2021 Conference – Transforming Care: Supporting Older Adults Post-COVID in Ontario

Date: October 19-21, 2021

Time: 8:30 am – 12:30 pm each day (Eastern time zone)

Cost: Free

Location: Online via Zoom and Slack (see our Code of Conduct here)

Audience: Ontario Health, Ontario Health Teams, Specialized Geriatric Service providers and planners.

Content: Prior to the pandemic, our health system was not effectively serving older adults with complex needs and their caregivers. We cannot simply return to the status quo; we must do better.

This three-day event was split into themed morning sessions:

  1. The Need: Older Adults with Complex & Chronic Health Conditions Including Frailty
  2. The Innovation: Integrated Care in Action
  3. The Transformation: Post-COVID Support and Recovery


Session 1: Welcome and Lived Experience

After a welcome from conference hosts, speakers shared their personal experience and identified what they believe is needed for older adults with complex conditions, including mental health and frailty.

Speakers: Cynthia Martineau, Anne-Marie Yaraskavitch and Blayne Mackey
Recording: View Session1 Webinar

Speaking Notes – Lived Experience – Anne-Marie Yaraskavitch
Speaking Notes – Lived Experience – Blayne Mackey

Session 2: Design Elements of Integrated Care for Older Adults and the Indicators for Integrated Care for Older Adults projects and Lessons Learned

Provincial Geriatrics Leadership Ontario shared evidence specific to the needs older adults with complex needs. They described design elements and indicators of integrated care. A panel of speakers participated in a moderated discussion, reflecting on what has failed this population and what we have learned over the last several years. They put a particular focus on gaps that emerged in the last two years during the pandemic.

Speakers: Kelly Kay, Dr. Benoit Robert, Dr. Lindy Killik and Dr. Jenny Ingram
Recording: View Session 2 Webinar

PDF Slides:
Designing to Address the Requirements for Older Person’s Care in Ontario – Kelly Kay

Designing Integrated Care for Older Adults Living with Complex and Chronic Health Needs: A Scoping Review
Honouring Voices and Experiences
PGLO Specialized and Focused Geriatric Asset Mapping Initiative
AVOID Frailty
Indicators for Integrated Older Persons’ Care in Ontario Initiative
Comprehensive Geriatric Assessment
Family Presence in Older Adult Care A Statement Regarding Family Caregivers1,2,3 and the Provision of Essential Care

1. Canadian Institute for Health Information. Canada’s Health Care Providers, 2015 to 2019 — Data Tables.
2. Seitz, D. (2019). A population based study of older adults in Ontario: Dementia, frailty and utilization of physician specialist human resources.
3. Provincial Geriatrics Leadership Ontario. Frailty Estimates by Census Division and Ontario Health Region.
4. Richter, L., Heidinger, T. (2021). Hitting Close to Home: The Effect of COVID-19 Illness in the Social Environment on Psychological Burden in Older Adults, Frontiers in Psychology, 12, p 4160
5. Tyler et al. (2021). A Study of Older Adults’ Mental Health across 33 Countries during the COVID-19 Pandemic, Int. J. Environ. Res. Public Health 2021, 18, 5090.
6. Hoffman, G. (2021). Physical functioning and falls during the COVID-19 pandemic.
7. Tosato M et al. (2021). Prevalence and Predictors of Persistence of COVID-19 Symptoms in Older Adults: A Single-Center Study. J Am Med Dir Assoc. 22(9):1840-1844. Doi: 10.1016/j.jamda.2021.07.003
8. Goveas, J. S., & Shear, M. K. (2020). Grief and the COVID-19 Pandemic in Older Adults. The American journal of geriatric psychiatry: official journal of the American Association for Geriatric Psychiatry, 28(10),1119–1125.
9. Schuster, N.A., de Breij, S., Schaap, L.A. et al. Older adults report cancellation or avoidance of medical care during the COVID-19pandemic: results from the Longitudinal Aging Study Amsterdam. Eur Geriatr Med 12, 1075–1083 (2021).
10.Canadian Institute for Health Information (2020). 1 in 9 new long-term care residents potentially could have been cared for at home.
11.Canadian Institute for Health Information. Profile of Clients in Home Care, 2019–2020. Ottawa, ON: CIHI; 2021

Session 3: What is needed to support this population?

