Team profiles :

County of Renfrew

At a Glance   

Region: Ontario

Setting: Rural and Remote

EAIP program principle(s): 

• Access to social and community supports
• Access to system navigation and support

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

• New

Team Profile  

The Ottawa Valley Ontario Health Team (OVOHT) is leading this initiative, in collaboration with Pembroke Regional Hospital, Renfrew County Community Paramedics, and Barry’s Bay and Area Home Support Services. Collaborating closely, leaders from these organizations, along with advisors from The Regional Geriatric Program of Eastern Ontario, Eganville & District Seniors, The Dementia Society of Ottawa and Renfrew County, The Upper Ottawa Valley Community Living and the Algonquins of Pikwàkanagàn First Nation, make up a robust team serving a large catchment area. OVOHT Patient, Family and Caregiver network (PFaC) will also act as partners and advisors to this project.

Community

• All organizations across the OVOHT operate in a rural setting, and some also work in remote areas, bordering northern communities.  
• OVOHT is a large rural catchment area with a population of approximately 78,000 residents. The area has one of the highest rurality population rates in the province, resulting in significant challenges in accessing care. 
• 23% of the population are over 65 years of age. 
• Approximately 9% self-identify of community members identify as Indigenous, and 12% are Francophone.
• OVOHT has a high rate of patients unattachment to primary care provider, nearing 25% of the population. For older adults, this creates greater risk for unexpected or poor health outcomes as there is limited access to preventive or consistent care opportunities. 

Program Focus 

Program Description  

• Informed by partners and individuals with lived/living experience, the team plans to develop and implement a Comprehensive Falls Pathway within community paramedicine. This pathway will utilize a first-contact, inter-professional, cross-sector collaborative approach to identify and implement a common and consistent, evidence-informed Falls Pathway across OVOHT for older adults at risk or post-fall. Building on identified practices, the local pathway will bring together clinical and volunteer groups to ensure a consistent and responsive experience for patients and community members.  

Implementation Approach: 

• Self-screening Tool: The Community Intervention and Falls Prevention Programs Self-screening Tool will be made available online, 24/7, through Ottawa Valley Health Connect (ovhc.ca) for individuals and/or caregivers to complete, identify their risk of fall and directing the user to the most appropriate program in the user’s location, based on screening results, raising awareness of the availability of local programs.   
• Cross-sectoral Collaborative Pathway and Working Group: The development of a cross-sectoral collaborative pathway ensures equitable access to timely services and programs for patients through a consistent approach. By building on existing pathways, enablers, and technology, this cross-sectoral working group aims to clarify, streamline, and simplify access to services related to falls. The team plans to consolidate existing services, promoting integration, and enhancing coordination to optimize resource utilization and support older adults in accessing the most appropriate services when needed. Once developed, the team plans to test, launch, and evaluate. 
• Communication: The team plans to develop and implement a communication and engagement plan across the region targeting the public, social, and health sectors. This plan will inform key partners about the project and its expected outcomes.