Collaborating as partners and communities to prevent frailty

Issue: BCMJ, vol. 64, No. 2, March 2022, Pages 62-63 Shared Care Committee

Good news: people are healthier and living longer. However, if a person’s quality of life in their final years is at a bare minimum, and they can no longer engage with others, or in activities that previously gave them joy, the news might not be so good. Sadly, this is the situation for over 1.5 million Canadians who live with frailty, a state of “increased vulnerability and functional impairment that is caused by an accumulation of multisystemic decline”[1] that poses significant risk to an individual’s quality of life and their potential for a healthy and happy old age. As our elderly population increases, so does the number of people living with frailty. It is projected that well over 2 million Canadians may be living with frailty within the next 10 years.[2]

Scope of impact and prevention

With increased understanding of the negative impact of frailty, not just on the individual but also on partners, caregivers, family, the health system, and society as a whole, there has been a growing commitment by the health sector, government, and community organizations to prioritize prevention. Identifying risk factors early and instituting measures to address them can prevent, reduce, or even reverse factors associated with frailty such as deteriorating mental health and cognition, social isolation, risk of falls, and decreased mobility.

Physicians can play an important role in prevention and are well situated to identify and screen for warning signs in their patients’ health, and to help raise awareness of risks with their patients.

Supporting early interventions to mitigate those risks, such as medication reviews, geriatric assessments, care planning, and encouraging exercise and social interaction, can significantly influence the trajectory of a person’s life and the lives of those around them. Many physicians are already engaged in this work through their practice, Doctors of BC initiatives, and the Joint Collaborative Committees.

Raising awareness and facilitating partnerships

Raising awareness of how to prevent and manage frailty has been a focus of Dr Grace Park’s work in her capacity as regional medical director of home health/specialized community health services for the complex medical/frail at Fraser Health. Dr Park has also been involved with and shared her knowledge, tools, and resources with physicians and project teams as part of the Shared Care Committee’s Coordinating Complex Care for Older Adults initiative.[3]

Building networks of health and social community supports

In a recorded webinar[4] hosted by Shared Care, Dr Park and geriatrician Dr Belinda Rodis describe how their CARES (Community Actions & Resources Empowering Seniors) model, currently available in Fraser Health, is facilitating health and community partnerships to support those most at risk. They also describe how resources and coaching are helping patients stay well and independent in their communities.

Funded by the Canadian government and the United Way, the CARES model includes an innovative social prescribing component, which allows medical practitioners to refer patients to a network of community supports, including exercise and social programs to improve health and well-being. First pioneered in the UK, this practice is gaining a foothold in Canada and has spread across communities in Fraser Health, with opportunities to be adopted elsewhere.

Brochure highlighting steps to AVOID, reduce, or reverse frailty

Building on these knowledge-transfer activities, Dr Park has worked with Shared Care to create a brochure for doctors to share with their patients on five key frailty prevention strategies. These can be easily remembered through the Canadian Frailty Network’s acronym, AVOID (activity, vaccination, optimizing medications, interaction, diet).

The brochure “How to reduce risks of frailty for healthy aging” has been designed to easily fit in a person’s purse or pocket by printing an 8.5 × 11 page and folding it in half twice. Color and black-and-white versions are available at

To explore your own frailty prevention or collaborative project as part of the Coordinating Complex Care for Older Adults initiative, contact your local Shared Care Liaison (
—Jiwei Li, MD
Co-Chair, Shared Care Committee


BC Guidelines: Frailty in Older Adults—Early Identification and Management:

Canadian Frailty Network:

Doctors of BC Policy Statement: Healthy Aging and Preventing Frailty:

Doctors of BC: Stay Active, Stay Safe—Physical Activity Resources and Recommendations for Older Adults During COVID-19:

Fraser Health: Frailty Management for Health Aging:

Shared Care, “How to reduce risks of frailty for healthy aging” brochure:

Pathways BC (search by community for seniors’ activities):

Webinar: Frailty Management in Primary Care: A CARES Model:



This article is the opinion of the Shared Care Committee and has not been peer reviewed by the BCMJ Editorial Board.

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1.    BC Guidelines. Frailty in older adults – early identification and management. 2017. Accessed 19 January 2022.

2.    Canadian Frailty Network. What is frailty? Accessed 19 January 2022.

3.    Shared Care. Coordinating complex care for older adults. Accessed 19 January 2022.

4.    YouTube. Frailty management in primary care: A CARES model. Accessed 19 January 2022.

Jiwei Li, MD. Collaborating as partners and communities to prevent frailty. BCMJ, Vol. 64, No. 2, March, 2022, Page(s) 62-63 - Shared Care Committee.

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