Once a month, health care professionals and community members invested in the health and wellness of our aging population, come together to plan and consider how to support, advocate for, and coordinate the regional programs and services designed to help aging adults thrive at home. They are the Aging Well at Home working group, a subgroup or branch of the Frontenac Lennox and Addington (FLA) Ontario Health Team (OHT).
The concept of region-based OHTs was introduced by the provincial government in February 2019. It is a new model of health care delivery that puts patients, families and their caregivers at the centre of the health care system. OHTs intend to improve the coordination of care between different health care settings and services, while emphasizing wellness and preventative health measures.
The FLA OHT’s Aging Well at Home working group includes members of Providence Care, the community, municipalities, and multiple other organizations like the Canadian Frailty Network (CFN).
Kyle Plumb is the project manager at CFN and sits on the Aging Well at Home working group. He says one of the biggest contributions his organization brings to the table is an inventory list, or database, of community-based supports and services.
“Access is difficult,” says Kyle. “CFN and the OHT are working to enhance accessibility to community-based, preventative, and behavioral supports for aging adults. The outcome of enhanced accessibility for community-based supports, such as the AVOID Frailty program, means reduced stress on medical and clinical-based supports.”
The AVOID Frailty program is newly launched and is in its developmental stage here in the KFL&A area. Older adults, 60 and above, are able to take an online self-assessment about their overall health and wellness and get a detailed report of what resources are best suited for them to stay healthy, living independently, and avoid frailty. After their self-assessment, they are also given access to the interactive and community based database that outlines all the community resources, services and programs available in KFL&A for aging adults.
AVOID is an acronym and a framework for healthy living. AVOID stands for activity, vaccination, optimizing medication, social interaction and diet. These four categories are evidence-based components known to prevent the onset of frailty.
“Frailty is a medical condition of reduced function. It means enhanced vulnerability to minor, medical issues like a fall, a cut or catching the flu. The risk of frailty increases with age but is not a part of regular aging and that is where our group’s expertise comes in to help,” explains Kyle.
The Aging Well at Home working group members also coordinates with Providence Care experts to support our aging population. Members of the AVOID Frailty program have access to in-person assessments on top of their self-responded survey. In-person assessments take place at Providence Care by a nurse and geriatrician, Dr. John Puxty who is the Director of the Centre for Studies in Aging and Health at Providence Care.
“The assessments provide community members with an in-person comprehensive geriatric assessment and evaluation which guides recommendations for them and their primary care provider, says Dr. Puxty. “The in-person assessment program started in March 2023, and since then we have had about 30 assessments with positive feedback. It provides an external validation of online self-assessments done previously.”
“A medical approach can’t be totally separate from a community-based approach to wellness,” adds Kyle. “Both need to work together in tandem. What we’d like to see is a full integration with all health teams. Where, if CFN can find a risk to an individual through our assessments we can point them to medical professionals and develop treatment plans together.”
Separate from CFN, Providence Care’s Dr. Sean Goldhar, a family physician in Care of the Elderly, is also involved in work being done in the Aging Well at Home group. Dr. Goldhar, in collaboration with the Loyalist Family Health Team, has established an embedded geriatric outreach model providing consultations and integrated support to the primary-care team supporting patients in our community.
“It is necessary to provide a coordinated approach from all levels of the health care system to support our aging population,” says Dr. Goldhar. “If we have accessible, preventative, community-based supports embedded within a patient’s ‘Health Home’, we have the opportunity to optimize health, reduce hospitalizations, and ultimately focus on what matters most to each individual.”
The Loyalist Family Health Team in partnership with the working group is putting on an upcoming event that will highlight current supports and programs available in the community. A Seniors Expo is set to take place on June 1 at the WJ Henderson Recreation Centre located at 322 Amherst Drive in Amherstview.
“Knowing where to turn for supports that not only encourage, but also inspire, aging adults to live a healthy lifestyle is how we support people to age well at home,” says Helen Cooper, a member of the Aging Well at Home working group.
Helen is also president of Oasis, a non-for-profit organization in Kingston offering a wide range of programming to older adults living in an apartment building in Kingston’s mid-town.
The goal of the Aging Well at Home working group is to support aging adults to live independently, maintain health and wellness and receive connected preventative, community-based care. This allows the OHT to achieve its goal of improved value of care, reducing the per capta cost of health care.
For more information on the Aging Well Together, Seniors Expo event visit: Seniors Expo – Loyalist Township
For more information on the Aging Well at Home working group and the AVOID Frailty program visit: Aging Well at Home – The Frontenac, Lennox & Addington Ontario Health Team (flaoht.ca)
Members of the Aging Well at Home working group include:
Indigenous community members, Loyalist Family Health Team, health care professionals like administration and Medical Doctors from Providence Care and Lennox & Addington County General Hospital. Members also represent the City of Kingston, Loyalist Township, Lennox & Addington Community Paramedicine, Rural Frontenac Community Services, Alzheimer’s Society, KFL&A Public Health, Home and Community Care, Kaymar, Community Rehabilitation, Queen’s University Health Sciences, St Elizabeth’s Research Institute and the Canadian Frailty Network.