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Over the past decade the team at UHN NORC Innovation Centre has had the privilege of learning from and working with aging adults living in naturally occurring retirement communities (NORCs). Together we have created a new integrated health and social care model that can be adapted to the needs of a diverse range of communities. The model currently supports up to ~4,000 aging adults including successfully addressing 95% of the needs identified through 0,000+ interactions. [PJ] Critical to the many successes has been the development and delivery of an Ambassador program as well as a steadfast commitment to take a participatory approach to build community and ensure aging adults have the agency to lead. The voices of aging adults guide implementation and improvement efforts as well as identify areas requiring innovation. Since many living in NORCs are relatively healthy and are living fairly independently there is a significant opportunity to preserve health system capacity by helping them stay healthy and, if needed, provide timely supports to get healthy. The community created through NORC programming as resulted in aging adults feeling they can take initiative and lead change, while their work in bringing community creates space to learn together, teach one another and normalize new ways to care for themselves and one another.These networks of mutual support resulted in the opportunity to address common health promotion and care challenges through care pathways that were initiated and co-developed by aging adults. In the first year of operation the team focused on three priorities- falls prevention, lung health and rapid access to appropriate care. We will share how care pathways have been developed and subsequently impacted care and health outcomes in participating sites. In one example, a resident who sustained a fall was cared for by a neighbour who kept a close eye for deterioration. Then, once a fractured hip was diagnosed, the person was supported by the community in the building both in the initial injury phase all through rehabilitation. Neighbors created a community of support for this person during rehab and worked closely with the NIC Team to ensure a smooth recovery.As a second example, aging adults indicated a desire to have a holistic end-to-end fall prevention, education and detection program. In this case on their won initiative, the aging adults in the building helped bring isolated individuals to the sessions, support the delivery of the intervention and assist with follow-up during the intervention.In a third example; a lung health initiative focusing on the early detection of COPD; neighbors were able to assist an individual in the building who presented as severely hypoxic. Working with the NIC Team, residents stepped up and assisted with the care delivery team to help get the person directly to the appropriate specialist while bypassing the emergency department.These and other similar instances provide several important learnings regarding people as partners in care: By providing agency to residents in buildings it possible to create a sense of confidence and courage for them to create supporting and engaged communities Responding to the needs identified in innovative ways can help create economies of scale by simultaneously reaching many individuals with one intervention. A community of aging adults can form and work with providers in delivering care to those who would normally be isolated and not have access to care. A group of aging adults can create a community of informal support for those who need extra help dealing with their conditions.

It is well known that, with adequate supports, many seniors desire to age in place in their own homes. NIC’s data shows that in Toronto, 70,000 seniors are living in 495 NORCs with over 53% of these having 2 or more co-morbid conditions. Rising to this challenge, the NIC's vision is to implement a 21st-century model of integrated health and social care in NORC buildings by developing health, social, and digitally-enabled solutions that provide Canadians with new options for aging in place with dignity and choice. Phase one, created and refined the NORC Ambassadors program (norcambassadors.ca) – an aging-in-place model based on mutual support, community engagement, and seniors' leadership. It was founded on a multi-year exploration that incorporated senior input, ethnographic observation, documentary stories, literature reviews, journey mapping, and the co-creation of service blueprints. Seniors led the implementation of the Ambassadors program based on participatory decision-making, self-management, agency, and choice. From the 2021 final report, 100% of respondents indicated a desire to continue organizing aging-in-place activities with 78% feeling their awareness of aging-in-place issues improved. Interestingly, 75% reported challenges with improving overall building engagement. Based on learnings from phase 1 and guided by IFIC's 9 pillars of integrated care, phase 2 layered in a service design approach to creating an enhanced model of health and social care that increases access to place-based services and support for seniors living in Toronto’s high-rise communities.     Phase 2 involves over 100 Senior Advisors, 37 Specialists, national partners, and a growing array of system partners. Central to phase 2 work is developing the NIC's Integrated Health and Social Care model. Inviting senior advisors to lead co-design activities ensured that their voice is front and centre in a system for seniors by seniors. Leveraging multi-sector involvement supported the development of one team to enable the provision of services most important to seniors that span the entire continuum of care and determinants of health. NIC's model focuses on two parts of a person's journey – \"\"I want to stay healthy\"\" where people can access an array of services that help them stay healthy, and connected, and address social isolation and loneliness. This approach added the introduction of a NORC Animator to the Ambassador model from phase 1. NORC Animators, are on site and function to create relationships with the residents, coordinate group health and social activities, and are a friendly resource for all resident needs. In addition, the NORC Animator can also watch for functional change and; where seniors state that \"\"I want to get healthier\"\"; support the connection to one-on-one health and social services.  This presentation will address the following questions: 1) How does the NIC model compare with other existing models in Ontario 2) What is required to effectively support seniors in participatory design? And how can you sustain involvement? 3) What is most important in designing what support is needed and how it is delivered? 4) What lessons learned have been identified from the early adopter site experiences?  

