Background: Residential Care Facilities (RCFs) are a vital part of the housing continuum, offering affordable housing with minimal support for nearly 1000 vulnerable residents in Hamilton. But the sector is in crisis. The complex needs of today’s residents have outgrown the RCF model of the 1950s. This gap, backed by outdated legislation and disconnected supports, undermines resident and staff well-being and fuels crisis situations with dire consequences.
Approach: The goal of our project was to improve the health and well-being of an under-served vulnerable population living and working in a community-based congregate setting (residential care facilities; RCFs) in Hamilton, Ontario. The project aimed to improve equitable access to coordinated health and social care for residents of subsidized residential care facilities (RCFs) through co-produced knowledge generated through community-based research, and implementation of impact activities designed to influence change at the frontline, legislative, and policy level. We report on two years of community-engaged research in partnership with the Greater Hamilton Health Network and its RCF Steering Committee of health, social, and housing partners as well as RCF operator and patient representatives. We co-developed the project proposal and the research plans of the subsequent studies. In the first year, to address power imbalances observed, changes were made to the research plan, and study approaches as well as targeted communication and knowledge sharing based on key partners to ensure all voices were heard. We conducted over 500 hours of ethnographic style fieldwork in 4 RCFs, over 50 interviews with different stakeholders, and secondary analysis of formal home care data. Results: Our findings demonstrate a housing and care approach where there is:
Resident vulnerability: Many RCF residents live with significant mental health, substance use, and physical health needs.
Staff under strain: RCF operators and frontline staff are filling care gaps well beyond their roles—often without adequate training, compensation, or mental health supports— leading to burnout and turnover.
Costly acute care: RCF residents averaged 9.4 emergency department visits and 2.9 hospital admissions over five years. Challenges with accessing care in the community contribute to increased reliance on emergency and hospital services.
Disconnected systems: RCFs operate at the intersection of housing, health and social care, welfare, and legal systems. Outdated legislation, siloed sectors, and rigid policies reinforce a reactive, crisis-driven model.
Implications: Achieving sustainable change requires meaningful engagement with diverse perspectives. RCF residents, staff, operators, local health and social care providers, City of Hamilton, Ministry of Municipal Affairs and Housing, Ministry of Children, Community and Social Services, and Ministry of Health all have a collaborative role to play in transforming the RCF model to better serve those who live and work in RCFs. While there is no one-size-fits-all approach to RCFs, aligning funding, modernizing policy, and building pathways for ongoing collaboration and learning can move the system forward and make Hamilton a city where everyone has a safe and secure place to call home. The implications drawn from the RCF model in this Canadian city resonates with the challenges of housing provision for vulnerable populations globally.

Abstract

Background: To promote ageing in place and reduce avoidable hospitalisations, Singapore has implemented the Community Case Management Service (CCMS) since 2018. This programme integrates health and social care services to address the complex and diverse needs of community-dwelling clients, while also alleviating caregiver burden. Although CCMS has been implemented nationwide, there is currently no local research that systematically examines clients’ outcomes following enrolment in CCMS. This study aimed to assess changes in clients’ functional, psychosocial, and clinical outcomes, and their risks related to resource utilisation and caregiver burden.

Approach: We conducted a retrospective pre-post study involving 673 clients enrolled in CCMS between April 2023 and March 2024. These clients completed interRAI Home Care assessments within one month prior to CCMS utilisation, and again prior to discharge from the programme. Needs-based recommendations from the interRAI assessments were used to guide personalised care planning under CCMS. Six outcome variables from the interRAI assessments were examined: fall risk, depressive symptoms, caregiver burden risk, vulnerability risk, institutionalisation risk, and risk of emergency department visits. Changes in the distribution of these categorical interRAI outcome variables between baseline and discharge were evaluated using the Stuart-Maxwell test of marginal homogeneity to determine whether significant shifts occurred.

