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The PACE (Program of All-Inclusive Care) Community Hub is an innovative program serving the needs of older adults in Burlington that officially launched in 2019, and is showing great promise in providing comprehensive housing, wellness, health and social needs of those from lower-socio-economic status. Inspired by a federal and state program in the United States, the PACE community hub was established through collaborators from health, emergency service, social and housing services. Its location downtown Burlington was chosen based on a data-informed process, and today it is contributing to the vision of a new collaborative cross sector approach to supporting Burlington’s older adults in the communities where they live. 

With the growing population of older adults that will be living with dementia in the years to come, this model seeks to proactively address health, wellness, social and housing needs as one integrated team of health care professionals. This allows older adults to live well and healthy, access the supports they require to improve their quality of life, reduce ER visits and hospital admissions, and reduce admissions to long term care. 

It aims to offer care and support through building trusting relationship and an integrated approach that proactively identifies and responds to physical, mental and social “flags” before individuals are in crisis and require acute care. PACE aims to offer a community-based Transitional Care Program which provides an enhanced care environment in periods of declining health (before hospitalization) and recovery (post hospitalization).

Lori-Anne Koopman is First Link Care Navigator at the Alzheimer Society of Brant, Haldimand, Norfolk, Hamilton and Halton (ASBHNHH) – one of several collaborative partners involved from across the community. Lori-Anne’s role is to provide in-person support to any members of the PACE program with needs based on memory concerns or a diagnosis of dementia. She provides information, connection to Alzheimer Society programs, and helps them connect with services while working with PACE’s interdisciplinary team. 

Being part of the PACE Community Wellness Hub is exciting, and its amazing to work with such wonderful health care professionals that all have the same goal in mind and are all part of this innovative new way of care” says Lori-Anne. She adds “for example, I was able to support a client in providing memory tips, helping fill out and submit forms for the Medical Alert Safely Home bracelet, register with the Vulnerable Persons Registry, and with this team collaboration, the client’s safety concerns were met and the continuum of care ensured ongoing needs were addressed in the home thereby allowing the client to make a warm transition to other providers to ensure that continuum of care.

Despite the continuing pandemic, everyone involved in this process has embraced the necessary changes to continue to address needs and provide this support to older adults in our community. For ASBHNHH, being involved as a collaborative partner with PACE is directly aligned with its vision that “People affected by dementia live well as vital and integral members of their community”. 

Together with approximately 15 other partners from across the community, PACE removes fragmented care delivery and silos of care that so often leave clients not knowing where to turn, and instead allows them to continue to age well in place. It contributes to a vision of a collaborative cross-sector approach to supporting older adults in the communities where they live, with the coordination and navigation support wrapped around them.

Acknowledgement: Our thanks to Burlington Ontario Health Team for source material referenced in the above article