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Sheth MS, Rochon PA, Altaf A, Boblitz A, Bronskill SE, Brown KA, Hahn-Goldberg S, Huynh T, Lewis-Fung SE, Feng P, Savage RD. Factors associated with transition to a nursing home in older adults living in naturally occurring retirement communities. J Am Geriatr Soc 2024. [PMID: 38888381 DOI: 10.1111/jgs.19038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Revised: 05/03/2024] [Accepted: 05/09/2024] [Indexed: 06/20/2024]
Abstract
BACKGROUND Naturally occurring retirement communities (NORCs) are geographic areas (generally high-rise buildings or neighborhoods) that have a high concentration of individuals 65 years and older. Supportive service programs in NORCs can address resident needs and delay nursing home (NH) admission but understanding what factors are associated with NORC residents requiring NH admission is needed to tailor such programs. Our aim was to examine individual- and neighborhood-level factors associated with NH wait-list status in NORC residents in Ontario. METHODS We conducted a population-based, cross-sectional study of Ontario adults 65 years of age or older living in a NORC building as of January 1, 2020, by linking a provincial registry of NORC high-rise buildings with health administrative data. Older adults were classified as being on the NH wait-list if they had an open application for a NH on the index date. We conducted a multilevel logistic regression analysis using generalized estimating equations to determine individual- and neighborhood-level factors associated with NH wait-list status, including sociodemographic, clinical, healthcare use, and building factors. We explored the role of sex and age through stratification by sex (male, female) and age (65-80 and 80+ years). RESULTS Among 220,864 NORC residents, 4710 individuals (2.1%) were on the NH wait-list. Female sex, older age, immigrant status, dementia diagnosis, receiving homecare, multimorbidity, and polypharmacy (five or more unique drug names) were associated with an increased odds of wait-list status. Several neighborhood-level variables were associated with a significantly increased likelihood of wait-list status, including low income, high dependency, high ethnic diversity, and living in a building with supports. CONCLUSION NORC supportive service programs can be tailored to account for the factors associated with NH wait-list status, allowing NORC residents who are living in the community to age in their desired place and achieve optimal health outcomes.
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Affiliation(s)
- Maya S Sheth
- Women's Age Lab, Women's College Hospital, Toronto, Ontario, Canada
- Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Paula A Rochon
- Women's Age Lab, Women's College Hospital, Toronto, Ontario, Canada
- Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Division of Geriatric Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | | | | | - Susan E Bronskill
- Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Kevin A Brown
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Public Health Ontario, Toronto, Ontario, Canada
| | - Shoshana Hahn-Goldberg
- NORC Innovation Centre, University Health Network, Toronto, Ontario, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Tai Huynh
- NORC Innovation Centre, University Health Network, Toronto, Ontario, Canada
| | | | - Patrick Feng
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Rachel D Savage
- Women's Age Lab, Women's College Hospital, Toronto, Ontario, Canada
- Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
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Sheppard CL, Hemphill J, Austen A, Hitzig SL. Designing and Implementing a New Seniors Services Coordinator Role for Low-Income Housing: A Qualitative Study. JOURNAL OF GERONTOLOGICAL SOCIAL WORK 2023; 66:83-102. [PMID: 36124399 DOI: 10.1080/01634372.2022.2118920] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 08/24/2022] [Accepted: 08/25/2022] [Indexed: 06/15/2023]
Abstract
Older adults living in social housing are disproportionally impacted by poverty, social isolation, and chronic health conditions that negatively impact their housing stability. In response, service coordination models of care that provide proactive case management have seen widespread adoption across low-income seniors housing communities. We examined the design and implementation of a new "seniors services coordinator" (SSC) role that was introduced by a social housing provider in Toronto, Canada. We conducted qualitative focus groups with tenants (n = 16), housing and policy staff (n = 16), and government-funded care coordinators (n = 16) to understand how the new SSC position formed relationships with tenants, assessed tenant needs and coordinated services, and built partnerships with government-funded system navigators. Since staff were assigned to specific buildings and had smaller caseloads, stakeholders felt that the SSC would be well positioned to build relationships of trust with tenants. Histories of mistrust, boundaries and time management, role conflicts, and system-level barriers, however, made it difficult for SSCs to fully carry out their role. Our findings highlight several design and implementation considerations that may impact the success of tenant-facing support staff such as SSCs, which can serve as a roadmap for other housing providers looking to implement similar initiatives.
