Ontario's aging population requires integrated, community-based models to help older adults age in place. The Community Wellness Hub (CWH) model meets this need by embedding proactive, interdisciplinary care within housing sites with high concentrations of older adults. Using a co-located “one-team” approach, CWH integrates health, social and housing services for individuals with complex needs. Implementation is described across seven stages: partner collaboration, governance, site selection, service tailoring, team integration, continuous evaluation and scaling. Impacts include improved member wellness and provider experience while reducing hospitalizations for ambulatory care-sensitive conditions and lowering per capita healthcare costs. This paper provides a blueprint for implementing this scalable, equity-focused model in other jurisdictions.

Introduction

Population aging is transforming communities across Ontario and Canada as a whole, creating an urgent need for integrated, community-centred approaches that enable older adults to age safely and independently in place. In Ontario, the number of older adults (aged 65 years and older) is projected to rise from about 3.0 million in 2024 (18.3%) to 4.6 million by 2051 (22.4%) (Ontario Ministry of Finance 2024). Older adults consistently express a strong preference to remain in their homes and communities as they age (American Association of Retired Persons 2014; DePaul et al. 2022), with 96% of Canadian adults reporting the same (National Institute on Ageing 2022). Yet many anticipate that their current living environments may not support future independence, highlighting a critical gap between desire and feasibility (DePaul et al. 2022).

Aging in place means having the health and social supports and services needed to live safely and independently at home or in the community for as long as you wish or are able (Federal/Provincial/Territorial Ministers Responsible for Seniors Forum 2012). Achieving this goal requires addressing not only medical needs but also the physical, social and environmental determinants that shape daily life (Brim et al. 2021). Informal caregivers can play an important foundational role in supporting older adults in the community; however, such support is not guaranteed and may be inadequate to overcome the multiple, intersecting barriers that can limit aging in place. Barriers to aging in place are multifaceted, including functional limitations, affordability, home accessibility, safety and maintenance challenges (Brim et al. 2021; Fausset et al. 2011). Social isolation further compounds these risks, contributing to increased morbidity and mortality, including cardiovascular disease, cognitive decline, depression and premature death, as well as higher rates of avoidable hospitalizations, extended stays and transitions to long-term care (DePaul et al. 2022)

Within Canada and internationally, there is great interest in moving toward community-based models that integrate health and social care. As such, diverse models have emerged to support older adults living in community, including the Program of All-Inclusive Care for the Elderly, Naturally Occurring Retirement Communities and the World Health Organization's Integrated Care for Older Persons framework (DePaul et al. 2022; Healthcare Excellence Canada 2023; Huang et al. 2025; Kyriacou and Vladeck 2011). While these approaches emphasize comprehensive assessment, multidisciplinary collaboration and ongoing monitoring, there is limited documentation on how to implement and sustain them across varied community and housing contexts. This study addresses this gap by providing a blueprint of an advanced Canadian example for health systems seeking to advance equitable, scalable aging-at-home initiatives.

The intervention

The Community Wellness Hub (CWH) model, developed by the Burlington Ontario Health Team (OHT) and Halton Community Housing Corporation (HCHC), addresses the urgent need for integrated care among high-priority populations – particularly older adults facing compounded vulnerabilities related to age, income, health and social determinants.

Burlington OHT serves 250,000 residents, while HCHC provides affordable housing, including seniors' residences where tenants often experience barriers to aging safely at home, such as limited mobility, chronic conditions, social isolation and poor access to coordinated services.

The CWH model closes these gaps by delivering proactive, person-centred care directly within housing sites with high concentrations of older adults. It unites health, housing and social service providers into one interdisciplinary team that supports CWH members with complex needs. Key features include:

• Integrated care: coordinated medical, social and wellness services to reduce fragmentation;
• Proactive outreach: CWHs located in areas with high-need populations identified through data;
• Team-based approach: providers from multiple sectors co-manage care plans and respond to emerging needs;
• Resource optimization: leverages existing services and infrastructure through co-location and shared governance;
• Equity and accessibility: brings care closer to home, removing barriers and fostering trust.

Launched in Burlington in 2019, the model has expanded to seven sites across Halton and Hamilton, serving residents and older adults in surrounding communities as members. It is attracting interest across Ontario as a scalable solution for aging in place.

