annette Garm (Project Lead)