June 2019

CARES: Proven approach to caring for seniors in the community takes flight

“CFHI’s collaboration gives us an opportunity to spread the CARES model across the country so that primary care physicians can assess and intervene with seniors before they become too frail,” said Dr. Park.

Frailty can be the enemy of the aging process. Frailty in people age 65 and older is associated with poor quality of life, and may lead to poorer nutrition, social isolation and greater difficulty recovering from routine illnesses. In Canada, nearly half of our healthcare budget is spent on seniors in this age group, largely due to the frailty that results from chronic diseases and major life events.

Fraser Health Authority has been at the forefront of an initiative called Community Actions and Resources Empowering Seniors (CARES). Using CARES, primary-care physicians identify seniors who are at risk of becoming frail, and intervene with healthcare and community supports to keep these patients healthy for as long as possible.

“Identifying frailty early gives healthcare providers an opportunity to intervene before the effects of frailty become too advanced to reverse,” said Dr. Grace Park, Fraser Health’s Regional Medical Director for Home and Community Care, a primary care physician, and one of the architects of the CARES model.

“As seniors age, you can pick out events in life, such as an illness or the death of a spouse, that will contribute to a health decline and eventual frailty. The question we’ve been trying to answer through CARES is, ‘What can we do to intervene at those moments so that we don’t see the senior in hospital in a few months?’”

CARES uses an evidence-based, comprehensive geriatric assessment – including tests such as having a senior stand repeatedly from a sitting position and having the patient perform memory tasks. The family physician then screens the patient using the Rockwood clinical frailty Scale to help identify vulnerable seniors.

Dr. Park said that to identify at-risk seniors, primary care providers administering geriatric assessments need to be on the lookout for common health issues, such as heart failure and COPD, as well as major life events, such as the loss of a spouse or social isolation.

Under the CARES model, when patients do show signs of frailty, their primary care providers refer them to community supports to help them lead the healthiest lives they can. One such support program uses specially trained volunteer coaches who teach seniors how to monitor and manage their health conditions, and follow up once a week over the phone to provide encouragement. “The coaches help the patients stay motivated with the self-management plans,” said Dr. Park.

A more recent support – and a major win for CARES – has emerged through Fraser Health’s new partnership with the United Way. The United Way now funds one designated expert in each of the 10 Fraser Health communities to work as a Seniors Community Connector. “Through this partnership we can provide primary care physicians with a specific individual who connects patients to the right supports in their communities,” said Dr. Park. “Physicians love this. They’ve always wanted to assist their patients this way, but haven’t had the information they needed.”

Another key feature of Fraser Health’s CARES model is their innovation of an electronic assessment tool that can be embedded into a patient’s electronic medical record. The primary care physician clicks a button to populate the comprehensive geriatric assessment with patient information, completes the assessment and then, with another click, generates a frailty index. As an added benefit, patients can view their scores on the frailty index and become more active participates in their own care. Dr. Park’s team also developed a stand-alone e-tool for situations where the software does not integrate easily into a healthcare organization’s existing EMR platform.

The CARES model has received active support from CFHI since 2015, when Fraser Health partnered with Nova Scotia Health Authority and Shannex Inc. to develop the model within CFHI’s EXTRA: Executive Training Program.

In 2019, CFHI announced the Advancing Frailty Care in the Community (AFCC) Collaborative in partnership with the Canadian Frailty Network (CFN) that is based on the top four frailty innovations from the 2018 CFN Frailty Matters Innovation Showcase. CARES is among the four innovations selected. The others are the Seniors’ Community Hub: Integrated Care for Seniors in Edmonton, Alberta; the Caring for Older Adults in the Community and at Home (COACH) Program in Prince Edward Island; and C5:75: Case-findings for Complex Chronic Condition in Person 75+ from the Centre for Family Medicine Family Health Team in Kitchener, Ontario.

“CFHI’s collaboration gives us an opportunity to spread the CARES model across the country so that primary care physicians can assess and intervene with seniors before they become too frail,” said Dr. Park. “Most pre-frail seniors can be supported to address many of their health issues through exercise, nutrition and community based programs, which makes pairing these patients with people in their own communities through the coach model a key factor for success.”

CFHI is inviting teams across Canada to apply for the AFCC Collaborative taking place November 2019 to September 2021. The deadline to apply is August 21, 2019.

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