From Pilots to Populations: Adapting a Proven Integrated Care Model to Diverse Community Needs

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.