Community Action and Resources Empowering Seniors (CARES) Program

The Community Action and Resources Empowering Seniors (CARES) program supports seniors to age well and live a higher quality of life within their community for longer. It is a primary healthcare, upstream intervention intended to decrease the downstream impact of frailty on acute care and emergency resources.

The CARES program targets seniors aged 65-85 years old living at home or in an assisted living setting who have a Rockwood Clinical Frailty Score between three and five, and who are vulnerable to deteriorate into frailty. Using a phased approach, CARES combines regular assessments by primary care providers with wellness coaching from trained volunteers.

CARES was established in 2014 as an inter-provincial initiative between Fraser Health Authority, Nova Scotia Health Authority and Shannex Inc. through the Canadian Foundation for Healthcare Improvement’s EXTRA Executive Training Program. Fraser Health Authority partnered with electronic medical records providers Intrahealth Canada Ltd., Telus Health Wolf EMR and Divisions of Family Practice to further enhance the CARES program – as a part of  routine care, an Electronic Frailty Index Comprehensive Geriatric Assessment (eFI-CGA) tool was introduced to measure the frailty index of seniors through ongoing periodic geriatric assessments.

The CARES program, specifically the Self-Management Health Coach program, is a partnership between primary care providers and community partners developed and implemented by the University of Victoria’s Institute on Aging and Lifelong Health, and funded by British Columbia’s Ministry of Health.

CARES demonstrates that the progression of frailty in seniors can be proactively delayed with proper assessment and care planning. The physical health of older adults at risk of frailty can be enhanced through active coaching which supports improved access to exercise, nutrition and social engagement resources.

Other benefits of the CARES program include reduced acute care and emergency department use by seniors, as well as healthcare providers’ improved sensitivity to the measurement of frailty through their use of the evidence-informed frailty assessment tool.

This is one of the innovations being implemented as part of Canadian Foundation of Healthcare Improvement’s Advancing Frailty Care in the Community Collaborative.

Download the CARES innovation profile