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The CARE (Coordinated, Accessible, Respectful, Equitable) program is designed to support frail older adults with complex health needs. A program of the Ontario Health Teams, it aims to reduce hospitalizations, improve care quality and promote aging in place for vulnerable seniors. Supporting the project from Osler were Emily Cichonski, Manager, Integrated Health Systems and Rishika Thakur Malhi, Director, Integrated Health Systems and Executive Lead, Central West Ontario Health Team.
This initiative showcases the effectiveness of collaborative, community-based health care in managing illness and improving outcomes for homebound older adults. A pilot study was launched in March 2023, and its results, summarized in the poster below, were presented at the North American Conference on Integrated Care in October 2024, where the project was awarded the Patient and Family Engagement Award for 2024.
The story was told through a case study of an 81-year-old female patient with multiple chronic conditions which illustrated the program's impact. The patient, who lives with her daughter, had a history of hypertension, Type 1 diabetes, stroke (CVA), arthritis and other health issues.
The CARE team, made up of a multi-disciplinary group of health care professionals, conducted a comprehensive assessment and identified key challenges, including poor diabetes management, high caregiver stress and mobility issues. The intervention plan addressed these concerns through improved diabetes control, medication management, physical therapy, wound care and emotional support for both the patient and her caregiver.
The CARE pilot also highlighted a 60 per cent reduction in acute care admissions, demonstrating its success in reducing Emergency Department visits and hospitalizations for high-risk older adults. A coordinated, integrated approach—including care coordination, home visits and personalized support—was key to these positive results.
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