Supporting Aging in Place: A Relational and Preventive Approach to Integrated Care in Naturally Occurring Retirement Communities

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.