Improving care for older people with frailty and supporting their family/friend caregivers

A 23-month Quality Improvement Collaborative

To improve care for older people with frailty and support their caregivers, CFHI and the Canadian Frailty Network have launched the Advancing Frailty Care in the Community (AFCC) Collaborative. This initiative supports 17 healthcare teams from across Canada to improve the identification, assessment and implementation of tailored evidence-informed interventions that address frailty in primary care.

Over the collaborative period, CFHI and CFN aim to:

  • Support teams to test and adapt evidence-informed innovations (or portions thereof) that address each of the seven AFCC intervention areas. (Figure 1)
  • Improve quality of life for older adults presenting to primary care who are identified as vulnerable to moderately frail.
  • Support capacity development for QI, change management and leadership, particularly as it relates to spreading and sustaining frailty-related improvements

Learning from proven frailty innovations

The design of the AFCC collaborative was informed by some of the top frailty innovations from the 2018 CFN Frailty Matters Innovation Showcase. These applied innovations were presented by practitioners and experts across Canada and have been selected to be spread further across the country through this collaborative.

Participating teams draw from these innovations to inform the design of their own frailty initiatives. The lead innovators from these programs are supporting design, delivery and evaluation of the AFCC collaborative as well as participating as clinical coaches, supporting participating teams throughout the 23-month period.

How does AFCC work?

Participating teams will advance frailty care in the community using a quality improvement (QI) approach in both primary care and home care settings. The AFCC interventions promote systematically identifying and assessing frailty in populations 75 years of age and over, with opportunistic screening for those 65 years and over. Geriatric assessments are followed up with customized care plans for those who are frail, in partnership with their caregivers, towards slowing the progression of frailty and maintaining or enhancing quality of life.

Figure 1

Figure 1

Key Dates


AFCC Key Dates

Participating Teams

The Advancing Frailty Care in the Community Collaborative brings together 17 teams from across 7 provinces. Find out where they are from and learn more about their projects.

Last Updated: February 2020