| Title: |
Neighbourhood Care Team - Integrated care-model for team based primary care and aging at home |
| Authors: |
Charles, Jocelyn; Ziegler, Naomi; Landau, Stacy; Smith, Jagger; Howells, Arlene; Fine, Kiara; Addis, Laura J; Jeyabalan, Vyshnave; Mcgarvey, Kay; Sauer, Renee |
| Source: |
International Journal of Integrated Care; Vol. 25 No. S2 (2025): North America Conference on Integrated Care, Calgary, Canada – 15-17 October 2024; 120 ; 1568-4156 |
| Publisher Information: |
Ubiquity Press |
| Publication Year: |
2025 |
| Collection: |
International Journal of Integrated Care (IJIC) |
| Description: |
Background: Seniors are living with more severe illness, while caregivers and providers are more prone to burnout 2. Systemic barriers contribute to seniors and families inability to access appropriate and timely healthcare services and poor outcomes.The challenge of coordinating/managing multiple services is worsened by language, cultural, income and functional barriers. Target populationToronto Seniors Housing Corporation (TSHC) provides housing for 5,000 low-income seniors in 83 seniors-designated buildings across the City of Toronto. The average age of tenants is 75 with a growing population of seniors over 85. A large percentage of tenants (44%) do not speak English as their first language, live on their own (90%), and suffer from a combination of mental health and chronic conditions that contribute to high rates of social isolation (TSHC ISM, 2023). Who did you involveThe NCT model, including all levels of care planning, was co-developed with the active participation of community members and local stakeholders from a variety of organizations such as: Community services, Primary-Care, Housing, Hospitals, City services, etc. and through active engagement with over 240 tenants in 7 languages. Engagement efforts included door knocking, surveys, lobby voting, and ongoing participation of tenant volunteers in planning meetings. The approach/intervention: The North Toronto Ontario Health Team (NT OHT) Neighbourhood Care Team (NCT) is an outreach-based integrated geriatric and population health model of care. The model brings together local partners from all sectors to operate as one team, beyond the walls of their institutions, in support of low-income tenants residing in Toronto Seniors Housing Corporation (TSHC) across North Toronto.The model objective is to promote an early identification of needs and support seniors access to team-based primary care and resources to prevent crisis, decrease use of institutional care, increase quality of life and promote aging at home.This scalable model brings existing ... |
| Document Type: |
article in journal/newspaper |
| File Description: |
application/pdf |
| Language: |
English |
| Relation: |
https://account.ijic.org/index.php/up-j-ijic/article/view/10028/10827 |
| DOI: |
10.5334/ijic.NACIC24120 |
| Availability: |
https://account.ijic.org/index.php/up-j-ijic/article/view/10028; https://doi.org/10.5334/ijic.NACIC24120 |
| Rights: |
Copyright (c) 2025 The Author(s) ; https://creativecommons.org/licenses/by/4.0 |
| Accession Number: |
edsbas.95FDDA62 |
| Database: |
BASE |