Table 1
Data sources for the evaluation of the UHN NORC Program model.
| DATA SOURCE | DESCRIPTION | POPULATION | TIMING |
|---|---|---|---|
| Resident Wellness Survey | Survey, co-created with NORC residents, includes questions assessing health and wellness, participation, and feedback on the most significant changes experienced due to the program | Anonymous cross-sectional survey of all building residents | Done at baseline in Summer 2023 and again in Summer 2025 |
| Chart Review | Detailed chart review of all visits and notes in residents’/patients’ electronic charts | Residents who receive individualized services from the ICL and/or NP | Chart review completed July 2025, after first two years of program |
| Program Tracking | Records of group programs occurring within NORC buildings including program type and attendance | Anonymous tracking collected at each building | Ongoing |
| Staff Reflections | Program staff working with NORC buildings and residents record regular reflections on factors impacting the programming. CCs track any time they interact with or support a resident. | Reflections entered by all staff including CCs, ICLs, and NPs | Ongoing |
Table 2
Metrics by impact domain to study implementation and effectiveness of the NIC integrated care program.
| METRIC | DESCRIPTION | RELEVANT DATA SOURCES |
|---|---|---|
| Healthy Communities | ||
| Improvement in supportive community networks | Self-report of top two response options of agree or strongly agree (Likert scale) to having neighbours to call on for support *Question adapted from the Canadian Community Health Survey (CCHS) | Resident Wellness Survey |
| Improvement in sense of belonging in the building community | Self-report of top two response options of agree or strongly agree (Likert scale) to feelings of belonging in the building *Adapted from Question 10 of the Lubben Social Network Scale | Resident Wellness Survey |
| Healthy People | ||
| Improvement in physical and mental health | Self-report of top three response options from good to excellent (on a five point scale from poor to excellent) physical and mental health *Question from the CCHS | Resident Wellness Survey |
| Improvement in comfort with technology | Self-report of the top two response options of intermediate or advanced (on a five point scale from none to advanced) level of comfort *Question regularly used by Tech TO | Resident Wellness Survey |
| Individual health and wellness needs addressed | Recording of issues addressed through individualized support from ICLs and NPs | Chart Review |
| Healthy System | ||
| Health system navigation and connections | Referrals to health services including primary care, home care, and other community services | Chart Review |
| Improvement in inappropriate health system utilization | Reduction in avoidable emergency department visits | Chart Review |
| Healthy Growth | ||
| Increased reach | Proportion of older adult residents participating in programming, interacting with the CC, and referred to individual support with the ICL and/or NP as identified by a yes/no checkbox on the survey or existence of a chart for review | Resident Wellness Survey and Chart Review |
| Factors impacting program implementation and sustainability | Qualitative data exploration | Staff Reflections |
[i] *CCHS 2023: https://www23.statcan.gc.ca/imdb/p3Instr.pl?Function=assembleInstr&a=1&&lang=en&Item_Id=1496615; Lubben Social Network Scale: https://www.brandeis.edu/roybal/docs/LSNS_website_PDF.pdf; TechTO unpublished survey: https://www.techto.org/.
Table 3
Demographics by complexity level.
| COMPLEXITY 1 (n = 65, 59%) | COMPLEXITY 2 (n = 34, 31%) | COMPLEXITY 3 (n = 10, 10%) | |
|---|---|---|---|
| Average age | 80.2 | 77.8 | 77.5 |
| Percent female | 75% | 71% | 50% |
| Percent living alone | 32% | 38% | 50% |
| Percent with an identified informal caregiver | 47% | 50% | 80% |
| Percent with a primary care provider | 87% | 93% | 90% |
| Percent receiving government funded homecare | 25% | 24% | 50% |
Table 4
Top reasons for and issues addressed during referrals.
| REASON/ISSUE ADDRESSED | ORIGINAL REFERRAL REASON | RE-REFERRAL REASON | ADDITIONAL ISSUE ADDRESSED | TOTAL |
|---|---|---|---|---|
| Falls prevention | 56 | 8 | 7 | 71 |
| Home accessibility modifications, mobility assessment and mobility equipment needs | 4 | 6 | 11 | 21 |
| Illness or injury | 5 | 9 | 2 | 16 |
| WheelTrans application or other disability paperwork | 4 | 8 | 2 | 14 |
| COPD screening | 5 | 6 | 0 | 11 |
| Chronic disease management support | 3 | 1 | 6 | 10 |
| Primary care provider attachment needs | 8 | 1 | 0 | 9 |
| Patient education | 1 | 5 | 2 | 8 |
| Personal support worker and other homecare needs | 3 | 2 | 2 | 7 |
| Medication management support | 3 | 2 | 2 | 7 |
| Mental health concerns | 1 | 2 | 3 | 6 |
| Caregiver respite or support | 5 | 1 | 0 | 6 |
| Pain | 2 | 3 | 1 | 6 |
| Post-hospital discharge support | 1 | 4 | 1 | 6 |
| Medical devices (e.g. hearing aids, CPAP) | 3 | 1 | 1 | 5 |
| Dementia support | 3 | 0 | 1 | 4 |
| Sleep issues | 2 | 2 | 0 | 4 |
| Grief counselling | 2 | 1 | 0 | 3 |
| Goals of care discussions | 0 | 0 | 2 | 2 |
| Housing issues and planning | 1 | 0 | 1 | 2 |
| Meals on wheels or other nutrition issues | 0 | 1 | 1 | 2 |
Table 5
Connections made by the integrated care team.
| CONNECTION MADE | COUNT |
|---|---|
| Falls pendant remote care monitoring program | 51 |
| Homecare – personal support worker (12), physiotherapy (8), nursing (1), housekeeping (2), home safety and accessibility assessments (6) | 29 |
| Outpatient clinics – spirometry, foot care, pain, physiotherapy, naturopathy, sleep, limb preservation, hypertension, geriatric psychiatry | 18 |
| Transportation programs | 10 |
| Mobility devices | 10 |
| Specialists – endocrinology, ophthalmology, respirology, dermatology, rheumatology, physiatry, nephrology, palliative care | 9 |
| Primary care | 7 |
| Community paramedics home visits | 4 |
| Nutrition (meals on wheels and dieticians) | 3 |
| Grief counselling (Care First and Catholic Family Services) | 2 |
| Imaging (ultrasound and CT scan) | 2 |
| Pharmacy (e.g. med-rec) | 2 |
| Rehabilitation (cardiac, inpatient) | 2 |
| Supportive housing | 2 |
| Caregiver respite (providence overnight respite and OCO) | 2 |
| Total connections | 152 |
Table 6
Methods of ED avoidance.
| METHOD OF AVOIDANCE | COUNT |
|---|---|
| Reassurance about symptoms | 2 |
| Post-fall arranged community paramedic visit and/or outpatient CT scan | 2 |
| Community paramedic home visit about urgent but not emergent symptoms (e.g. seizure) | 4 |
| As part of a plan to call and monitor symptoms as part of GOC while palliative | 1 |
| Total | 9 |