A panel of speakers participated in a moderated discussion, reflecting on what is needed to support this population. They discussed what transformation could look like and how a post-COVID system of support can and should differ from the structures and services in place for older adults with complex needs and their caregivers before the pandemic.

Speakers: Dr. John Puxty, Dr. Sophiya Benjamin, Dr. Sina Sajed and Charissa Levy
Recording: View Session 3 Webinar


Pandemic Recovery Planning for Older Adults
Position Statement for Mental Health Care in Long-Term Care During COVID-19

1. Overview of Rehab Care Alliance initiatives with a focus on older adults
2. Rehabilitative Care: An Essential Component of Connected Care — A Guide for Ontario Health Teams provides an overview of how rehab contributes to the quadruple aim and the implications for OHTs.
3. Patient and System-Level Benefits of Rehabilitative Care: A primer to support planning by OHTs and Ontario Health provides an accessible overview of current evidence to help OHTs better understand the role rehabilitative care can play in improving outcomes.
4. Rehabilitative care for older adults living with or at risk of frailty: From Frailty to Resilience. Joint publication of the Rehabilitative Care Alliance and Provincial Geriatrics Leadership Office – to be published in November, 2021.
5. Realizing the Potential of Rehabilitative Care for People with Complex Health Conditions: The Time Is Now. Levy, C., Balogh, S., Perkins, E. Healthcare Quarterly, 19(2) July 2016: 49-54. doi:10.12927/hcq.2016.24699
6. Aging Well Report
7. Pandemic Recovery Planning: Enhancing Care for Older Adults in Ontario
8. PGLO and RGPs of Ontario Position Statement. The Need for Expert Clinical Care for Older People Living with Complex Health Conditions: Required Services in Every Ontario Health Team
9.The Impact of COVID-19 on Older Adults: Findings from the 2021 International Health Policy Survey of Older Adults
10.Leading Practices to Prevent Hospitalization and Extended Stays for Older Adults: Previously known as the ‘2017 Alternate Level of Care (ALC) Leading Practices User Guide’. Ontario Alternate Level of Care (ALC) Leading Practices Working Group (2021) (to be published)


Session 4: Lived Experience, Collaboration with CSS Sector, Community Paramedicine, GeriMedRisk and GEM Fellowship

The morning began with a caregiver describing their experience within the health care system, with an emphasis on what has worked well. Presenters described innovative strategies such as community paramedicine, GeriMedRisk, a geriatric emergency management fellowship initiative, and collaborations with community support services.

Speakers: Gweneth Gowanlock, James Meloche, Dr. Mark Lachmann, Mathieu Grenier, Pam Howell and Karen Hicks
Recording: View Session 4 Webinar

PDF Slides:
Lived Experience – Gweneth Gowanlock
Collaboration with Community Support Service Sector – James Meloche
Community Paramedicine – Mathieu Grenier
GeriMedRisk – Pam Howell
GEM Fellowship – Karen Hicks

• Fisher P, Elnitsky C. ( 2012) Health and social services integration: a review of concepts and models. Social Work in Public Health, 27, 441-468.
Paramedic County of Renfrew
How to make a referral to GeriMedRisk (including the communication tool)
Register for GeriMedRisk monthly rounds
Access freely available Drug information summary documents
Geri-EM Personalized E-Learning in Geriatric Emergency Medicine
SIGECAPS Depression Screening Can Help Depressive Disorder
Understanding Motivational Interviewing
Timed Up & Go (TUG)
Mini-Cog Test for Dementia and Alzheimer’s: Accuracy, Administration & Scoring
The Confusion Assessment Method (CAM)
• Mukhalalati BA, Taylor A. Adult Learning Theories in Context: A Quick Guide for Healthcare Professional Educators. Journal of Medical Education and Curricular Development. January 2019. doi:10.1177/2382120519840332

Session 5: Concurrent Session A: Integrated Care

During this concurrent session speakers described local and regional examples of integrated care strategies including: a focus on integration between geriatric medicine and geriatric psychiatry at Waypoint Centre for Mental Health Care, a conceptual model of acute care dementia care from The Ottawa Hospital, an Integrated Memory Clinic at Providence Care, and North Simcoe Muskoka’s successes with integrated, high intensity supports for older adults.