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Affiliation(s)
- Christine L Sheppard
- St. John's Rehab Research Program, Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Canada
- Wellesley Institute, Toronto, Canada
- Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, Canada
| | - Julia Hemphill
- St. John's Rehab Research Program, Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Andrea Austen
- Seniors Services and Long-Term Care, City of Toronto, Toronto, Canada
| | - Sander L Hitzig
- St. John's Rehab Research Program, Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Canada
- Department of Occupational Science and Occupational Therapy, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
- Rehabilitation Sciences Institute, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
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Access to Community Support Services among Older Adults in Social Housing in Ontario. Can J Aging 2022; 42:217-229. [PMID: 36373328 DOI: 10.1017/s0714980822000332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Abstract
Community support services are an integral enabler of aging in place. In social housing, older adult tenants struggle to access these services because of the siloed nature of housing and health services. This study examined the provision of government-funded community support services to 83 seniors’ social housing buildings in Toronto, Ontario. Although there were 56 different agencies operating within the buildings, only about one third of older tenants were actually receiving services. There was a subset of services that were available in more than 80 per cent of the buildings, and the most widely accessed services were food supports, crisis intervention, transportation, caregiver support, and hearing/vision care. There were also many cases in which multiple agencies offered duplicative services within the same building, suggesting that there are opportunities for improving service coordination. Practice recommendations for increasing access to community support services among low-income older adults in social housing are provided.
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Boll AM, Ensey MR, Bennett KA, O'Leary MP, Wise-Swanson BM, Verrall AM, Vitiello MV, Cochrane BB, Phelan EA. A Feasibility Study of Primary Care Liaisons: Linking Older Adults to Community Resources. Am J Prev Med 2021; 61:e305-e312. [PMID: 34497030 DOI: 10.1016/j.amepre.2021.05.034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 05/10/2021] [Accepted: 05/12/2021] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Programs and services available through the aging services network can help community-dwelling older adults to age in place but are often not discussed in routine primary care. The primary care liaison was developed as a novel integration intervention to address this disconnect. METHODS Employed by an Area Agency on Aging, primary care liaisons performed outreach to primary care with the goal of raising awareness of community-based programs, resources, and services available to older adults and their caregivers and facilitating referrals. The evaluation of the primary care liaison model, conducted from December 2015 to February 2019, used the Reach, Effectiveness, Adoption, Implementation, Maintenance framework and assessed reach (number of clinics contacted), adoption (number of referrals to the Area Agency on Aging), implementation (number of follow-up contacts with a practice), and effectiveness (proportion of referrals reached and provided relevant resources). RESULTS The primary care liaisons contacted a median of 18.5 clinics per month (IQR=15-31). Primary care referrals averaged >100 per month, and referrals increased over time. Successful follow-up outreach visits had a median of 3 (IQR=2-10), and follow-up contacts had a median of 3 (IQR=1-7) per practice. Three quarters of caregivers for people with dementia reached by Area Agency on Aging staff were provided with information about relevant resources. CONCLUSIONS The primary care liaison model is feasible, fosters ongoing interactions between primary care and Area Agencies on Aging, and connects older adults and their caregivers to relevant programs and services. Adoption of the primary care liaison model by other Area Agencies on Aging across the U.S. may help further the vision of optimized health and well-being of older adults.
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Affiliation(s)
- Allison M Boll
- Aging and Disability Services (ADS) Seattle King-County, Seattle, Washington
| | - Melissa R Ensey
- Area Agency on Aging & Disabilities of Southwest Washington, Vancouver, Washington
| | - Katherine A Bennett
- Division of Gerontology and Geriatric Medicine, Department of Medicine, University of Washington, Seattle, Washington
| | - Mary P O'Leary
- Aging and Disability Services (ADS) Seattle King-County, Seattle, Washington
| | | | - Aimee M Verrall
- Division of Gerontology and Geriatric Medicine, Department of Medicine, University of Washington, Seattle, Washington.
