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Integrated Client Care for Frail Older Adults in the Community

Preliminary Report on a System-Wide Approach

By: Jodeme Goldhar, Stacey Daub, Irfan Dhalla, Philip Ellison, Dipti Purbhoo and Samir K. Sinha


The Toronto Central Community Care Access Centre is leading in a collaborative local health integration network systemic change initiative to implement and evaluate a practical model of integrated care for older adults with complex needs. The approach is embedded in the community where older adults and their families live and is designed to first and foremost improve the quality of care while ultimately bending the cost curve. The model is leveraging and aligning existing system resources by bringing together sectors from across the health system to create ways of working that build capacity in the system to be more responsive to this population. Outcomes to date will be discussed and next steps described. The secondary goal was to understand the key elements of this integration that can be scaled locally across the province.

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