Team profiles :

Algonquin Family Health Team (NOSM)

At a Glance   

Region: Ontario  

Setting: Rural  

EAIP program principle(s):  

• Access to specialized healthcare services  
• Access to social and community supports  
• Access to system navigation and support  

Implementation (new, spread, and/or expand):   

• New  

Team Profile   

This initiative is led by the Algonquin Family Health Team (AFHT) within a new clinic for individuals without a primary care provider (unattached patients), The Annex. The team includes representatives from AFHT, including physicians, clinic leadership, IT support, and a research coordinator from the Huntsville Education Group.  

Community  

• This initiative is targeted towards older adults without a primary care provider in Huntsville, Ontario, and surrounding areas.   
• Huntsville, is the largest municipality within the District of Muskoka, covering 711 square kilometers. According to the 2021 Census, it has a population of approximately 21,147 residents, with a significant portion being seniors.  
• Individuals without a primary care provider represent more than 30% of the community population.   

Program Focus  

Program Description  

• The Algonquin Family Health Team (AFHT), through its new program "Aging in Place at The Annex," aims to provide continuous, comprehensive care to unattached older adults in Huntsville, Ontario. This initiative addresses the critical need for primary care among seniors who currently rely on emergency departments, leading to long wait times that could be mitigated with comprehensive, ongoing care. The program aims to reduce hospitalizations and emergency department visits while supporting seniors in managing chronic illnesses, navigating the healthcare system, and aging at home. With a multidisciplinary team including physicians, a Nurse Practitioner, Community Paramedics, and mental health support, The Annex will provide unattached seniors with a health home, ensuring comprehensive health management and reducing the need for, and demand on, acute services.  

Implementation Approach: 

• Specialized Geriatric Assessment: Expand existing services to offer specialized geriatric assessments for frail older adults at The Annex, addressing dementia, delirium, mental health concerns, falls, and mobility issues. Targeting all geriatric patients, this service mobilizes community assets like home care, remote monitoring, and palliative providers. 
•  Continuity of Care: Provide continuous, quality primary care for older adults without access to primary care at The Annex. Targeting all older adults presenting or referred, this service mobilizes community resources, including a multidisciplinary team and partnerships.   
• Specialized Referral and Follow-up Care: Facilitate patient referrals for specialist care and diagnostics, which are challenging to access without a primary care provider. The AFHT geriatric care team will provide and facilitate referrals based on comprehensive assessments.