title: Integrated client care for frail older adults in the community: preliminary report on a system-wide approach.
abstract: The Toronto Central Community Care Access Centre is leading a collaborative local health integration network systemic change initiative to implement and evaluate a practical model of integrated care for older adults with complex needs. The approach is embedded in the community where older adults and their families live and is designed to first and foremost improve the quality of care while ultimately bending the cost curve. The model is leveraging and aligning existing system resources by bringing together sectors from across the health system to create ways of working that build capacity in the system to be more responsive to this population. Outcomes to date will be discussed and next steps described. The secondary goal was to understand the key elements of this integration that can be scaled locally and across the province.
authors.affiliation: Lead for Health System Integration for complex Populations and Primary Care at the Toronto Central CCAC. She is an innovative leader and has considerable strength in facilitating transformational and complex change across multiple interests and stakeholders.
authors.forename: Jodeme
authors.initials: J
authors.lastname: Goldhar
authors.affiliation: Senior executive with over 20 years of experience in healthcare delivery and design. Currently the CEO of the Toronto Central Community Care Access Centre (CCAC), Stacey leads a large community-based healthcare organization that provides healthcare and support services to the citizens of Toronto.
authors.forename: Stacey
authors.initials: S
authors.lastname: Daub
authors.affiliation: Previously served as a medical advisor to the Toronto Central Community Care Access Centre. He is currently vice-president, Health System Performance at Health Quality Ontario, and he continues to care for patients and teach medical students and residents at St. Michael's Hospital and the University of Toronto, where he is an assistant professor in the Department of Medicine and the Institute of Health Policy, Management and Evaluation.
authors.forename: Irfan
authors.initials: I
authors.lastname: Dhalla
authors.affiliation: An associate professor at the University of Toronto, holds the Fidani Chair, Improvement and Innovation with the Department of Family and Community Medicine. He is a medical advisor to the Toronto Central CCAC with a special interest in new models and strategies for healthcare delivery in the community.
authors.forename: Philip
authors.initials: P
authors.lastname: Ellison
authors.affiliation: Beginning as a care coordinator with the Toronto CCAC and advancing through the ranks to her current position as senior director of Client Services. Dipti holds a Master of Health Administration from the University of Toronto and remains a Registered Nurse with the College of Nurses of Ontario.
authors.forename: Dipti
authors.initials: D
authors.lastname: Purbhoo
authors.affiliation: Director of Geriatrics at Mount Sinai and the University Health Network Hospitals and an assistant professor of Medicine, Family and Community Medicine and Health Policy, Management and Evaluation at the University of Toronto. In 2012, Dr. Sinha was also appointed by the Minister of Health to serve as the inaugural Provincial Lead of Ontario's Seniors Strategy.
authors.forename: Samir K
authors.initials: SK
authors.lastname: Sinha
mesh_terms: D000368:Aged; D003695:Delivery of Health Care / Q000458:organization & administration; D019033:Delivery of Health Care, Integrated / Q000458:organization & administration*; D016330:Frail Elderly; D006299:Health Services for the Aged / Q000458:organization & administration*; D006801:Humans; D017146:Models, Organizational; D009864:Ontario; D016730:Program Development; D015397:Program Evaluation