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 target group is seniors aged 65–85 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 Healthcare Excellence Canada’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 – introducing, as a part of routine care, an Electronic Frailty Index Comprehensive Geriatric Assessment (eFI-CGA) tool to measure seniors’ frailty index 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. Community partners can help enhance the physical health of seniors at risk of frailty through active coaching to improve their 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 our Advancing Frailty Care in the Community Collaborative.