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

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 housing buildings in Toronto for over four years has been very challenging, not solely due to the COVID 9 pandemic. Various challenges have included complex tenant issues, integrating workflows and accountability between organizations, and secure communication between team members and other sectors involved in tenants care and services. Tenant issues include difficulties with social determinants of health, mental health and addictions, new onset or progression of neurocognitive disorders, lack of family supports, poor access to preventive and responsive care, issues related to capacity to make personal care decisions and hoarding and pest infestation issues. Iterative interprofessional and inter-organizational collaboration with tenants has led to a wide range of initiatives and programs to address identified tenant needs. Although we have implemented many successful strategies and processes, earlier identification of tenant needs and ensuring consistent, timely and coordinated responses remain persistent challenges. As our tenant advisor stated we are missing the wake-up calls by tenants for earlier intervention to facilitate successful aging in place.We would like to engage with people who have first hand experience living or working with more vulnerable populations to share additional engagement strategies and initiatives that have been successful and any additional barriers they have experienced. This includes people living in the community and their families, primary care providers (interprofessional), community and home care providers, mental health and addictions providers, hospital staff and administrators, paramedics, and housing coordinators and administrators.Workshop 60 minutes:Introduction to the Neighbourhood Care Team model and its development - 5 minutesSuccessful engagement strategies and resulting initiatives to enhance tenant outcomes - 0 minDemonstrate barriers and challenges that limit earlier identification and coordinated responses through a case study - 0 minSmall groups - each group addressing one of the barriers/challenges and working on possible solutions based on the case study presented - 20 minGroup feedback: 0 minutesClosing: 5 minutesParticipants will listen and respond to the case study and then collaborate in small working groups to brainstorm new and creative strategies to address the challenges as well as share experiences to inform possible solutions to the barriers/challenges highlighted in the case study. We will summarize the large group list of successful engagement strategies with vulnerable populations, and the processes and pathways needed to identify and respond to their health and social needs in a timely, coordinated and consistent fashion to optimize health outcomes. We will generate a summary of the group discussion which we will share with the participants at the end of the workshop through a shared link. Following the workshop we will encourage attendees to try implement solutions recommended so that we can build knowledge on how to best integrate care and social services at this local high needs population level

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