Results: The mean age of clients was 73 years, and 51% were women. At baseline, 25.0% were at risk of falls, 42.6% exhibited depressive symptoms, 63.9% had caregiver burden risk, 22.5% had vulnerability risk, 29.0% were at risk of institutionalisation, and 64.5% were at risk of emergency department (ED) visits. The interval between baseline and discharge assessments ranged from 3 to 12 months, with a median of 5 months. Significant shifts in the distribution of four of the six outcome variables were detected between baseline and discharge assessments (all p<0.05), specifically in fall risk, depressive symptoms, caregiver burden risk, and risk of ED visits. Improvements were observed across these four outcome variables. At discharge, the number of clients assessed as having no falls in the past 90 days increased by 7.3%, no depressive symptoms by 13.7%, and lowest risk of ED visits by 9.2%, while the number of caregivers assessed as having high caregiver burden risk decreased by 21.1%. No significant changes were detected in the remaining two outcome variables: vulnerability and institutionalisation risks.

Implications: This study provides the first large-scale quantitative analysis of outcomes among older adults enrolled in CCMS. The findings suggest that participation in CCMS is associated with improvements that support independent ageing, including lower risks of falls and utilisation of acute emergency services, enhanced mental well-being, and alleviation of caregiver burden. These outcomes highlight the potential of CCMS to enhance person-centred care through timely and coordinated interventions across health and social care sectors, particularly for clients with complex needs. To ensure sustained impact and inform future enhancements of Singapore’s integrated care strategy, ongoing evaluation is essential. This includes assessing the long-term effects of CCMS and understanding client and caregiver experiences.

Background
Naturally Occurring Retirement Communities (NORCs) offer a unique opportunity to deliver integrated, community-based care within existing housing where many older adults already live. In this context, NORCs are defined as high-rise buildings with at least 50 units, where 30+ percent of residents are aged 65+. Many residents face fragmented access to health and social supports, leading to preventable emergency visits and early institutionalization. This case study explores how the NORC Innovation Centre’s (NIC) integrated care model bridges health and community care and applies relational care practices to improve access, strengthen connections, and support aging in place.

Approach
The NIC model partners with housing, community, health and social care providers to transform existing buildings into platforms for community-based care. An interprofessional team that includes a Nurse Practitioner (NP), Integrated Care Lead (ICL), and Community Connector collaborates with residents and local organizations to co-produce building-level health and wellness supports. The Connector is onsite to build relationships, nurture resident leadership, and provide timely access to relevant care. The NP and ICL support individuals with more complex needs through assessment, navigation, care coordination and planning with primary care. This case study focuses on residents referred for individualized support. A mixed-methods evaluation used resident surveys, staff reflections, and chart reviews, analyzed descriptively and thematically to assess experience, access, utilization, and implementation facilitators.

Results
Across seven Toronto NORCs, the program engaged about 60 percent of residents, with 7 percent (n=135) referred for individualized support. Most were women (72 percent), 36 percent lived alone, and 51 percent had a caregiver. The most common referral reasons included falls prevention, mobility, and home care. Findings highlight the program’s role in addressing system gaps, supporting care escalation directly from the community, facilitating post-discharge transitions, and providing holistic, person-centred care. Relational care practices that emphasized trust-building, advocacy, and strengths-based engagement were key enablers of success and team satisfaction. A particularly notable outcome was a reduction in average annual emergency department visits, from 0.38 visits per person to 0.14. This case study will share insights into the factors that contributed to this decrease and explore opportunities for a sustainable, community-enabled approach to integrated care.

Implications
This model demonstrates how integrated care can be embedded within existing housing infrastructure using a relational, team-based approach that links health, social, and community systems. It aligns with ICIC26 themes of Improved Outcomes through Community-Based Care and Strengthening Integrated Care through Workforce Innovation. The NIC approach offers a scalable, community-led framework that broadens access, enhances experience, improves outcomes, and relieves pressure on hospitals and long-term care. International delegates can draw lessons on embedding relational care, leveraging community connectors, and integrating health and social services to support aging in place.

Background:
Social connections are fundamental to human well-being across the lifespan, and especially crucial as we get older. Nearly 1 in 5 adults over 65 in Canada report social isolation or loneliness and nearly 50% of adults over age 60 are at risk. Social isolation and loneliness are associated with an increased risk of depression, anxiety, disability and frailty. Older adults want to maintain their independence and age in place, yet many face barriers to accessing supportive healthy lifestyle programs to connect with others and optimize health.

