Promising Practices for Enabling Aging in Place

Setting: Community paramedicine

The Community Paramedic Post-Fall Rehab Care Pathway supports older adults who have had a fall to reduce functional decline and prevent future falls. Community paramedics provide assessments and referrals to rehab supports, helping improve access to care and reduce avoidable emergency department visits.

Supported by Healthcare Excellence Canada’s Enabling Aging in Place collaborative.

Setting: Community paramedicine

CP@clinic is an evidence-based initiative, focusing on chronic disease prevention, management and health promotion. Implemented by local community paramedics, this program provides health services to older adults in social housing communities and helps them navigate to health and social supports. The program’s impacts include improvement in health and quality of life, reduced social isolation and better connection with primary care and community resources, while reducing the economic burden of avoidable 911 calls.

Setting: Community paramedicine

The first implementation of CP@clinic in Quebec, this initiative was inspired by the original model developed at McMaster University and adapted for the Québec City region. Community paramedics provide chronic disease prevention and management, along with health promotion in buildings operated by municipal housing authorities (OMH). The program aims to reduce social isolation, improve access to primary care and community resources, and decrease avoidable 911 calls through prevention and early intervention.

Supported by Healthcare Excellence Canada’s Enabling Aging in Place collaborative.

Setting: Primary care

The Healthy Aging Program supports older adults in maintaining their well-being, independence and connection to their communities. Designed for individuals both with and without access to a primary care provider, it focuses on early identification of frailty and timely access to supports and resources. The program aims to improve quality of life while reducing pressure on the local healthcare system.

Supported by Healthcare Excellence Canada’s Enabling Aging in Place collaborative.

Setting: Primary care

Home ViVE provides 24/7 in-home care by family physicians and nurse practitioners for older adults living with moderate to severe frailty who cannot access traditional healthcare. By delivering primary care support at home, the program helps older adults remain safely and comfortably in their homes for as long as possible while reducing unnecessary emergency department visits and hospital admissions.

Setting: Primary care

KW4 ICT is an integrated care model that brings specialized services into primary care to better support older adults with complex health needs. By providing more coordinated and accessible care, the initiative helps reduce avoidable emergency department visits, streamline waitlists, and support the well-being of older adults and their caregivers.

Supported by Healthcare Excellence Canada’s Enabling Aging in Place collaborative.

Setting: Community-based seniors’ services organizations

Better at Home enables older adults to maintain independence and community connections by assisting with non-medical daily tasks. This model is a community-based approach that complements existing services by engaging local organizations to respond to individual needs. Each program is tailored to the unique circumstances of the individual being served.

Setting: Community-based organizations

Compassionate Communities (CCs) is a global movement that promotes collective action and shared responsibility in supporting people experiencing aging, serious illness, dying and grief. Community groups provide psychosocial, spiritual and practical support, improving well-being and reducing reliance on healthcare services.

Setting: Primary care and community-based organizations

Home Assist provides personalized, non-medical supports to help older adults maintain quality of life and remain in their communities. Serving remote, ferry-dependent islands, the program offers accessible social and emotional support through flexible and integrated services that respond to local needs.

Supported by Healthcare Excellence Canada’s Enabling Aging in Place collaborative.

Setting: Long-term care and community-based organizations

Nursing Home Without Walls supports older adults living in the community by connecting them to services, supports and activities typically available through nursing homes. Community-focused staff work with local partners to identify needs and build solutions that enable older adults to remain at home.

Now being spread across Canada through Healthcare Excellence Canada

Play Forever supports older adults to remain connected to their community, enhancing social engagement and reducing loneliness. By focusing on health promotion, social connection and technology skills, Play Forever supports older adults in maintaining independence and improving their quality of life as they age in place.

Supported by Healthcare Excellence Canada’s Enabling Aging in Place collaborative.

Setting: Community-based organizations and primary care

The Maple Ridge/Pitt Meadows Community Services Seniors Social Prescribing Program provides a formal pathway for healthcare providers to address the social determinants of health of their older adult patients. The program connects older adults with community programs, services and resources that support their mental, physical and social well-being.

Setting: Home care and community-based organizations

The Services to Seniors program helps older adults and their care partners navigate local health and community services. To better understand the supports available locally, the team travelled across the region to map community assets and host ideas fairs. These gatherings brought together residents and community organizations to share knowledge, build on existing strengths and identify new opportunities to support healthy aging in their communities.

Supported by Healthcare Excellence Canada’s Enabling Aging in Place collaborative.

Setting: Naturally Occurring Retirement Communities

The UHN NORC Innovation Centre (NIC) merges integrated care delivery with a community development approach to provide new options for aging in place. NIC NORC Programs apply one of three models of NORC delivery, which all are centred around the principles of being community-led, partnership based and data driven but differ in terms of their staffing model and level of health service integration.

Setting: Naturally Occurring Retirement Communities

Oasis works with older adults living in NORCs to identify their needs and determine the services and activities that will best support them. Programming is designed to help older adults age in their communities, with support from an on-site coordinator who helps build on the strengths of members and connect them with existing community services and programs.

Setting: Naturally Occurring Retirement Communities, social housing and community-based organizations

Ottawa West Aging in Place offers comprehensive supports for older adults living in social housing to reduce barriers to care and help them remain independent in their homes. Working in collaboration with community agencies and healthcare centres, an on-site coordinator helps arrange services such as foot care clinics, Meals on Wheels, transportation to medical appointments, homemaking support and health promotion activities.

Setting: Community-based organizations

Nav-CARE is a free a volunteer navigation program that supports people with declining health to live well at home for as long as possible. Trained volunteers help individuals access community resources while providing companionship and emotional support, improving quality of life.

Setting: Acute care

The Acute Care of the Elderly (ACE) units in Newfoundland and Labrador provide person-centred care tailored to the needs of older adults, supported by integrated clinical services and specialized care pathways. Delivered by an interdisciplinary team, the program helps reduce length of stay, prevent deconditioning and social isolation, support safe transitions home and minimize hospital readmissions.

Supported by Healthcare Excellence Canada’s Enabling Aging in Place collaborative.

Setting: Long-term care

The STEPS program supports older adults in acute care who have been designated as requiring an alternate level of care by providing a homelike environment that helps prepare them to transition back into the community or to a new care setting. Using a relational and holistic approach focused on abilitation, the program supports participants in maintaining and building on their existing abilities. STEPS is also supported by the Friends volunteer program, which provides accompaniment and support to help older adults make informed decisions about transitions and accessing services.

Supported by Healthcare Excellence Canada’s Enabling Aging in Place collaborative.

Setting: Adult day programs

DFLEP provides individual and group services for people living with dementia and their care partners. By connecting participants with peers and support services, the program helps reduce isolation and strengthen their sense of belonging and connection. It also enhances quality of life and can help delay entry into long-term care by reducing care partner burnout.

Supported by Healthcare Excellence Canada’s Enabling Aging in Place collaborative.

Setting: Adult day programs

NetCare Connect at Home is a virtual day program that offers gentle Carefit exercises, bingo and interactive falls prevention education for older adults. These activities help address modifiable factors associated with frailty, including social isolation, reduced physical activity and cognitive decline. By promoting social connection, movement and cognitive stimulation, the program aims to reduce the risk of falls and support healthy aging at home.

Supported by Healthcare Excellence Canada’s Enabling Aging in Place collaborative.