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Naomi Ziegler

Biographic Data

ID6775483
NAMENaomi Ziegler
GIVEN NAMESNaomi
FAMILY NAMEZiegler
SIGNATUREZIEGLER N
AFFILIATIONSPublic Health Ontario
VERIFIEDNo
TOTAL WORKS11
TOTAL CITATIONS0
WORKS AS AUTHOR11
WORKS AS EDITOR0
FIRST PUBLICATION YEAR2022
LATEST PUBLICATION YEAR2026
H-INDEX0
  • The Development of an Integrated Model of Dementia Care in the Community for Low-Income Seniors

    Open Access•Jocelyn Charles, Kitty Liu et al.•ARTICLE•International Journal of…•2026

    More than 8% of Canadians over the age of 65 are estimated to live with a form of dementia. However, the real number is likely higher for older adults living in social housing as they are disproportionately impacted by poverty, social isolation and poor health, which increases their risk of developing dementia. Community service providers care for persons living with dementia across ambulatory care clinics, hospitals, rehabilitation facilities, n…

  • Bridging Hospital and Community

    Open Access•Naomi Ziegler, Stacy Landau et al.•ARTICLE•International Journal of…•2026

    Canada’s population is rapidly ageing. Its life expectancy, now among the highest in the world, exceeds 82 years. This rapidly ageing population contributes to the unprecedented strain on the health care system. Toronto's seniors have additional challenges with equitable access to preventive health promotion services. SPRINT Senior Care, a small Community Support Service agency and Sunnybrook Health Sciences Center, a large academic hospital, hav…

  • Integrated Model of Primary Care Delivery for Unattached Low-Income Seniors in Community Housing

    Open Access•Jocelyn Charles, Alison Culbert et al.•ARTICLE•International Journal of…•2025

    City of Toronto owned Toronto Seniors Housing Corporation (TCHC) provides housing for 15,000 low-income seniors in 83 seniors-designated buildings across Toronto. The North Toronto Ontario Health Team (including primary care, hospital, community, home-care) partnered with Toronto Senior Housing to develop and implement a Neighbourhood Care Team (NCT) integrated model to address tenants' health and social needs, co-designed with the tenants. Centr…

  • Neighbourhood Care Team - Integrated care-model for team based primary care and aging at home

    Open Access•Jocelyn Charles, Naomi Ziegler et al.•ARTICLE•International Journal of…•2025

    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 housin…

  • Integrating Care and Social Services for Low Income Seniors in Toronto Community Housing

    Open Access•Einat Danieli, Jagger Smith et al.•ARTICLE•International Journal of…•2025

    The North Toronto Ontario Health Team has partnered with the Toronto Seniors Housing Corporation (TSHC) and its tenants to develop and implement a Neighbourhood Care Team model to address tenants health and social needs. Successes will be shared and creative solutions to the significant and/or ongoing barriers and challenges encountered will be discussed.Improving access to integrated care and social supports for vulnerable seniors in social hous…

  • A Depiction of the Scope of Practice of a Mental Health Navigator for Older Adults and Patient Outcomes

    Open Access•Tracey DasGupta, Marina Motsenok et al.•ARTICLE•International Journal of…•2025

    Navigating the health system can be especially challenging for older adults with mental health (MH) issues. To address the MH needs of older adults, an acute care hospital partnered with a community agency to co-create a novel MH Patient Navigation Program to support older adults with MH needs

  • Navigating Across Hospital and Community Settings to Create a Patient Navigation Program for Older Adults

    Open Access•Stacy Landau, Tracey DasGupta et al.•ARTICLE•International Journal of…•2025

    Background: A co-created Patient Navigation Program (PNP) between a major acute care hospital and community agency was implemented to promote better integrated care for older adult patients transitioning from the hospital back to the community. Audience: This workshop is for decision-makers, frontline clinical staff, older adults and family members, and researchers interested in patient navigation and older adult health. Approach: The goal of thi…