Approach:
We partnered with older adults living in neighbourhoods with health inequities and community-based service providers to co-design an integrated community-based program aimed at improving mobility, health, and social connections and addressing service access barriers. This process resulted in EMBOLDEN (Enhance physical and community MoBility in OLDEr adults with health inequities using commuNity co-design), a 12-week, multicomponent, community-based primary prevention intervention. EMBOLDEN incorporates physical activity, healthy eating, social participation, and system navigation, and is jointly delivered through intersectoral collaborations.

We conducted a mixed-methods randomized controlled trial of the EMBOLDEN program in ten neighbourhoods across Hamilton and Toronto, Canada, compared to usual care (n=324). Social network data were captured for intervention group participants through a digital tool called GENIE® at the start (T1), middle (T2), and end (T3) of the 12-week program. GENIE® captured the number of people in a participant’s network at each timepoint, classified by relationship type: family, friends, and community/hobby groups. Frequency of contact was scored by multiplying interaction frequency (ranging from 1 = less than once a month to 4 = daily) by the subjective value of each member’s relationship [1 (lowest/loose ties) – 3 (highest/close ties)] and summing over all network members. Intervention participants (n= 161) received up to three 1:1 sessions with a system navigator who used GENIE® to track changes in their social network size and help them connect with community supports aligned with their interests.

Results:
Most intervention group participants engaged in the system navigation component (n=143); GENIE® data showed statistically significant increases in both the size of their social networks and the frequency of contact with network members over time (p ≤ 0.05).

On average, network size increased by 36% (mean # of members: T1=6.4, T2=7.7, T3=8.7) representing an average growth of >2 people. Frequency of contacts increased by 34% (mean contact frequency: T1=29.6, T2=36.1, T3=39.7). The growth in network size occurred in members with looser ties to the participant (primarily friends and community groups), with statistically significant increases over time (p ≤ 0.05). Older adults reported making a new friend, meeting up with others from the group, and connecting with a variety of community programs to continue to engage with local supports beyond the program.

Implications:
A community-based, co-designed lifestyle intervention can enhance social connections in older adults living in neighbourhoods with health inequities. These findings underscore the potential of participatory, equity-focused, community-based programs to enhance social well-being and reduce isolation among older adults — outcomes that are increasingly critical in aging populations.

The EGS+V Model: Integrated Care for Multimorbidity and Aging
Accelerated population aging and the growing prevalence of multimorbidity (multiple chronic diseases) and polypharmacy (use of multiple medications) represent a structural challenge for the National Health Service (SNS) in Portugal. The country records high rates of emergency service use (more than double the OECD average), reflecting the fragmentation of care and the difficulty in coordinating the response across various levels.
Context and MissionPortugal is one of the oldest countries in Europe, with projections showing that more than 30% of the population will be over 65 by 2050. Around 48% of this age group already has two or more chronic diseases, increasing clinical and therapeutic complexity. The Coimbra region, in particular, faces a high rate of elderly people with multimorbidity, leading to an increasing reliance on hospitals, multiple emergency visits, and avoidable hospitalizations.The Health Management Team for the Elderly and their Environment (EGS+V), created at ULS Coimbra, emerges as a response to this reality. Its objective is to develop and test a coordinated care model focused on elderly individuals with multiple chronic diseases, promoting effective integration between primary care, hospital care, and the community.
Approach and StructureThe EGS+V model is based on a multidisciplinary intervention and inter-institutional co-creation (Primary Healthcare, Hospital Care, Community Pharmacies, Municipalities, and Parish Councils), fostering shared responsibility and territorial integration.The team is composed of doctors, nurses, social workers, and technical assistants. Inclusion criteria focus on complex patients: age over 70 years, more than 3 chronic diseases, 6 or more different medications, and high utilization of acute services (4+ emergency visits and/or 3+ hospitalizations in the last year).
Main Intervention Components: Home Assessment: Initial and semi-annual by a medical, nursing, and social team.Individual Health Plan: Co-constructed with the patient and caregiver, involving all professionals. Monitoring and Continuity: Through teleconsultation and remote monitoring. Community Connection: Social prescription to combat isolation and support therapeutic adherence in partnership with pharmacies. Alternatives to Inpatient Care: Direct connection to Home Hospitalization. Digital Support: Use of dashboards for proactive patient identification and real-time monitoring.
Preliminary Results and Implications: Preliminary results demonstrate significant gains in the management of complex patients and in system efficiency: Indicator Baseline EGS+V Target/Result Average Emergency Episodes/year4.5 Estimated 50% reduction / less than 2 for 75% of patients, Average Inpatient Episodes/year 3 estimated 50% reduction / less than 2 for 75% of patients. Economic Gains/patient-€3,338/year. Patient Satisfaction 4.1 to 4.5 (on a 1–5 scale)Therapeutic Adherence/Literacy more 70\% Environmental Impact Frequent, repetitive travel Reduction of carbon footprint more than 20\%.
The EGS+V model proves that care integration based on case management, interprofessional collaboration, and digital support can transform the response to multimorbidity. The lessons learned highlight the importance of coordinated teams, the value of social prescription, and the use of clinical data for continuous improvement.This model is replicable and scalable to other regions, aligned with SNS strategies and the WHO "Decade of Healthy Ageing 2021–2030" program, offering a path toward the sustainability, integration, and digitalization of healthcare.

