Team profiles :

Brightshores Health System

At a Glance

Region: Ontario

Setting: Rural

EAIP program principle(s): 

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

Grey Bruce Ontario Health Team is leading this initiative in collaboration with Brightshores Health System, Bruce County Paramedic Services, and the Grey Bruce Design & Implementation Working Group. The team comprises representatives from each organization, including interdisciplinary staff such as paramedics, nurse practitioners, specialized geriatric nurses, a project manager for evaluation and measurement support, and patient/caregiver advisors.

All four partner organizations serve Grey and Bruce counties in the South West Region of Ontario, covering a total area of 8,601 sq km. The region is bordered by Georgian Bay, Lake Huron, and several other counties.
Grey and Bruce counties consist of 17 municipalities (8 in Bruce, 9 in Grey) and two First Nation reserves: Saugeen First Nation No. 29 and Chippewas of Nawash First Nation No. 27. The Grey Bruce population is split between rural areas (53%) and small population centres (47%).
In 2021, Grey Bruce had 47,725 residents aged 65 and older, projected to increase to 63,895 by 2040. There were an estimated 10,904 frail older adults in 2021, expected to rise to 19,248 by 2040.
Regional demographic data suggests that geographical isolation, socio-economic status, and other social determinants of health may elevate the risk of isolation and impact overall mental and physical health.

Program Description 

This initiative aims to address the challenge of health and social system navigation by empowering older adults in the Grey Bruce Community with knowledge and information about local health services, social and community support, and personalized system navigation. This will be achieved through the creation and distribution of a “Wise and Well” calendar, co-designed in collaboration with older adults from the Grey Bruce community along with health and social service providers.
Additionally, the project will promote awareness of the newly available telephone navigation service. This helpline is available to older adults and caregivers in Grey Bruce who require more personalized navigation support including warm transfers, additional support, and follow-up calls.

Implementation Approach:

Community Engagement: Deepen connections with the older adult community using asset-based community development (ABCD) through community conversations, surveys for feedback, and engaging groups facing participation barriers.
Creation and Distribution of the "Wise and Well" Calendar: Informed by engagement with healthcare providers, project partners and older adults, the "Wise and Well" calendar resource will highlight existing programs and services for older adults in Grey Bruce. The calendar will be distributed by Community Paramedics, local businesses, groups, and community centers.
Access to Navigation Line: The Grey Bruce Ontario Health Team (GBOHT) navigation line, staffed with dedicated navigators, uses referral pathways co-designed with partner agencies and community members. Available from 8 AM to 8 PM, this service offers a "warm transfer" experience, directly connecting users to the needed services or programs. Follow-up occurs within one week to ensure needs are met, provide additional resources, and collect feedback.