Speakers: Dr. Kevin Young, Dr. Frank Molnar, Dr. John Puxty and Sandra Easson-Bruno
Recording: View Session 5 Webinar

PDF Slides:
Integrating Care in a Mental Health Institution – Kevin Young
Acute Care Dementia Care Conceptual Model at the Ottawa Hospital – Dr. Frank Molnar
Integrated Memory Clinic Providence Care Hospital – Dr. John Puxty
System Approach to Integrated Care – Sandra Easson-Bruno

Improving BC’s care for persons with dementia in emergency departments and acute care hospitals (2011): see page 13
Dementia care in the acute hospital setting: issues and strategies, a report for Alzheimer’s Australia (2014): see page 12
• Irish National Audit of Dementia Care, version 2 (2020): see page 26

Session 6: Behavioural Supports Ontario

During this concurrent session speakers described innovation within the Behaviorual Supports Ontario (BSO), including: a capacity building strategy for BSO in the South East, BSO service delivery in multiple sectors across Central East, and how Behavioural Technologists are supporting BSO in Champlain.

Speakers: Kim Schryburt-Brown, Kelly Davies, Brandi Flowers, Kaitlin Loudon and Nancy Lesiuk
Recording: View Session 6 Webinar

PDF Slides:
Capacity Enhancement in South East – Kelly Davies and Kim Schryburt-Brown
Central East Behavioural Supports Ontario Service Delivery in Multiple Sectors – Brandi Flowers and Kaitlin Loudon
Behaviour Therapy Supporting BSO – Nancy Lesiuk

Session 7: Adult Day Programs

During this concurrent session speakers described innovation adult day programs, including: virtual adult day program support, behavioural support to adult day programs and a developmental evaluation of adult day programs.

Speakers: Rhonda Schwartz, Dr. Sabeen Ehsan, Natasha Poushinsky, Jennifer McDonnell, Gillian Barrie and Margaret Camp
Recording: View Session 7 Webinar

PDF Slides:
Developmental Evaluation of Central East Intra-COVID Hybrid ADP Model – Sabeen Ehsan and Rhonda Schwartz
Enhancing Behaviour Supports in Community Settings: The Champlain Adult Day Program Pilot Project – Natasha Poushinsky
Virtual Day Programs Central East – Jennifer McDonnell Gillian Barrie and Margaret Camp

• Ontario Health (East) Central East Region Intra-COVID Hybrid Adult Day Program Model Guidelines

Session 8: Central Intake

During this concurrent session speakers described a provincial central intake project as well as specialized geriatric service coordinated access in WaterlooWellington, Hamilton-Niagara-Haldimand-Brant, and Champlain regions.

Speakers: Jane McKinnon-Wilson, Jenny Siemon, Adam Morrison and AnnMarie Dimillo
Recording: View Session 8 Webinar

PDF Slides:
Waterloo Wellington Development of Clinical Intake – Jane McKinnon-Wilson
BSO/SGS Central Clinical Intake: Hamilton Niagara Haldimand Brant – Jenny Siemon
PGLO SGS Coordinated Access Project – Adam Morrison
Champlain Regional Sub-Acute Coordinated Access – AnnMarie DiMillo


Session 9: Lived Experience and Evidence

During this session speakers shared their experience and recommendations for what transformative care should look like. Presenters described how provincial and regional evaluations and best practice guides can inform and shape post recovery planning.

