Community Health Teams (CHT) is a team-based model care model that enables older adults with moderate levels of frailty to live at home for as long as possible. The model encourages a preventative approach to healthcare, evolving community-based care and supporting clinically and socially frail older adults through the provision of integrated health supports and social care coordination. The emphasis is on identifying frailty earlier to improve the person’s health outcomes by shifting existing resources upstream to delay, stabilize or reverse declining function and ultimately shifting the trajectory away from avoidable higher levels of care. The model requires OHT-ÉSO partners to collaborate in simplifying the current system and work differently to provide more integrated and responsive care to support for FOAs. ​

Goals of the Pilot

• Improve accessibility and service availability for FOAs by implementing a coordinated, team-based approach and connecting them with comprehensive services in their local area through the deployment of Health and Social Facilitators who offer community support in their homes​.
• Develop targeted preventive interventions for FOAs to enable them to continue living independently at home, facilitated by the establishment of a standardized frailty screening process for FOAs.
• Build Capacity to improve specialized care services for FOAs.​

Key Learnings

• Comprehensive system navigation support improves access to essential services. Facilitating streamlined access to care and services was pivotal in achieving positive health outcomes for clients.
• The integration of pragmatic support significantly improved health outcomes. Tailoring practical support to account for social determinants of health (SDOH) and meet the specific needs of clients enhances the overall effectiveness of health interventions.
• Establishing and maintaining strong referral systems is vital. Continuous communication and alignment with referral sources are essential for optimizing client sourcing and ensuring seamless CHT model implementation.
• Standardizing technology and data management practices across partners enhances operational efficiency and minimizes redundant efforts.