| | - Michael V Vitiello
- Department of Psychiatry & Behavioral Sciences, University of Washington, Seattle, Washington
| | - Barbara B Cochrane
- Department of Child, Family, and Population Health Nursing, University of Washington, Seattle, Washington
| | - Elizabeth A Phelan
- Division of Gerontology and Geriatric Medicine, Department of Medicine, University of Washington, Seattle, Washington; Department of Health Services, School of Public Health, University of Washington, Seattle, Washington
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Levinger P, Parker A, Barry J, Tan E, Batchelor F, Catrice A. Development of a Victorian Falls and Balance Service Directory. Australas J Ageing 2021; 41:138-146. [PMID: 34708893 DOI: 10.1111/ajag.13004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 09/12/2021] [Accepted: 09/14/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Falls and fall-related injuries amongst older people continue to be a long-term public health issue. Access to specialist services that target fall prevention has been shown to improve outcomes. This project aimed to develop an online directory of public outpatient and ambulatory falls and balance clinics and programs in Victoria. METHOD Environmental scan of existing services and survey of service providers between January and August 2020. RESULTS Forty-seven community-based and 53 hospital-based falls and balance services across metropolitan (46%) and regional (54%) Victoria registered. The majority of services were programs (70%) targeting exercise and/or education, as opposed to clinics (30%), which focus on diagnosis and developing management plans. Survey responses were collated to develop an online service directory: https://www.nari.net.au/victorian-falls-directory CONCLUSION: The Victorian Falls and Balance Service Directory provides a centralised and accessible reference for clinicians and community members regarding available outpatient and ambulatory services that target fall prevention.
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Affiliation(s)
- Pazit Levinger
- National Ageing Research Institute, Melbourne, Victoria, Australia.,Institute for Health and Sport, Victoria University, Melbourne, Victoria, Australia.,Rehabilitation, Ageing and Independent Living Research Centre, Monash University, Melbourne, Victoria, Australia
| | - Amy Parker
- National Ageing Research Institute, Melbourne, Victoria, Australia
| | - Jess Barry
- National Ageing Research Institute, Melbourne, Victoria, Australia
| | - Esther Tan
- National Ageing Research Institute, Melbourne, Victoria, Australia
| | - Frances Batchelor
- National Ageing Research Institute, Melbourne, Victoria, Australia.,Department of Physiotherapy, The University of Melbourne, Melbourne, Victoria, Australia
| | - Andre Catrice
- Health and Community Ageing, Aged Care Branch, Victorian Department of Health, Melbourne, Victoria, Australia
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Valaitis R, Gaber J, Waters H, Lamarche L, Oliver D, Parascandalo F, Schofield R, Dolovich L. Health TAPESTRY: Exploring the Potential of a Nursing Student Placement Within a Primary Care Intervention for Community-Dwelling Older Adults. SAGE Open Nurs 2021; 6:2377960820909672. [PMID: 33415272 PMCID: PMC7774422 DOI: 10.1177/2377960820909672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2019] [Revised: 01/29/2020] [Accepted: 02/04/2020] [Indexed: 12/03/2022] Open
Abstract
The increasing prevalence of chronic diseases in aging places demands on
primary care. Nurses are the major nonphysician primary care
workforce. Baccalaureate nursing programs should expose students to
primary care and older adults to support these demands and help
recruit new graduates to this setting. However, many baccalaureate
nursing programs focus on acute care and placements aimed at older
adults are viewed negatively. To address these curriculum challenges,
third-year Canadian baccalaureate nursing students were placed in an
innovative primary care program—Health TAPESTRY—for community-dwelling
older adults. Health TAPESTRY involves an interprofessional primary
care team, trained lay volunteers conducting home visits, system
navigation, and an online software application. The goal of this study
was to explore third-year baccalaureate nursing students’ perceptions
of this unique clinical primary care placement. This qualitative
descriptive study explored students’ perceptions of this placement’s
strengths, weaknesses, opportunities, threats (SWOT), and outcomes.
Nursing students participated in focus groups
(n = 14) or an interview (n = 1) and
five completed narrative summaries following visits. Qualitative
content analysis was supported by NVivo 10. Strengths of the clinical
placement included training for the intervention; new insights about
older adults; and experience with home visiting, interprofessional
team functions, and community resources. Weaknesses included limited
exposure to older adult clients, lack of role clarity, lack of
registered nurse role models, and technology challenges. Opportunities
included more exposure to primary care, interprofessional teams, and
community resources. No threats were described. Nursing students’
clinical experiences can be enhanced through engagement in innovative
primary care programs. Adequate exposure to clients, including older
adults; interprofessional teams; mentoring by registered nurses or
advanced practice nurse preceptors; and role clarity for students in
the primary care team should be considered in supporting baccalaureate
nursing students in primary care clinical placements.