  • Neighbourhood Care Teams

    Open Access•Jocelyn Charles, Einat Danieli et al.•ARTICLE•International Journal of…•2023

    Toronto Seniors Housing Corporation (TSHC), owned by the City of Toronto, provides housing for 15,000 low-income seniors in 83 seniors-designated buildings across Toronto. The North Toronto Ontario Health Team (including primary care, hospital, community and home-care) partnered with one of the TSHC buildings in North Toronto to develop and implement a Neighbourhood Care Team (NCT) model to support TSHC’s Integrated Service Model to address tenan…

  • Describing the scope of practice of patient navigators for older adult patients with complex care needs

    Open Access•Grace Liu, Kristina M Kokorelias et al.•ARTICLE•International Journal of…•2023

    Introduction: Transitions in care (e.g., discharge to home) are stressful for patients, especially for older adults living with complex conditions. To bridge the care gap and improve the continuity of care across care transitions, a new model of care was introduced at a large metropolitan hospital in partnership with a community agency that uses patient navigators which are embedded in the hospital’s care teams, including emergency, acute, and re…

  • Patient Navigation to Improve Hospital to Home Transitions for Older Adults with Complex Needs and their Circle of Care

    Open Access•Kristina M Kokorelias, Stephanie Posa et al.•ARTICLE•International Journal of…•2022

    The International Journal of Integrated Care (IJIC) is an online, open-access, peer-reviewed scientific journal that publishes original articles in the field of integrated care on a continuous basis.IJIC has an Impact Factor of 2.913 (2021 JCR, received in June 2022)The IJIC 20th Anniversary Issue was published in 2021

  • Key informants' perspectives on Implementing Patient Navigator Programs within Hospital Settings

    Open Access•Kristina M Kokorelias, Sarah Gould et al.•ARTICLE•International Journal of…•2022

    The International Journal of Integrated Care (IJIC) is an online, open-access, peer-reviewed scientific journal that publishes original articles in the field of integrated care on a continuous basis.IJIC has an Impact Factor of 5.120 (2020 JCR, received in June 2021)The IJIC 20th Anniversary Issue was published in 2021

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  • Patient Navigation to Improve Hospital to Home Transitions for Older Adults with Complex Needs and their Circle of Care

    Open Access•Kristina M Kokorelias, Stephanie Posa et al.•ARTICLE•International Journal of…•2022

    The International Journal of Integrated Care (IJIC) is an online, open-access, peer-reviewed scientific journal that publishes original articles in the field of integrated care on a continuous basis.IJIC has an Impact Factor of 2.913 (2021 JCR, received in June 2022)The IJIC 20th Anniversary Issue was published in 2021

  • Key informants' perspectives on Implementing Patient Navigator Programs within Hospital Settings

    Open Access•Kristina M Kokorelias, Sarah Gould et al.•ARTICLE•International Journal of…•2022

    The International Journal of Integrated Care (IJIC) is an online, open-access, peer-reviewed scientific journal that publishes original articles in the field of integrated care on a continuous basis.IJIC has an Impact Factor of 5.120 (2020 JCR, received in June 2021)The IJIC 20th Anniversary Issue was published in 2021

  • Neighbourhood Care Teams

    Open Access•Jocelyn Charles, Einat Danieli et al.•ARTICLE•International Journal of…•2023

    Toronto Seniors Housing Corporation (TSHC), owned by the City of Toronto, provides housing for 15,000 low-income seniors in 83 seniors-designated buildings across Toronto. The North Toronto Ontario Health Team (including primary care, hospital, community and home-care) partnered with one of the TSHC buildings in North Toronto to develop and implement a Neighbourhood Care Team (NCT) model to support TSHC’s Integrated Service Model to address tenan…

  • Describing the scope of practice of patient navigators for older adult patients with complex care needs

    Open Access•Grace Liu, Kristina M Kokorelias et al.•ARTICLE•International Journal of…•2023

