Meeting the needs of an aging population will require more than expanding existing services. It will require strengthening integrated, person-centred models of care that support people across the care​ continuum, improve access to care closer to home, and promote health, function and quality of life over time. It also means co-designing services with older adults, patients, and caregivers, to ensure that care reflects the needs and experiences of the people it serves. 

The stories featured in this issue of Health System News show how hospitals and their partners are putting these principles into practice. In Toronto, teams from Sunnybrook Health Sciences Centre, Baycrest and SPRINT Senior Care have adapted the MINT Memory Clinic model to provide care directly within Toronto Seniors Housing buildings. By providing dementia assessment and care in tenants’ homes, the model helps address barriers such as mobility challenges, limited income and difficulty navigating appointments, while exposing frontline clinicians to social factors impacting patients’ health needs. 

Other organizations are rethinking how patients move between care settings. At Queensway Carleton Hospital and The Royal, Behavioural Supports Ontario nurses and specialized geriatric mental health teams are working together​ to support older adults with complex cognitive, behavioural and mental health needs during transfers. Through coordinated communication, individualized support during transport and collaborative handovers, the partnership is helping make vulnerable transitions safer, more seamless and less distressing for patients and families. 

These approaches also offer practical opportunities to strengthen health system capacity. William Osler Health System’s Osler@Home program, delivered in partnership with Bayshore HealthCare, allows eligible older adults to recover at home through coordinated clinical, rehabilitation and daily living supports. By connecting people with personalized services before and after discharge, the program helps patients return home safely while also supporting hospital flow and reducing alternate level of care rates in hospitals. 

Together, these stories demonstrate that supporting older adults is not the responsibility of any one part of the health system. It requires coordinated action across hospitals, primary care, specialized services, home and community care, housing, social services, and caregiver supports. It also requires person-centred models of care that recognize the broader factors shaping health and well-being and are designed around the needs, goals and experiences of the people they serve.  

Earlier intervention, stronger care transitions, integrated rehabilitation services that support recovery, function and quality of life, and expanded access to care closer to home can help ensure that older adults receive the right care, in the right place, at the right time. These models show how person-centred models of care can improve care experiences and quality of life while contributing to a more sustainable health system.  

As Ontario looks ahead, there is an opportunity to build on and scale approaches that are already demonstrating positive impacts for patients, caregivers and the health system. The organizations featured in this issue illustrate the impact of working across traditional boundaries to deliver care that is more connected, proactive and responsive to people’s needs. 

Together, they offer a vision of a health system that responds to the evolving needs of Ontario’s population while supporting older adults to maintain their health, well-being, and quality of life in their homes and communities. ​