Methods

This paper adopts a descriptive implementation case study design to examine the design, implementation and outcomes of the CWH model in Ontario, Canada (Baxter and Jack 2008; Yin 2018). This approach was selected for its capacity to document an in-depth description of “how” and “why” an integrated, place-based intervention was developed and operationalized within a complex health and social care system (Yin 2018). As such, a descriptive case study was particularly suited to capturing the implementation logic and real-world dynamics that shaped this model, providing a blueprint of actionable insights for jurisdictions seeking to design or replicate similar initiatives.

The blueprint for development and implementation is structured around seven stages: (1) collaboration among core CWH partners; (2) governance; (3) identifying priority neighbourhoods for implementation; (4) tailoring service offerings to community needs and assets; (5) building the multidisciplinary team of service providers and partnerships; (6) establishing continuous measurement and refinement; and (7) scaling and spreading. Finally, a brief overview of CWH outcomes is discussed. By articulating the methods and governance underpinning each stage, this paper addresses a critical gap in the literature and provides actionable guidance for jurisdictions seeking to integrate health and social care through community-centred CWHs.

Case study overview

In this section, the seven stages of implementation shown in Figure 1 are described, along with a brief description of what this looks like in practice from one of the operational CWHs.

1. Collaboration among core CWH partners

The strongest foundational component of every CWH is the partnerships established across health, housing and social sector organizations that agree to work together as a team to establish a CWH. The partners required for a CWH include: (i) lead organization: typically a community support service organization with expertise in system navigation, responsible for implementing and managing the operations of the CWH; (ii) housing or space provider: the organization that will be providing the shared space for the CWH to operate within; (iii) additional partner to take on project management and data collection management (if not completed by the lead organization). Partnerships are established in writing through a Memorandum of Understanding, which clearly defines the expectations and accountabilities of each partner as well as the overarching vision, goal and guiding principles of the CWH.

2. Governance

Each CWH operates under a local collaborative governance structure composed of executive leaders from the local OHT(s), housing partner, lead organization and other partners. This group sets the overall strategy, goals, resource allocation and decisions related to spread and scale. To support implementation, many CWHs also establish an Operations Table, which includes operational leaders from partner organizations. The Operations Table is accountable for day-to-day performance, quality improvement and executing priorities set by the Leadership Table. Together, these tables ensure alignment between strategic direction and operational delivery.

At the provincial level, the Community of Practice, introduced by Burlington OHT in 2025, connects organizations exploring, implementing or managing CWHs. It facilitates knowledge sharing, supports advocacy for spread and scale and demonstrates collective impact. While not part of local governance, it strengthens consistency and learning across CWHs.

3. Identifying priority neighbourhoods for implementation

This process starts with population health data review, during which a team of population health and data experts scores buildings based on a needs index that quantifies vulnerable population density and health and social needs. This scoring system is then used to rank the buildings from the highest to the lowest need, where those with the highest need are prioritized for CWH development. The selected location of a CWH can be in or near community housing where older adults, made vulnerable by social determinants of health, reside in high densities. In cases where the CWH is not situated within an apartment building, it is valuable to establish partnership(s) with nearby housing organization(s) as part of the CWHs' foundational partners.

4. Tailoring service offerings to community needs and assets

Services at each CWH are determined through an assessment of local gaps, needs and existing resources. Before implementation, members participate in an education and feedback session to learn about the model, review examples and complete a survey rating the need for health, housing, wellness and social services.

CWHs collaborate with publicly funded providers already serving the area to identify current offerings and service gaps based on their experience with members. Leaders also draw on insights from the Community of Practice to incorporate highly requested and impactful services into tailored offerings (Figure 2).

5. “One-team approach” across a multidisciplinary team of service providers and partners

The CWH lead organization partners with service providers to deliver integrated, publicly funded health, social and housing services through a cross-sector team approach. At each CWH, providers work collaboratively to:

• Use a single intake assessment and care plan to reduce duplication.
• Communicate changes in member status for timely follow-up or care plan updates.
• Problem-solve complex cases together.

