Advancing Frailty Care in the Community Collaborative

  • Forming Teams
  • Planning Initiative
  • Launch
  • Changes Tested
  • Some Improvement
  • Improvement
  • Significant Improvement
  • Sustainable Improvement

The burden of frailty1 in Canada is steadily growing, especially in older adults. Today, more than 1.5 million Canadians are medically frail. In 10 years, more than two million Canadians may be living with frailty.2 Frailty is linked to a higher reliance on healthcare resources.

While frailty may occur throughout a lifespan, a large proportion of those who are living with frailty are aged 65 years of age or over. There is an urgent need and tremendous opportunity to improve care and the quality of life for older people living with frailty, as well as support their family/friend caregivers.

The Canadian Foundation for Healthcare Improvement and the Canadian Frailty Network (CFN) launched the Advancing Frailty Care in the Community (AFCC) Collaborative in November 2019.

AFCC is supporting healthcare teams from across Canada to adapt and implement evidence-informed innovations to improve the identification, assessment and management of frailty in primary care.

How AFCC contributes to better healthcare in Canada 

AFCC is part of CFHI’s ongoing efforts to spread and scale proven innovations that deliver high quality care that is closer to home and the community. The innovations being spread through this collaborative have shown measurable progress in improving the health and wellbeing of older adults and advancing frailty care within primary care and home settings, while positively impacting health system utilization.

Through this collaborative, CFHI and CFN aim to:

  • Support 17 participating teams in the following core frailty intervention areas:
    • Frailty Identification
    • Geriatric Assessment
    • Tailored Interventions
    • Person and Family Centred-Care
    • Collaborative Care
    • Community Supports
    • Quality Improvement (QI) and measurement
  • Improve the care and quality of life for older adults who are vulnerable to moderately frail (a score of 4 - 6 on the Clinical Frailty Scale or equivalent), and support their family/friend caregivers.
  • Build QI capability and capacity among teams, particularly as they relate to implementing, spreading and sustaining frailty-related improvements.
AFCC Approach

AFCC Core Frailty Intervention Areas

Throughout the collaborative, all teams are regularly collecting and submitting a mix of patient-reported, caregiver-reported and clinician-reported data based on the core frailty intervention areas. Final AFCC results are expected to be available in 2022. To check out the results when they are available, subscribe to our newsletter.

The Approach

CFHI and CFN have jointly contributed $1.2 million in seed funding to support teams that are implementing the frailty innovations and advancing frailty care in the community in primary care and/or home care settings.

Teams are supported by expert faculty and coaches to systematically identify and assess frailty in populations 75 years of age and over, and conduct opportunistic screening for those 65 years of age and over. For those identified as vulnerable, mildly or moderately frail, geriatric assessments are followed up with customized care plans (developed in partnership with patients and caregivers) to slow the progression of frailty, and maintain or enhance their quality of life.

Teams are adapting one of four of the top frailty innovations identified in the 2018 CFN Frailty Matters Innovation Showcase and designing their own frailty initiatives.

  • COACH Program: Caring for Older Adults in the Community and at Home, developed by Health PEI, Prince Edward Island 
  • CARES: Community Action and Resources Empowering Seniors, developed by Fraser Health Authority, British Columbia 
  • C5-75: Case-findings for Complex Chronic Conditions in Persons 75+, developed by the Centre for Family Medicine, Family Health Team, Ontario 
  • The Seniors’ Community Hub, developed in Edmonton, Alberta

AFCC teams’ capacity and skills are enhanced through participation in the collaborative’s curriculum that includes:

  • Regular interactive webinars that delve into relevant topics related to both practice change and QI
  • In-person workshops focused on peer-to-peer learning and knowledge development
  • Regular coaching calls with content experts to ensure a rapid pace for testing change
  • Online learning tools
  • Cross-team learning and networking opportunities
  • Opportunities for site visits

The Teams

The Advancing Frailty Care in the Community Collaborative brings together 17 teams from across seven provinces.


Caring for Older Adults in the Community and at Home (COACH)
Read more >

What We Do

Better Care Care Closer to Home and the Community
Read more >

Tools / Resources

Value-Based Healthcare Toolkit
Read more >

1We refer to frailty as a state of increased vulnerability resulting from reduced reserve and loss of function across multiple systems reducing the ability to cope with normal or minor stressors.

2Research on Aging, Policies and Practice. (June 2018). A profile of caregivers of older adults (65+). Retrieved February 27, 2020 from: