New model of care makes aging at home easier

June 13, 2025.

Across Frontenac, Lennox and Addington counties, more people are living longer—and many want to continue living at home as they age. But navigating the health and social services needed to make that possible isn’t always easy—care can be fragmented and  services can be often siloed. While help is available, it isn’t always well connected or easy to access, especially for people with complex needs. At the same time, primary care providers (family doctors and nurse practitioners) are stretched, without the time or tools to coordinate the range of support people may need.

Recognizing the need for change, the Frontenac, Lennox & Addington Ontario Health Team (FLA OHT) brought together local partners to design a more connected model of care to support people to age well at home. The result is the Living Well with Home Care project—an innovative new approach that makes it easier for people to access care at home, where they feel safest and most comfortable.

Launched in February 2025 at the Loyalist Family Health Team, an FLA OHT primary care partner, the project is a collaboration between Kingston Health Sciences Centre, Loyalist Family Health Team, Ontario Health atHome, SE Health, and the FLA OHT. It builds on years of work by the FLA OHT’s Aging Well at Home Working Group, a network of care providers, community organizations, researchers, and older adults who identified practical ways to support people to live and age well at home.

A foundation in collaboration

The FLA OHT led the development of this pilot through a local, collaborative process—grounded in real community insight and driven by a commitment to health equity and person-centred care.

“This project is an important step toward our vision of a more connected and fair health system,” says Jonatan Bobadilla Maldonado, Home Care Project Lead for the FLA OHT. “By bringing care providers together and making services easier to access, we’re helping people get the right support at the right time—based on their unique needs.”

The project is part of a broader provincial initiative to modernize home care, and the FLA OHT’s model was selected as a Leading Project by Ontario Health. It reflects not only local innovation but regional leadership—positioning FLA OHT as a blueprint for other communities reimagining home and community care.

A more connected model of care

At the heart of the Living Well with Home Care project is a new model that brings primary care and home care providers together into one coordinated team—right inside a person’s Health Home.

“Primary care is the foundation of a strong health system,” underscores Jonatan Bobadilla Maldonado, Home Care Project Lead. “When we integrate home care and connect people to community supports, we can help more people live well at home—and ensure those who need the most help get it.”

This means that home care providers—like personal support workers, nurses, physiotherapists, and care coordinators—work directly alongside family doctors, nurse practitioners, and allied health professionals in the same primary care setting. This integrated approach allows the team to share information, meet regularly, and respond more quickly to each person’s evolving needs. It also reduces confusion, delays, and duplication of services.

“Working in an interdisciplinary team gives me comfort in knowing there are multiple perspectives and skillsets coming together to brainstorm how we can best optimize each person’s health and function,” explains Dr. Jenna Moodie, family physician and the physician lead for the project. “I’ve learned a lot from my allied health colleagues about different community resources and supports that can fill gaps in patient care that I didn’t know how to address prior.”

“The program has allowed me to provide a holistic approach to care, we have the benefit of time and are able to put the patient first, always,” adds Leeann Miller, Registered Nurse Practitioner with the project.

To support this model of care, the project has introduced two new roles:

• The Aging Well at Home Advocate works with people in the minimal support stream, helping them stay well and independent by connecting them with local resources—like transportation, meal programs, and wellness supports.
• The Health and Social Care Integrator is a clinician who supports people in the maximal support stream. They provide direct care, coordinate medical supplies and services, adjust care plans as needs change, and help navigate both health and social services—ensuring people get timely access to the full range of care they require.
  

These roles also work together to address maximal support patients. By strengthening the connections between primary care, home care, and community services, this model delivers a more personal, proactive, and effective experience—especially for older adults and those with complex needs. It’s already having a positive impact on members in our community. 

“One of my patients previously told me during an appointment that she was very isolated and lonely in her apartment,” shares Dr. Moodie. “She struggles with chronic pain secondary to severe hip and knee arthritis, and this greatly impacts her mobility. Since being connected with care workers from the Living Well With Home Care project, not only has she worked to improve mobility and function with occupational therapy / physiotherapy, but she was extremely grateful for the company and continuity of the same care workers in her home.”

Scaling a model that works

To make care more proactive and equitable, the FLA OHT introduced a population-based approach that helps make sure the right services are delivered to the people who need them most. Everyone receiving home care through this project is grouped into one of three levels of support—minimal, moderate, or maximal—based on their risk of emergency department visits, hospital stays, or readmissions. This helps the care team match services to each person’s needs, ensuring resources are used more effectively and fairly.

“Health is not the responsibility of a single person or organization,” Jonatan emphasizes. “That’s why building a united health system—where different organizations work together to provide care tailored to each person’s needs—is so important.”

As our population continues to age, innovative and community-led models like Living Well with Home Care will be essential. With strong leadership from the FLA OHT and its partners, this region is setting the pace for a more connected, equitable, and compassionate future of care.

“What excites me most about this project is the opportunity to help people stay independent and safe in the place they know best—their home,” adds Jonatan. “We’re supporting people to live well, stay engaged in their care, and get the services that truly match their needs.”

Learn more about the Living Well with Home Care project here.