CFHI Interview with Antonina Garm, CARES Project Lead, Fraser Health, British Columbia

April 2016

In an occasional feature, we interview leads of CFHI-supported projects. This month we profile a joint Fraser Health (BC) and Nova Scotia Health Authority team about their involvement in CFHI's EXTRA: Executive Training Program.

Please describe your involvement in CFHI’s EXTRA program? What is CARES?

In 2014, through CFHI’s Executive Training in Research Application (EXTRA) program, Fraser Health, the Nova Scotia Health Authority and Shannex Inc. (Nova Scotia) partnered to design, implement and evaluate the CARES inter-provincial initiative. It was the first team ever in the eleven years of CFHI’s EXTRA Fellowship that brought together two provinces and a private sector company to implement an integrated intervention project that considered what factors facilitate healthy aging and impede frailty. Four Fraser Health, two Nova Scotia Health Authority and one Shannex executive joined the EXTRA program to create a quality improvement initiative aimed at reducing frailty in their communities.

CARES is an upstream proactive community primary health care intervention that decreases the downstream impact of frailty on acute and emergency resources, while promoting seniors to age well. The CARES model is based on research evidence that frailty can be delayed and the period of suffering prior to the last years of life can be compressed and shortened. The CARES model partners pre-frail seniors with primary care providers and community-trained wellness coaches, as depicted in Figure 1.


Figure 1: CARES Model

What improvement project is your team undertaking as part of CARES?

In British Columbia, Fraser Health, Divisions of Family Practice and Self-Management BC Active Choices Program, are now collaborating to improve the delivery of senior care in British Columbia by implementing the “Community Actions and Resources Empowering Seniors” (CARES) model to proactively delay the onset and or progression of frailty in the pre-frail senior population using a phased in approach.

Phase 1 will include implementing the CARES model in the Maple Ridge community using technology as an enabler of change by automating the community comprehensive geriatric health (CCGA) and associated assessment tools to support electronic information management in the primary care setting. In addition, geriatric health assessments will be supported in the community GP office with the assistance of a CARES designated nurse who will assist GPs with the completion of assessments and data entry into the electronic medical record (EMR). Participating physicians will be provided with additional geriatric management education support. For seniors who are considered pre-frail, a wellness plan will be created subsequent to their CCGA health assessments that will include a referral to longer term health coaching in the community.

In Nova Scotia, the Nova Scotia Health Authority and Parkland Clayton Park, a Shannex Retirement Living community, have partnered with Geriatrics in Motion, a primary care clinic located on site at Parkland to implement the CARES model in this residential setting. Participants are assessed by both their primary care physician and a family practice nurse at Geriatrics in Motion who work with the senior and a Shannex Wellness Coach to translate this health information into a personalized wellness plan utilizing the Harmony by Parkland wellness program.

What key challenge will your innovation solve?

Our innovation will hopefully solve both quality of life issues associated with aging and frailty, and the subsequent costs they have on the healthcare system. The project also hopes to enhance primary care provider education on senior care and frailty prevention and enhance provider satisfaction with resources available to both themselves and the seniors to address these issues.

CARES provides a rapidly aging population with access to a primary care model aimed at enhancing their health protector factors to keep them healthier longer and living at home in their communities. It provides primary care providers, seniors, families and community agencies an evidenced based model for addressing frailty prevention which is very important.

How does your innovation improve care for patients, families and caregivers?

Short Term Benefits for patients, families and caregivers include the following:

  • Seniors will have a CGA performed pre- and post-intervention, which based on evidence suggests seniors will have improved health outcomes.
  • Seniors will be supported to become more aware of their health status, and more self-managed.
  • Seniors will have the opportunity to work with an Active Choices coach during a six month mentoring program.
  • Seniors will become more aware of the value of and their ability to engage their health protective factors to delay frailty.
  • Skill enhancement and education for primary care providers on how to do a CGA in community practice and manage the pre-frail senior.
  • Primary care providers will have the opportunity to pilot new technology using an electronic CGA which will allow for efficient documentation and evaluation.
  • Primary care providers will have access to CARES visiting nurses to assist with geriatric health assessments and data entry.
  • Connection of primary care providers to community programs to reinforce protective factors.

Long Term Benefits of CARES include:

  • Seniors improved health and quality of life in later years.
  • Seniors have greater knowledge on how to delay frailty.
  • Seniors are better informed partners in the self-management of their health care.
  • Seniors are better connected to community support agencies and volunteers.
  • Reduced costs and increased sustainability of the health system.
  • Fewer unnecessary emergency room visits.
  • Reduced admissions to acute care.
  • Contribute to a body of knowledge that informs research and best practice in senior care.

Are there any cost savings that can be realized from CARES? If yes, please describe.

It is anticipated that CARES will support a reduction in the costs associated with aging and frailty, and their impact on health care costs in the acute care health sector. For example, we hope to decrease falls related Emergency Room visits and prevent unnecessary admissions. It has been estimated that frailty and its poor outcomes are associated with senior’s disproportionate use of the healthcare system resources. Some experts have estimated that frailty is associated with using up to half of the healthcare budget – especially in the last 10 years of a senior’s life. We hope to delay or prevent that slide into frailty. Frailty is also associated with poor quality of life and there is research that indicates that frailty can be prevented, and when it is prevented quality of life improves and those seniors with reported better quality of life have a substantial reduced use of the healthcare system.

What has your experience been like working with CFHI?

In one word, excellent. CFHI has been a supportive and encouraging partner from concept to spread. They helped us with all the steps of creating evidenced-based healthcare innovation, from accessing leading research and researchers, project development, project management, evaluation and in spreading the innovation at the regional level. They helped us to realize the true potential of our quality based improvement project and have become partners in all facets of its execution.

What kind of support did CFHI provide to you and your teams?

Access to education, clinical research, researchers, all aspects of project management information, communication and presentation opportunities, and introduced us to stakeholders. Plus they added the benefit of a pan Canadian perspective. In short they opened our eyes and raised and expanded our perspective which in turn helped us to create a higher quality and evidenced-based project for primary care providers and seniors.

What challenges did you encounter during the CARES project? How were these challenges overcome?

The challenges were, of course, time to do the work for busy fulltime healthcare executives and both healthcare authorities underwent significant changes which resulted in the change of their CEOs and restructuring of the organizations. CFHI helped us stay steady and on track as we negotiated those changes which easily could have become barriers.

What feedback have you received concerning CARES and EXTRA so far?

The CARES project has received very positive feedback wherever we have presented it. Physicians and healthcare administrators, seniors and community agencies have all recognized the potential for CARES to be a game changer in how seniors age and how we manage the onset of frailty in the community. The fact that the project had its roots in a reputable and much respected program like EXTRA also lent to its credibility especially for senior executives.

Do you have any results from your improvement project that you can share?

Early evaluation results show we were able to demonstrate a statistically significant shift in the frailty markers of seniors and that the CARES intervention did support the research that it is possible to delay frailty by engaging seniors in the CARES model. On average the seniors’ frailty score decreased by 0.032 from baseline to the six month follow up CCGA. This is equivalent to having two less health problems at the six month follow-up visit in the GP’s office.


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