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Affiliation(s)
- Ruta Valaitis
- School of Nursing, McMaster University, Hamilton, Ontario, Canada
| | - Jessica Gaber
- Department of Family Medicine, McMaster University, David Braley Health Sciences Centre, Hamilton, Ontario, Canada
| | - Heather Waters
- Department of Family Medicine, McMaster University, David Braley Health Sciences Centre, Hamilton, Ontario, Canada
| | - Larkin Lamarche
- Department of Family Medicine, McMaster University, David Braley Health Sciences Centre, Hamilton, Ontario, Canada
| | - Doug Oliver
- Department of Family Medicine, McMaster University, David Braley Health Sciences Centre, Hamilton, Ontario, Canada
| | - Fiona Parascandalo
- Department of Family Medicine, McMaster University, David Braley Health Sciences Centre, Hamilton, Ontario, Canada
| | - Ruth Schofield
- School of Nursing, McMaster University, Hamilton, Ontario, Canada
| | - Lisa Dolovich
- Department of Family Medicine, McMaster University, David Braley Health Sciences Centre, Hamilton, Ontario, Canada
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Valaitis R, Cleghorn L, Ploeg J, Risdon C, Mangin D, Dolovich L, Agarwal G, Oliver D, Gaber J, Chung H. Disconnected relationships between primary care and community-based health and social services and system navigation for older adults: a qualitative descriptive study. BMC FAMILY PRACTICE 2020; 21:69. [PMID: 32326880 PMCID: PMC7181491 DOI: 10.1186/s12875-020-01143-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Accepted: 04/15/2020] [Indexed: 11/24/2022]
Abstract
Background There are gaps in knowledge and understanding about the relationships between primary care and community-based health and social services in the context of healthy aging at home and system navigation. This study examined provider perspectives on: a) older adults’ health and social needs; b) barriers to accessing services; c) the nature of relationships between primary care and health and social services; and d) ways to facilitate primary care and health and social services navigation to optimize older adults’ health. Methods Four focus groups were conducted involving providers (n = 21) in: urban primary care clinics and health and social services organizations serving older adults in Hamilton, Ontario, Canada. Purposive sampling was employed to recruit community health and social services managers, directors or supervisors and primary health care providers in a Family Health Team via email. Results Health and social services needs were exacerbated for community-dwelling older adults with multiple chronic conditions. Strong family/caregiver social support and advocacy was often lacking. Access barriers for older adults included: financial challenges; lack of accessible transportation; wait times and eligibility criteria; and lack of programs to address older adults’ needs. Having multiple providers meant that assessments among providers and older adults resulted in contradictory care pathways. Primary care and health and social services linkages were deficient and complicated by poor communication with patients and health literacy barriers. Primary care had stronger links with other health services than with community-based health and social services; primary care providers were frustrated by the complex nature of health and social services navigation; and care coordination was problematic. Health and social services referred older adults to primary care for medical needs and gathered patient information to gauge program eligibility, but not without challenges. Conclusions Results point to strategies to strengthen primary care and health and social services system navigation for older adults including: using a person-focused approach; employing effective primary care and health and social services communication strategies; applying effective system navigation; building trust between primary care and health and social services providers; advocating for improved program access; and adapting services/programs to address access barriers and meet older adults’ needs.
