Submitted by the NLCHC

The Primary Care Outreach Program to Seniors is a new program being offered through the North Lanark Community Health Centre starting in October 2014. This program has provided support to vulnerable frail seniors with complex care needs living at home with or without supports since 2008 in Ottawa. The NLCHC official program launch will take place at the North Lanark Community Health Center on Tuesday October 28th from 9:30 am to 10:30 am. All members of the community are welcome to attend to help launch this new program.

According to Jane Coyle, the Director of Health Services at the North Lanark Community Health Centre “The primary care outreach team works in collaboration with other health professionals to support high risk seniors in leading healthy and independent lives in their own homes and we are thrilled to offer this new service in north Lanark.”

The program is delivered by a Registered Nurse, Meredith Cullen, who is responsible for early intervention, assessment and monitoring. She will support the implementation of care plans as established by the clients’ Primary Care Provider. Joellen McHard the Community Health Worker works with the Registered Nurse by linking people with supports and services in the community.

“Most seniors want to remain in their home as long as possible” said McHard, “and we want to help them do that safely by providing support, information and health care at home.” Meredith Cullen shares that “We aim to help seniors maintain their health and independence so they can continue to do the things they like to do and also so we can reduce the number of emergency visits, hospital and long term care admissions.” By working in collaboration with other health professionals, geriatric partners, community agencies and the Community Care Access Centre, we are able to reduce the number of emergency room visits, prevent hospital admissions and reduce isolation.

Vulnerable seniors with complex needs face multiple challenges, frequently requiring an intense and integrated service response to enable the senior to live at home safely. Services include response to immediate needs, monitoring and support for care plans, individual health information, advice and education, screening for environmental/safety risks and mobilization. Meredith (RN) shares that older adults “might be living in isolation or have little care or support, they may have challenges accessing or maintaining a relationship with their primary care provider or they may have no or limited support services in place.” These are the seniors who resort to calling 911 or presenting at the emergency department, sometimes unnecessarily.

Primary Care Outreach to frail seniors will have a crucial role in care coordination, acting as a gateway to more acute or specialized health care services. McHard shares that “I think the hardest part will be getting our ‘foot in the door’ and I expect that it will take time to

build a trusting relationship with many of the seniors.” Meredith and Joellen are available to do a brief presentation or meet with any seniors group or agency.

The program is offered at no cost to the senior. Referrals are accepted from any source, including self referral for eligible seniors aged 65 and older, who may be isolated and at risk of hospitalization. “You do not have to be a health care provider to make a referral to the program,” says Jane Coyle. “Perhaps you know a senior in your community who is struggling at home? We encourage you to talk to them about this program and ask them to call. Alternatively you can get their consent to call and make a referral on their behalf or encourage them to talk to their doctor about making a referral.”

To make a referral to the program please call 1-844-726-5115. Referral forms are available online at or you can get a copy of the form at the Community Health Centre in Lanark. For more information about the program or to invite a speaker to come to your group/organization, call the North Lanark Health Centre at 613-259-2182 and ask to speak with Joellen or Meredith. This program is funded by the Champlain Local Health Integration Network (LHIN).