Background:
The authors used co-design to fill gaps in primary care for a semi-rural county in Ontario, Canada. Bringing together leaders and front-line providers from multiple organizations including primary care, mental health, elder care, and social supports, the team identified local gaps, brainstormed solutions, and developed three service models tailored to the local community. In this workshop they will focus on one: a service to support older adults in planning for long-term independence.

Audience:
Community members, providers (including: mental health & addictions, social services, and emergency services), administrators, policy makers, researchers, patients, and family care partners. This workshop will be exciting for people with an interest in primary care, elder care, co-design, or localization of services.

Approach:
In this workshop we will present our project process, outcomes, and engage workshop participants in a facilitated discussion about adapting services to local community needs.

[See: Workshop Synopsis for more information and proposed time allocations]

Outcomes:
The participants will learn strategies for adapting health services to local populations. They will consider how to apply those strategies to their local context and discuss their learnings with other participants. They will also learn about the value of co-design as a tool to achieve these goals.

Background:
Of the 75,000 patients aged over 20 years registered with a GP in Crewe, around 20,000 live in the highest 20% of national socio-economic deprivation.
Unmet need is demonstrated by patients presenting in crisis, unplanned admissions and emergency care, prolonged admissions, delayed hospital discharge, late diagnosis of significant health conditions, patients with reduced life expectancy
Our aim was to understand the problems and barriers in accessing support, enable engagement with the services, and reduce demand on emergency and unscheduled care.
Approach:
We applied and were awarded funding of £120,000 from the Better Care Fund, the requirement that our project aligned to the frailty agenda and was tailored to the local population health needs.
We involved:
Transformation and Population Health Project Manager - to identify cohort of patients to invite, and to establish Information Governance rules.
Care Community Operational and Support Managers - to project manage and lead on staff team recruitment which includes: Care Coordinator, Physiotherapist and assistant, dietician, social prescriber and GP, each leading 4 stations at the clinic.
District Nurse Team - experienced in establishing a Leg Club model successfully increasing recovery and wellbeing.
Care Community Clinical Lead - establishing clinic operation and liaison with secondary care Frailty Team.
PCN Manager - good communication and Data Sharing Agreements with all 5 GP practices.
Community and Voluntary Services - to establish their involvement.
Patients - experience of those attending the Leg Club.
We used CIPHA (Combined Intelligence for Population Health Action) to identify patient cohort, looking at Patient Need Group and Resource Utilisation Data, selecting patients mainly from Patient Need Group 5 and those in the highest resource utilisation band.
The clinic is a 3 hour session, with patients personally invited and welcomed, spending time at each of the 4 stations and time with other services present.
Results:
Over 50% of those patients identified and contacted attended. Feedback obtained from all attending showed recurring themes. Patients valued time in a non-medical setting to discuss the issues important to them such as poor mobility, loss of confidence, poverty, loneliness and low mood or motivation.
With each professional using the patient centred care model, they were enabled to engage with support appropriate to them.
The 12 month resource utilisation data showed overall reduction in unplanned emergency care service utilisation for all cohorts of patients who had attended the intervention.
Implications:
With feedback we changed the clinics location, retaining a community non-medical setting, improving access and privacy requirements.
Workforce support to align with the clinic ethos and aims for positive patient and carer experience was crucial.
How it was presented to patients was important. We understood the term Frailty, but it was a barrier for patients. We changed the F in CFOSS to “Focussed”.
We plan to extrapolate the model in line with the NHS 10 year plan, local service transformation and our specific population health needs.
By identifying other cohorts of patients with, for example respiratory illness, mental health, orthopaedic or vascular disease should be successful in changing patient outcomes.

Background: The Community Wellness Hub (CWH) model is a proven integrated care approach that coordinates the providers of health, wellness, housing, and social services to deliver integrated and collaborative care to older adults made vulnerable by social determinants of health. This innovative approach addresses many health system challenges including access, social isolation, and high utilization of costly health services such as emergency care and long-term care. Having now successfully implemented and scaled this model to seven unique locations, we recognize and wish to explore the applicability of this model for other priority populations including at-risk youth, rural seniors, and immigrant or newcomer communities. In this workshop, we will provide a brief overview of the CWH model and then join in population-focused, round table discussions to explore how the model could be adapted to meet the needs of priority populations.

Developed collaboratively by the Burlington Ontario Health Team (BOHT) and Halton Community Housing Corporation (Ontario, Canada), the CWH model was created to better coordinate care and supports for older adults. Since 2019, CWHs have been established in Burlington, Hamilton, and Oakville, Ontario, with growing interest from other regions. In collaboration with Davis Pier, a professional services firm specializing in social impact and public sector transformation, BOHT has captured the model’s essence in a standardized implementation guide and articulated its value through a business case. Elements from these resources will be incorporated into our workshop to support small-group discussions and illustrate tangible steps for scaling and spreading the CWH model to new contexts. While the conference will feature many examples of integrated care models, this workshop offers a distinct opportunity to build on practical experience implementing the CWH model and explore how its principles can be tailored to the unique needs and priorities of specialized populations.

