That outcome changed when the Neighbourhood Care Team (NCT) stepped in. Working with her primary care provider, the team arranged her transfer to Baycrest Hospital and coordinated supports to prepare her apartment for her changing needs. With the right services in place, Dorothy was able to return home, where she remains nearly two years later. 

The NCT is a collaboration led by Baycrest, Sunnybrook Health Sciences Centre and SPRINT Senior Care. It is an outreach-based model of health and social care designed to help older adults age safely in their own homes. The program brings together local health care providers to function as one integrated team beyond the walls of their institutions. In addition to its lead organizations, the NCT involves Toronto Seniors Housing Corporation and 16 organizations from the North Toronto Ontario Health Team and North York Toronto Health Partners. Together, they repurpose existing staff and resources to improve outcomes and reduce the cost of care. 

For Dorothy, it made all the difference. “Thank you for listening to me. Thank you for letting me go home. All I wanted is a chance to go home,” she says. ​

Team members include primary care providers, nurses, social workers, pharmacists, rehabilitation specialists, personal support workers and community agencies, all working in close collaboration. This support helps older adults remain safe and independent in their homes. 

For many aging adults, accessing medical care is complicated by limited mobility, frailty, transportation challenges, language barriers, untreated mental health conditions and financial hardship. These obstacles often force people to move into institutions to receive the support they need. The NCT helps change that story. In one case, a newcomer to Ontario was hospitalized and later discharged without access to their psychiatric medication injections. The NCT reconnected the individual with their clinic, pharmacist and family physician, arranging for injections to be given at home. With coordinated support, they remained stable and independent. 

Since launching, the NCT has directly connected nearly 90 older adults with complex needs to primary care. 100 per cent of providers involved reported the model was effective in helping tenants better manage their care. Eighty-five per cent of tenants said they can access the care they need. The program now operates in eight TSHC buildings that are home to more than 1,300 tenants. By bringing care into homes and communities, the NCT ensures faster response times, higher quality of care and better chances for older adults to live independently. 

The NCT and the partnership behind it are expanding care beyond hospital campuses, reducing pressure on long-term care homes and helping older adults maintain dignity and independence. Aging in place is cost-effective, but more importantly it allows older adults to stay connected to their communities and keep a sense of purpose. With the right supports, the NCT is showing that more people like Dorothy can return home and remain there.