A Community Connector, employed by the lead organization, serves as the on-site first point of contact for members and providers. This role manages intake, care planning and care coordination, engages members about evolving needs and ensures that they are informed about CWH programming.

To enable secure, efficient information sharing among interdisciplinary teams, Burlington CWHs launched a one-year pilot of a shared digital care record in 2025. Its impact on collaboration and integration will be evaluated.

6. Establishing continuous measurement and refinement via a learning health system approach

A cornerstone of the CWH model is its commitment to continuous measurement and iterative refinement, ensuring that integrated care delivery remains responsive, effective and equitable for high-priority older adult populations. This approach is embedded from the outset of implementation and sustained through structured governance, shared accountability and data-informed decision-making. The CWH model operates as a learning health and social care system, where data collection, reflection and adaptation are integral to daily operations. Each CWH is required to report on a standardized set of operational and outcome metrics, enabling both local and system-level learning.

1. Operational metrics: these metrics track day-to-day operations; examples include number of active members, completed care plans, referrals made, participation in wellness programming, workshop attendance and satisfaction. These data are synthesized into monthly dashboards reviewed by the CWH Operations Table, a cross-sectoral group of implementation leaders. This structure ensures that real-time insights drive local adaptations, such as expanding high-demand services or addressing barriers to engagement, while also contributing to broader system learning. The CWH model prioritizes equity-driven measurement, recognizing that high-priority populations often face systemic barriers to care. Data are disaggregated by key social determinants, such as income, language and housing status, to identify disparities and tailor interventions accordingly. For example, if a CWH identifies low participation among linguistically isolated members, it may introduce multilingual programming or culturally appropriate outreach strategies.
2. Impact metrics: these metrics are organized around the quintuple aim framework (Nundy et al. 2022) to showcase the various impacts of the CWH as an integrated care model. Metrics track progress toward the overarching aims of the CWH, which include enhancing collaboration among providers, increasing social connectedness, reducing barriers to services and supporting aging in place. Three co-designed tools formed the foundation of impact data collection across CWH sites:
   1. CWH member experience survey: captures members' perceptions of accessibility, coordination, cultural responsiveness and social connectedness. Administered annually, it includes Likert-scale items and open-ended questions to capture both quantitative trends and narrative insights.
   2. CWH provider experience survey: measures provider perspectives on interprofessional communication, collaboration, workflow efficiency and job satisfaction. Conducted annually, this survey reflects the CWH's focus on provider well-being as a key component of system sustainability.
   3. CWH assessment tool (intake and follow-up survey): a repeated-measures instrument administered at intake and every six months. It assesses physical and mental health, loneliness, community belonging and overall quality of life, enabling tracking of change over time at both individual and aggregate levels.

Additional data sources included administrative datasets that track acute care utilization and tenancy duration.

CWHs fundamentally transform the provider experience by fostering interdisciplinary teamwork, resource sharing and streamlined communication. Providers report that working within a CWH enables them to serve more patients efficiently, reduce travel time and avoid duplication of services. The presence of an on-site Community Connector facilitates daily relationship-building with both members and other providers, increasing awareness of available services and promoting a sense of shared accountability. Providers describe the CWH as a space where they can leverage each other's strengths, collaborate on care plans and collectively address member needs. This team-based approach not only improves effectiveness and retention but also enhances job satisfaction by allowing providers to witness real-time improvements in members' health and well-being. The CWH model transforms care delivery from isolated organizational silos to a unified, collaborative system, making providers feel part of a larger mission to improve community health.

For members, the CWH model delivers accessible, adaptable person-centred services that support aging at home. Members benefit from a close-knit community, monthly social activities and the comfort of receiving most services on-site.Testimonials highlight the value of having a trusted Community Connector available daily, who assists with tasks ranging from reading mail to navigating health appointments. Members report increased social inclusion, improved self-esteem and a renewed sense of dignity, describing the CWH as a place where they feel visible and supported.

The model is designed to serve equity-deserving populations, with co-designed processes that address cultural, language and accessibility needs. Demographic data from Burlington's CWH shows an average member age of 74, average income of $20,000 and 11% of members speaking a non-English first language, underscoring the CWH's reach into vulnerable communities. Members consistently express appreciation for the ability to access comprehensive services within their own community, reducing barriers to care and fostering a sense of belonging. Data show that the CWH is helping older adults maintain or improve their health and wellness, even as they age living with complex, chronic conditions.