Speakers: Catherine Ingram, Art Seymour, Kelly Kay, Stacey Hawkins, Ronaye Gilsenan and Dana Corsi
Recording: View Session 9 Webinar

PDF Slides:
Lived Experience – Catherine Ingram and Art Seymour
From Recovery Planning to Transformation – Kelly Kay
Using Developmental Evaluation – Stacey Hawkins and Ronaye Gilsenan
Alternate Level of Care (ALC) Leading Practices Guide – Dana Corsi

2021 Health System Concerns (Sept 1, 2021) by Art Seymour
#IAMRESILIENT Project – Honouring Older Ontarians and their resilience [Video]
Pandemic Recovery Planning for Older Adults
PGLO events
Making Canada the best place in the world to age by 2030: a senior centric strategy
Aucoin, P. & Treasury Board of Canada Secretariat (2005). Decision-making in government: The role of program evaluation. Ottawa, ON: Treasury Board of Canada Secretariat.
• Donebedian, A. (1966). Evaluating the quality of medical care. The Millbank Quarterly, 44(3), 166-206.
Dozois, E., Langlois, M., & Blanchet-Cohen, N. & The J.W. McConnel Family Foundation for the International Institute for Child Rights and Development (2010). DE 201: A practitioner’s guide to developmental evaluation.
Gamble, J. A. A., & The J.W. McConnell Family Foundation (2008). A developmental evaluation primer.
• Mark, M.M., Henry, G.T., & Julnes, G. (2000). Evaluation: An Integrated Framework for Understanding, Guiding, and Improving Policies and Programs. San Francisco, CA: Jossey-Bass
• Patton, M. (2011). Developmental Evaluation: Applying complexity concepts to enhance innovation and use. New York, NY: The Guildford Press.
• Westley, F., Zimmerman, B., & Patton, M. (2009). Getting to maybe: How the world is changed. Toronto, ON: Random House of Canada.

Session 10: Virtual Care

During this session speakers discussed virtual care strategies, with an emphasis on what works post-COVID, for whom, and when.

Speakers: Kelly Macintyre Muddle, Melanie Briscoe, Krista Dineley, Hyemi Lee, Taryn Mackenzie and Dr. Shirley Huang

Recording: View Session 10 Webinar

PDF Slides:
Leveraging Virtual Care Strategies – Melanie Briscoe and Kelly McIntyre Muddle
Virtual Care in GAIN Clinics – Krista Dineley and Hyemi Lee
Geriatric Medicine Clinics Hybrid Model – Taryn MacKenzie and Shirley Huang

Leveraging Virtual Care Strategies in Delivery of Comprehensive Geriatric Assessment (CGA)
Virtual Care Decision Tool for Older Persons’ Care
• Health and Safety Guidance During COVID-19 For Physician and Primary Care Provider Employers
Privacy and security considerations for virtual health care visits
The Virtual Neurologic Exam: Instructional Videos and Guidance for the COVID-19 Era (Hussonaa et al., 2020) Videos are in Supplemental Materials: https://doi.org/10.1017/cjn.2020.96

Session 11: Aging at Home and Conference Wrap up

During this session, speakers addressed recommendations that emerged from the Ageing Well Report and transformation that has happened as a result.
Speakers: Don Drummond and Dr. Duncan Sinclair
Recording: View Session 11 Webinar

PDF Slides:
Key Messages from Transforming Care Supporting Older Adults PostCOVID in Ontario – John Puxty

Ageing Well Report
AVOID Framework



Supporting Older Adults in Ontario Post-Covid: Recommendations for Transforming Care

These recommendations represent a summary of key messages from the October 2021 conference, hosted by Specialized Geriatric Services East, that brought together 48 expert speakers and more than 300 clinicians, policy makers, service providers, planners, researchers, older adults and care partners.


Background: Check out the recording and resources from the SGS East June 2021 webinar for more background on Special Geriatric Services and the Ontario East context.

Bookmark this page and check back throughout the summer for more information!

Hosted by: This conference is hosted by Specialized Geriatric Services East, a collaborative group of clinicians and administrators supporting older adults with complex health conditions (including frailty) across Ontario Health (East).

Specialized Geriatric Services (SGS) are those services focused on older adults living with complex health conditions including frailty, distinguished by greater specialization and the use of interprofessional teams and inter-organizational collaboration in service delivery.

This conference was hosted by Special Geriatric Services East, a collaborative
group of clinicians and administrators supporting older adults with complex
health conditions (including frailty) across Ontario Health (East).
Specialized Geriatric Services (SGS) are those services focused on older
adults living with complex health conditions including frailty, distinguished by
greater specialization and the use of interprofessional teams and interorganizational collaboration in service delivery.