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Affiliation(s)
- Ruta Valaitis
- Aging Community and Health Research Unit, School of Nursing, McMaster University, HSC 3N25, 1280 Main Street West, Hamilton, ON, L8S4K1, Canada.
| | - Laura Cleghorn
- Department of Family Medicine, McMaster University, David Braley Health Sciences Centre, 100 Main Street West, 5th floor, Hamilton, ON, L8P 1H6, Canada
| | - Jenny Ploeg
- Aging Community and Health Research Unit, School of Nursing, McMaster University, HSC 3N25, 1280 Main Street West, Hamilton, ON, L8S4K1, Canada
| | - Cathy Risdon
- Department of Family Medicine, McMaster University, David Braley Health Sciences Centre, 100 Main Street West, 5th floor, Hamilton, ON, L8P 1H6, Canada
| | - Derelie Mangin
- Department of Family Medicine, McMaster University, David Braley Health Sciences Centre, 100 Main Street West, 5th floor, Hamilton, ON, L8P 1H6, Canada
| | - Lisa Dolovich
- Department of Family Medicine, McMaster University, David Braley Health Sciences Centre, 100 Main Street West, 5th floor, Hamilton, ON, L8P 1H6, Canada
| | - Gina Agarwal
- Department of Family Medicine, McMaster University, David Braley Health Sciences Centre, 100 Main Street West, 5th floor, Hamilton, ON, L8P 1H6, Canada
| | - Doug Oliver
- Department of Family Medicine, McMaster University, David Braley Health Sciences Centre, 100 Main Street West, 5th floor, Hamilton, ON, L8P 1H6, Canada
| | - Jessica Gaber
- Department of Family Medicine, McMaster University, David Braley Health Sciences Centre, 100 Main Street West, 5th floor, Hamilton, ON, L8P 1H6, Canada
| | - Harjit Chung
- School of Nursing, McMaster University, HSC 3N25, 1280 Main Street West, Hamilton, ON, L8S4K1, Canada
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Ploeg J, Valaitis RK, Cleghorn L, Yous ML, Gaber J, Agarwal G, Kastner M, Mangin D, Oliver D, Parascandalo F, Risdon C, Dolovich L. Perceptions of older adults in Ontario, Canada on the implementation and impact of a primary care programme, Health Teams Advancing Patient Experience: Strengthening Quality (Health TAPESTRY): a descriptive qualitative study. BMJ Open 2019; 9:e026257. [PMID: 31201187 PMCID: PMC6575818 DOI: 10.1136/bmjopen-2018-026257] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
OBJECTIVES The aim of the study was to explore the perceptions of older adults on the implementation and impact of Health Teams Advancing Patient Experience: Strengthening Quality (Health TAPESTRY), a multicomponent primary care programme that seeks to improve care coordination for individuals through health-related goal-setting supported by trained lay volunteers who are an extension of an interprofessional team, and the use of technology to support communication among the team. DESIGN This study used a qualitative descriptive design. SETTING The setting for this study was two primary care practice sites located in a large urban area in Ontario, Canada. PARTICIPANTS The sample consisted of community-dwelling older adults aged 70 years and older. Participants were recruited from a convenience sample obtained from 360 clients who participated in the 12-month Health TAPESTRY randomised controlled trial. METHODS Semistructured interviews were conducted with 32 older adults either face-to-face or by telephone. Interviews were transcribed verbatim. Data were analysed using a constant comparative approach to develop themes. RESULTS Older adults' perceptions about the Health TAPESTRY programme included (1) the lack of a clear purpose and understanding of how information was shared among providers, (2) mixed positive and negative perceptions of goal-setting and provider follow-up after inhome visits by volunteers, (3) positive impacts such as satisfaction with the primary care team, and (4) the potential for the programme to become a regular programme and applied to other communities and groups. CONCLUSIONS Older adults living in the community may benefit from greater primary care support provided through enhanced team-based approaches. Programmes such as Health TAPESTRY facilitate opportunities for older adults to work with primary care providers to meet their self-identified needs. By exploring perceptions of clients, primary care programmes can be further refined and expanded for various populations.
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Affiliation(s)
- Jenny Ploeg
- School of Nursing, McMaster University, Hamilton, Ontario, Canada
| | | | - Laura Cleghorn
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Marie-Lee Yous
- School of Nursing, McMaster University, Hamilton, Ontario, Canada
| | - Jessica Gaber
- Department of Family Medicine, McMaster University Faculty of Health Sciences, Hamilton, Ontario, Canada
| | - Gina Agarwal
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Monika Kastner
- Research and Innovation, North York General Hospital, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Dee Mangin
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Doug Oliver
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Fiona Parascandalo
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Cathy Risdon
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Lisa Dolovich
- Department of Family Medicine, McMaster University/McMaster Innovation Park, Hamilton, Ontario, Canada
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