Despite expected disease progression, 63% of members report their general health is the same or better after joining the CWH; similar or improved ratings are seen for pain/discomfort (68%), physical health (68%), feelings of loneliness (74%), mental health (79%) and feeling anxious or depressed (68%). Most members feel their overall wellness is the same or better since participating in the CWH, and average tenancy is longer among CWH members (8.6 years) than non-CWH tenants (7.9 years), suggesting the model supports stability and aging in place.

CWH members also use hospital care more appropriately: 94% of their emergency department visits are urgent/emergent (Canadian Triage and Acuity Scale [CTAS] 1–3) and only 6% are less-urgent/non-urgent (CTAS 4–5), compared with 80% and 20%, respectively, in the broader Ontario 65+ population. Rates of hospitalizations for Ambulatory Care-Sensitive Conditions (ACSCs) are much lower for CWH members (1,724 per 100,000) than for frail community homecare clients (2,493 per 100,000) and high-chronic, high-frailty populations (8,123 per 100,000). For those who are hospitalized with ACSCs, the average length of stay is about one day shorter for the CWH group (approximately 7.6 vs. 8.6 days), contributing to an estimated CAD$89.7 million in annual cost savings per 100,000 people compared with a high-chronic, high-frailty comparison group.

7. Scaling and spreading

As champions of the CWH model, we have actively sought opportunities to share its approach and impact through local media, health and social care conferences and engagements with funders and system leaders (Welsh 2024). A Standardized Implementation Guide was developed to outline core components, practical steps and tools for scaling the model. Current efforts focus on tailoring CWH for other priority populations and determining which elements of this complex intervention are essential for consistent implementation versus those adaptable to local contexts.

Key Lessons Learned

Co-design and shared governance are essential for true integration

Successful implementation of the CWH model hinges on collaborative governance structures that bring together health, housing and social service partners. The use of leadership and operations tables ensures that strategic decisions and day-to-day operations are informed by diverse perspectives and aligned with community needs. The heart of this approach is the creation of a shared vision that unites all partners together and keeps them working toward the same goal.

Evaluation must be embedded and iterative

Embedding evaluation within operations from the outset has enabled CWHs to function as a learning system where data are continuously collected and analyzed from everyday practice. Data can be used to generate actionable insights that inform performance and refinement of the model until it reaches optimization, then scale and spread. Achieving the quintuple aim within integrated care models remains a global challenge (Kumpunen et al. 2019). One key reason is that corresponding evaluations rarely align with the model's maturity level or use tailored data collection tools. When measured against the quintuple aim, the CWH succeeded in delivering positive outcomes across all five domains by carefully timing what to measure and when. For example, during early implementation, experience metrics served as the most meaningful indicators – acting as early signals of change. Over time, as the model matured, other domains such as health outcomes and value began to demonstrate measurable improvements.

Scaling requires standardization while staying sensitive to local needs

A key lesson in scale and spread has been the importance of balancing fidelity with flexibility, especially because equity is a central design principle of the CWH model. Standardized elements such as the Memorandum of Understanding, intake assessments and shared evaluation tools ensure consistency across sites and enable scalable implementation. At the same time, flexibility is essential to ensure that services remain relevant and meaningful to members, particularly in communities facing systemic barriers to access.

Sustained leadership and advocacy drive spread

The spread of the CWH model has been catalyzed by visible leadership, strategic advocacy and demonstration of impact. Presentations at international, national and provincial forums, engagement with funders and alignment with broader health system priorities such as OHTs and community safety and well-being plans have positioned the CWH as a practical and scalable solution to aging-at-home challenges.

Conclusion

The CWH model provides an innovative approach to aging at home by addressing social determinants of health through proactive, integrated care. Guided by local governance, services are tailored to community needs and delivered close to home. Ontario's transformation in primary care, emphasizing interdisciplinary collaboration and social service integration, creates an opportunity to scale evidence-based models such as CWH, fostering partnerships across health, social and housing sectors for more connected systems of care.

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