Background: We developed a community pathway for chronic obstructive pulmonary disease (COPD), one of the most prevalent chronic respiratory conditions in Canada. We had the unique opportunity to co-develop a pathway that truly reflects health status and care continuum perspectives and strengths in COPD. Approach:COPD is one of the most common reasons for hospital admission in Canada, and in Ontario accounts for up to one-third of all health care utilization. COPD is also one of the most common comorbidities in the community.During this presentation, the audience will learn how Connected Care in partnership with the University of Toronto Division of Respirology and Toronto Paramedic Services Community Paramedicine developed a comprehensive COPD pathway for residents of the Greater Toronto Area (GTA). We will also demonstrate how these groups worked together to co-design a pathway, and will share interesting findings from this complex patient population.Planning involved bringing key partners and stakeholders together in the engagement phase to better understand the target patient population we proposed to screen for COPD. Leveraging existing resources was key given the abundance of information about the COPD journey and the testing required for this patient population. The clinical team, including nurse practitioners, respiratory therapists and Respirologists were instrumental in the design of the pathway, providing input and clinical guidance. Throughout the pathway pilot phase, we will continue to revise the process based on both clinical and patient feedback.This pathway will provide earlier access to treatment for community residents with diagnosed and un-diagnosed COPD that are often missed, preventing unnecessary 9 calls, Emergency Department visits, and hospital admissions. Results:The COPD Pathway aims to keep residents in their community and manage symptoms to prevent unnecessary 9 calls, visits to the Emergency Department, and hospitalization. The pathway has multiple services and streams of follow-up based on the patients needs: ) Proactive outreach and screening in high priority settings such as Naturally Occurring Retirement Communities (NORCs) with an emphasis on prevention and health promotion in addition to intervention;a. NORCs present an opportunity to keep people healthy; this was an opportunity to not re-invent the wheel but bring together evidence-based models that are working to be even greater than the sum of its parts2) Leveraging the experience and scope of various roles to create an effective pathway3) Patients are treated based on the pathway that suits their needsa. We have an escalation of care option where a nurse practitioner is able to refer patients living with moderate to severe COPD to a Respirologist4) Patients receive ongoing monitoring and care5) Patients are reintegrated into community and able to self-manage their condition.The pilot was initiated in April 2024 and residents were identified through Paramedic Led Wellness Clinics. So far, we have conducted four Wellness Clinics, where 95 residents have been screened, and 0 referrals to the pathway have been generated. We will provide initial results and impacts at the conference. Implications: Through this pathway, our highly engaged team is: Detecting residents who may be living with undiagnosed COPD earlier than otherwise possible Monitoring existing COPD patients to reduce exacerbation/unnecessary 9 calls/Emergency Department visits Providing seamless care from community to hospital In addition, we have discovered that we are screening not only patients who may screen positive for COPD through spirometry testing, but also patients who fall outside this pathway but equally require a more comprehensive assessment for another respiratory condition, and we therefore are providing our findings back to their primary care provider for further investigations and treatment.

Weiss et al, highlighted the inequities in the access of FPPs/1) Since the access of medical services follows the inverse care law,(3) older adults with lower socioeconomic status, education, and physical fitness are less likely to receive referrals and/or participate in FPPs/4) To address the gaps in FPP accessibility, the Naturally Occurring Retirement Communities (NORCs) Innovation Centre at the University Health Network has developed a community-led FPP approach working with local older adult leaders. Through our initial proofs-of-concepts, we have seen the creativity and commitment of communities in advocating for needs, encouraging neighbours to participate, and promoting peer education and modeling to sustain change. CONFLICT OF INTEREST DISCLOSURES We have read and understood the Canadian Geriatrics Journal's policy on conflicts of interest disclosure and declare we have none.