Audience:
This workshop is designed for anyone interested in or with experience to share on integrated care models for priority populations, including older adults, care partners, integrated care leaders and providers, policymakers, and researchers.
Approach:
This 90-minute workshop will include:
1. Introduction and background (25 mins): i. Share the background of the CWH model and its essential components and principles; ii. Review scale and spread progress to date within the Ontario, Canada context for older adult population; iii. Discuss dissemination and implementation strategies employed to date.
2. Objectives and group set-up (5 mins): Participants divide into three groups focused on at-risk youth, rural seniors, or newcomers/immigrants.
3. Small group discussions (40 mins): Each group will explore: Relevance and adaptability of the core and peripheral components of the model; Important partnerships to support needs across the social determinants of health; Potential barriers, facilitators and strategies for implementation.
4. Share back (15 mins): Facilitated discussion to hear small group insights.
5. Closing (5 mins): Summary of key takeaways and resources shared via QR code.
Outcomes:
Participants will gain practical insights into how adaptable, partnership-driven approaches like the CWH can inform the design and sustainability of integrated care models for diverse priority populations.

Background
The risks for developing chronic conditions are often rooted in a person’s lifestyle as well as their cultural, social, and physical environment. Many people live with multiple conditions that are commonly treated as individual conditions without consideration of the person’s health and social context. To meaningfully improve health outcomes, care must extend beyond traditional healthcare settings to ensure a comprehensive, holistic, and integrated, team-based approach to chronic disease management within the community.

Approach
The North Toronto Neighbourhood Care Team (NT NCT) is an integrated outreach model that unites organizations across sectors to work collaboratively with clients in the community specifically supporting low-income seniors living in Toronto Seniors Housing Corporation (TSHC) buildings. Through a co-design process with community members and system partners, we developed “user stories” from both tenant and stakeholder perspectives to guide the design and implementation of a proactive, on-site chronic disease management clinic within the buildings where tenants live. These clinics bring together diverse health and community providers to support early identification and holistic management of chronic conditions while addressing associated risk factors and social determinants of health.

Results
The team proactively screened 193 tenants, 48% of whom presented with three or more comorbidities. Through community-based chronic disease management clinics, the team addressed key risk factors and supported improved health management, including tenants not yet engaged with formal healthcare services. This proactive, localized approach helped improve risk identification, health literacy and co-management to reduce unnecessary complications, prevent deconditioning and optimize health outcomes.

Implications
This model highlights the critical importance of early identification through proactive screening and team-based person-centred intervention in chronic disease management. It demonstrates how integration, attention to local context, and the development of trusted relationships can meaningfully improve health outcomes. The presentation will share key factors contributing to the model’s success, along with the care planning tools and assessment approaches developed to sustain and scale its impact.

Background: Integrated care developments recognise the importance of improving access to formal health and social care support to address health inequalities, and in coordinating with Voluntary, Community, Faith and Social Enterprise sector (VCFSE) resources, but understanding how best to do this within different locations is not yet known. This research evaluated Community ‘Hubs’ set up to provide social care for diverse communities in UK local public ‘third’ spaces (e.g. libraries, community centres, football clubs, foodbanks and supermarket cafés) which are open spaces for the public. Hubs take a systems-level, strengths-based approach where local authority social care, health services and VCFSE organisations work together to engage people with formal and informal support services. This builds on community and individual well-being and social capital. The presentation will include both academic and a colleague with lived experience sharing research findings and practical examples highlighting what we can learn for good practice.
Approach: The research was guided by; a group of people with lived experience of social care, practice organisations, and human geography’s Third Space theory (Oldenburg 1999). It used a mixed methods study design which included ethnographic observations of hubs across four case study sites, surveys with hubs attendees, interviews with multi-agency staff and hub volunteers.
Results: Community hubs can be beneficial for people needing support and can change the ways communities access support services. Hub location is crucial for the inclusion of different communities. This relates to the type of space occupied, physical accessibility, the primary use of the building, the resources and organisations within it, geographic location and routes the hub is on. We relate this to the social capital for included and excluded communities. The research highlights how hubs enabled service providers to become more embedded in communities and therefore offer tailored supports for specific groups accessing hubs.
Implications: Service providers should consider: the hub's geographic location; the space’s primary purpose; how and by which services it is populated; how attendees navigate the space; and how the hub is promoted as points for success in attracting diverse communities to access support. The use of third space theory helps understand factors to consider and potential benefits. All communities have third spaces which could be used to develop social capital, therefore findings are relevant across international boundaries.

Collaboration with communities has become essential to address health inequalities. But despite the rhetoric of health improvement policy, it will continue to prove hard in practice to achieve real change in communities and health and social care systems. Community-driven approaches are widely adopted but remain pockets of innovation with limited influence and financial security. This paper presents a novel relational approach developed in the context of social prescribing, a popular way to address the wider determinants of health by referring people to community-based activities. It argues that embedding relational learning in the practice of social prescribing can enable previously disconnected community members, local authority officials, and third sector workers to develop reciprocal relationships and shared resources for changing health inequalities. Based on action research with a social prescribing service in East-Birmingham, it demonstrates how to co-produce a relational learning space and reflects on structural challenges with changing health and social care systems. It concludes by discussing how embedding this community-driven approach could change health inequalities.