Keeping our aging population healthy and engaged: facts and challenges

by Valérie Levert-Gagnon, Centretown Community Health Centre

Centretown is home to a diverse community. If you venture out in the neighbourhood, you may have noticed a significant proportion of older citizens.

In fact, 16.8 percent of Centretown’s population is aged over 60, according to the latest Ottawa Neighbourhood Study. While this percentage is in line with the city average, what makes our neighbourhood stand out is that 52.8 percent of seniors (aged 65 and older) living in Centretown live alone—twice the city’s average. Should these people need support to stay healthy and engaged in the community, they face more challenges than seniors with an established support network do.
In our neighbourhood, many vulnerable seniors with complex needs live on a low income. They cannot afford to pay for personal support or home support and struggle to purchase essential health care supplies.

It is also extremely challenging for seniors to navigate through and access the myriad of services and supports that enable them to live at home independently. Providers responsible for supporting seniors to navigate the system are themselves challenged to stay abreast of what services are available and to whom.

Many seniors in our catchment areas struggle with missed appointments, frequent ER visits, difficulty following medical directions, pain, food insecurity and chronic disease management (e.g., diabetes). They also face mental health and addictions issues and/or are experiencing cognitive decline.

We believe that community health centres (CHCs) are part of the solution, as they provide a comprehensive range of services to seniors in Ottawa. In addition to regular primary care services, CHCs adhere to a model of care that focuses on illness prevention, health promotion, community capacity building and service integration. However, it can be difficult to provide services when seniors are isolated.

To bridge the gap between isolated seniors in our community and our services, CHCs piloted a Primary Care Outreach Service (PCO) in 2008, operating from two CHCs—South-East Ottawa and Centretown. With successful results, the program has since expanded its operations to additional CHCs in the region, such as Carlington, Pinecrest-Queensway and Somerset West.

Within this program, registered nurses and community health workers work in partnership with patients’ physicians/nurse practitioners and other service providers in the community to provide care and appropriate support to enable vulnerable seniors with complex needs to live at home independently with assurance and dignity. This includes help with medications, chronic illness management, travel to medical appointments, assistance with documentation completion, home safety assessments, cognitive screenings, help to get a primary care provider, health system navigation, case management, referrals to supportive community programs and help to access housing support services.

PCO offers services to people who suffer from declining physical and cognitive health, live in isolation or have compromised care or support, have challenges accessing and/or maintaining a relationship with a primary care provider, and have no or limited services and support in place.

Our clientele may also have significant barriers to accessing services and support, and make unnecessary use of the health system. This can mean visits to the emergency room for non-urgent needs.

In addition to seniors’ outreach, CHCs also offer free exercise classes for seniors, cooking groups and transportation for seniors (60+) to a local grocery store and shopping mall (from the Somerset West CHC).

With reduced resources in community support at municipal and provincial levels, the demand for community health centre services is constantly growing. It is becoming increasingly difficult to offer this range of services with limited resources. CHCs now need to rely on other community support services to deliver high-quality care to seniors in our community. Currently, we lack the resources to help those living with major health issues such as bed bugs and hypertension.

As the provincial government transitions the community care access centres (CCACs) to the local health integration networks (LHINs) in 2017, it is hopefully an opportunity to improve care coordination and home support services by integrating them within team-based community health services. That way, seniors get the right care at the right place at the right time. The federal government has also expressed its intention to invest in home support services. It is vital that we remind them of the importance of integrated care at the community level.

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This column is a collaboration between the Centretown and Somerset West Community Health Centres (CHCs). They provide a full range of health and social services to individuals and families. Through leadership and support, they foster the active participation of individuals and groups in a common effort to build healthier communities.