As people age, staying active, healthy, and socially connected becomes essential for wellbeing. Aligned with the WHO ICOPE framework (WHO 2017), the +ÀGIL Barcelona programme —led by Primary and Community Care— supports older adults with early signs of frailty in their own environments to maintain intrinsic capacity and live independently for as long as possible. +ÀGIL Barcelona programme is a multidisciplinary initiative driven by Primary and Community Care, aimed at preventing and managing early frailty among community-dwelling older adults (Pérez et al., 2019). It combines personalised, group-based multicomponent interventions, including structured physical exercise, health education on lifestyle habits, with medication optimisation. Previous findings from the programme have demonstrated sustained improvements in intrinsic capacity in older adults living in the community (Ferrara et al., 2023).
In this communication, we reflect on the co-design and implementation process of the +ÀGIL programme across three primary care centres in Barcelona, carried out from September 2022 to early 2025. The programme was developed and introduced through a participatory and adaptive approach grounded in co-creation, iterative learning cycles, and shared governance. Accordingly, rather than implementing a pre-defined model, +ÀGIL was developed collaboratively with primary care professionals, community agents, and older adults, adapting to each centre, professional team, and neighbourhood context. This approach sought to ensure alignment with local resources and priorities, enhancing contextual relevance, flexibility and long-term sustainability.
Participatory action research and co-creation methods guided the process. The initial phase focused on co-designing the programme content and delivery model through co-creation workshops and focus groups with primary care professionals, community stakeholders, and older adults, alongside community mapping and more in-depth technical working sessions with primary care teams. Implementation then followed through cycles of testing and adaptation, allowing teams to refine referral pathways, professional roles and materials. A dual governance structure supported implementation at both central and local levels.
+ÀGIL was successfully embedded into routine Primary and Community Care practice, generating progressive uptake and consolidation over time (Mazzarone et al, submitted). A total of 198 older adults showing early signs of frailty participated in the programme during this period. The participatory and adaptive approach enabled each centre to tailor delivery to local needs and resources while maintaining core programme components. Key implementation achievements included establishment of clear referral processes, defined professional roles, co-produced educational materials, integration of community resources, and strengthened collaboration between primary care and neighbourhood organisations.
Implementation experience findings emphasised the value of iterative learning cycles, shared governance structures, and learning spaces in fostering ownership and capacity among primary care teams (Sitjà-Rabert, in review). Professionals reported increased confidence in addressing early frailty, improved interprofessional coordination, and enhanced connection with community assets. Older adults expressed high adherence and satisfaction, highlighting accessibility, neighbourhood-based format, and perceived benefits, confidence, and social participation.
Overall, the implementation process demonstrated that co-design, structured governance, and adaptive deployment strategies can support the sustainable integration of a multidomain frailty intervention within Primary and Community Care settings. The programme’s implementation-research approach allows real-world evaluation and continuous adaptation to local contexts