    Introduction: Transitions in care (e.g., discharge to home) are stressful for patients, especially for older adults living with complex conditions. To bridge the care gap and improve the continuity of care across care transitions, a new model of care was introduced at a large metropolitan hospital in partnership with a community agency that uses patient navigators which are embedded in the hospital’s care teams, including emergency, acute, and re…

  • Integrated Model of Primary Care Delivery for Unattached Low-Income Seniors in Community Housing

    Open Access•Jocelyn Charles, Alison Culbert et al.•ARTICLE•International Journal of…•2025

    City of Toronto owned Toronto Seniors Housing Corporation (TCHC) provides housing for 15,000 low-income seniors in 83 seniors-designated buildings across Toronto. The North Toronto Ontario Health Team (including primary care, hospital, community, home-care) partnered with Toronto Senior Housing to develop and implement a Neighbourhood Care Team (NCT) integrated model to address tenants' health and social needs, co-designed with the tenants. Centr…

  • Neighbourhood Care Team - Integrated care-model for team based primary care and aging at home

    Open Access•Jocelyn Charles, Naomi Ziegler et al.•ARTICLE•International Journal of…•2025

    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 housin…

  • Integrating Care and Social Services for Low Income Seniors in Toronto Community Housing

    Open Access•Einat Danieli, Jagger Smith et al.•ARTICLE•International Journal of…•2025

    The North Toronto Ontario Health Team has partnered with the Toronto Seniors Housing Corporation (TSHC) and its tenants to develop and implement a Neighbourhood Care Team model to address tenants health and social needs. Successes will be shared and creative solutions to the significant and/or ongoing barriers and challenges encountered will be discussed.Improving access to integrated care and social supports for vulnerable seniors in social hous…

  • A Depiction of the Scope of Practice of a Mental Health Navigator for Older Adults and Patient Outcomes

    Open Access•Tracey DasGupta, Marina Motsenok et al.•ARTICLE•International Journal of…•2025

    Navigating the health system can be especially challenging for older adults with mental health (MH) issues. To address the MH needs of older adults, an acute care hospital partnered with a community agency to co-create a novel MH Patient Navigation Program to support older adults with MH needs

  • Navigating Across Hospital and Community Settings to Create a Patient Navigation Program for Older Adults

    Open Access•Stacy Landau, Tracey DasGupta et al.•ARTICLE•International Journal of…•2025

    Background: A co-created Patient Navigation Program (PNP) between a major acute care hospital and community agency was implemented to promote better integrated care for older adult patients transitioning from the hospital back to the community. Audience: This workshop is for decision-makers, frontline clinical staff, older adults and family members, and researchers interested in patient navigation and older adult health. Approach: The goal of thi…

  • The Development of an Integrated Model of Dementia Care in the Community for Low-Income Seniors

    Open Access•Jocelyn Charles, Kitty Liu et al.•ARTICLE•International Journal of…•2026

    More than 8% of Canadians over the age of 65 are estimated to live with a form of dementia. However, the real number is likely higher for older adults living in social housing as they are disproportionately impacted by poverty, social isolation and poor health, which increases their risk of developing dementia. Community service providers care for persons living with dementia across ambulatory care clinics, hospitals, rehabilitation facilities, n…

  • Bridging Hospital and Community

    Open Access•Naomi Ziegler, Stacy Landau et al.•ARTICLE•International Journal of…•2026

    Canada’s population is rapidly ageing. Its life expectancy, now among the highest in the world, exceeds 82 years. This rapidly ageing population contributes to the unprecedented strain on the health care system. Toronto's seniors have additional challenges with equitable access to preventive health promotion services. SPRINT Senior Care, a small Community Support Service agency and Sunnybrook Health Sciences Center, a large academic hospital, hav…

Health care (8 works) · Medicine (8 works) · Integrated care (7 works) · Nursing (7 works) · Family medicine (4 works) · Geriatric Care and Nursing Homes (4 works) · Gerontology (4 works) · Business (3 works) · Primary care (3 works) · Psychology (3 works)

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