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Support by Sector
It is important to recognize that many sectors provide services to older adults living at risk. Each sector is guided by different legislation and mandates which results in unique responses. The information provided here highlights the different roles and possible responses to supporting older adults at risk across sectors.
Mental Health Services
For ease of use of this cross-sectoral support guide, Mental Health Services were seen as necessary supports across all of these sectors and are embedded into each appropriate area below.
Sectors
Mental Health Services: Mental Health Services were seen as necessary supports across all of these sectors and are embedded into each appropriate area below.
Justice
For the purposes of this guide, the Justice Sector includes:
Justice Resources & Links
This guide outlines a variety of age-related conditions and presents strategies for working with or caring for these populations. Best practices for engaging with the police and the courts are explored, with detailed summaries of the criminal and mental health law systems. Finally, challenges and available services in correctional facilities are described, including supportive housing options.
Police
As a service provider, it is important that you are aware of how involving police services may impact your client/family and when/how to initiate a call for support. We split this category into 4 areas (click each for more information):
The Seniors at Risk Officer (attached to the domestic violence unit) fully investigates all elder abuse cases, works with community partners to mitigate risk, supports safety planning, and ensures the appropriate victim services are provided. The Seniors at Risk Officer acts as a secondary response unit; As uniformed officers respond to calls and identify older adults at risk, the information is forwarded to the Seniors at Risk Officer for follow up.
The vulnerable persons registry is also available through the Guelph Police Services.
The Ontario Provincial Police values the aging population and has developed the “Resource Guide to Living Well Aging Well” to provide seniors, loved ones and caregivers with information and resources available to assist them in maintaining their safety and wellness in a variety of situations.
Wellington County O.P.P. continues to commit to supporting older adults at risk by working collaboratively with community partners to support social development initiatives to minimize risk to seniors and increase community safety through safety-focussed consultation.
Consists of specially-trained clinicians to mental health + addictions related calls alongside police officers. This is a regional partnership and includes both Guelph Police and Wellington County OPP. Referrals to IMPACT are initiated through police dispatch. IMPACT clinicians assist in liaising with acute care, making appropriate referrals to community services and support the transition between those services.
A few helpful definitions:
Domestic incident – Any incident that the police have been called to investigate, between persons who have been or are presently involved in an intimate relationship regardless of whether a criminal offence has occurred.
Intimate partner violence (domestic violence) – Any use of physical force, actual or threatened, or threatening/harassing behaviour between persons who are or have been involved in an intimate relationship. Intimate partner violence can be a pattern of abuse or a single act
Intimate Partner = Include those between opposite-sex and same-sex partners, including current and former dating, common-law or married couples or in instances where one party feels like they are in a relationship, regardless of whether or not there has been sexual activity.
If an instance of intimate partner violence is reported to the police and a charge has been laid, the process that unfolds is directed by the justice system. At times, a spouse/partner of a senior living at risk, particularly in situations of intimate partner violence, may be reluctant to contact police. This is because once charges are laid there is a complex set of rules and procedures that must be followed. It is important that caregivers clearly understand that if they report a criminal offence to the police, the police will investigate. Once the police have knowledge that a crime has been committed, the police are obligated to lay a charge in cases of intimate partner violence.
Tip: Encourage caregivers to ask for the officer’s business card so that they can contact him or her with any information or questions.
Police can arrange contact with Victim Services if the caregiver/partner wants the support of this resource.
Police Resources & Links
Project Lifesaver Guelph Wellington: helps families protect members who may wander in Guelph and Wellington County. Typically these are people living with Alzheimer’s, autism, Down’s Syndrome, acquired brain injury or other types of cognitive impairment. These individuals can be equipped with a 1 ounce wrist transmitter that sends a radio signal which can be tracked up to a 2 kilometer radius. The system operates all day, every day of the year.
Interpretative Services: The Ministry of Citizenship and Immigration offers free interpretative services for victims of DV, sexual violence or human trafficking.
Safe Pathways: supporting dementia in the justice system is a collaborative community approach, to support and guide individuals with dementia and their care partners away from and/or through the Guelph and Wellington County Judicial System while maintaining dignity and respect. A caregiver/family safety plan is available for service providers.
Crown Attorney
Once charges are laid, the Crown Attorney is the person who determines how to proceed with a legal case and whether charges are prosecuted. They will proceed with screening all files, notifying Family and Children’s Services if appropriate, meet with the victim (caregiver/partner), seek appropriate conditions to protect the victim, witnesses and the public should the senior be released, and request reports and/or psychiatric assessment, where appropriate.
If you are a healthcare provider and you have questions about supporting your client with respect to privacy legislation, please refer to the section on privacy and speak with your privacy officer.
Court Support
Mental Health Court: Support Coordinators provide bail, diversion and non-diversion support to address needs such as housing, treatment, crisis planning and court support. These services are available for youth and adults depending on the region.
Mental Health and Justice Services – CMHA WW
CMHA Mental Health and Justice Services helps people who are experiencing mental health concerns (whether diagnosed or symptoms suggesting a major mental illness) who are also charged with a criminal offense in Waterloo or Wellington region. They offer advocacy and individual assistance in accessing services and community resources for adults 18+. Referrals are made through Here 24/7 (1-844-HERE 247). The MH&J team is also available for consultation.
Guelph-Wellington Women in Crisis
Women In Crisis also offers a Family Court Support Program for women who have experienced abuse and are currently involved in or about to enter the Family Court process.
Court Support can enable easier navigation through the justice system and connect individuals with community service providers to address their concerns.
Court Support Resources & Links
- CMHA Mental Health and Justice Services
- 1-844-437-3247 (HERE247) TTY: 1-877-688-5501
Victim Services Wellington
Victim Services Wellington is responsible for providing on-site emotional and practical support to victims of crime and tragic circumstances throughout Guelph and Wellington County. There are a number of other programs and services available.
Victim/Witness Assistance Program
The Victim/Witness Assistance Program is offered through the Ontario Victim Services Secretariat within the Ministry of the Attorney General. The program’s mandate is to provide information, assistance and support to victims of crime throughout the criminal court process in order to increase their understanding of, and participation in, the criminal court process.
Once a criminal charge has been laid, services are offered on a priority basis to victims of sexualt assault, intimate partner violence, hate crimes, families of homicide victims or traffic fatalities, vulnerable victims with special needs and older adult victims.
Legal Support
Advocacy Centre for the Elderly (ACE)
ACE provides direct legal services to low-income seniors, public legal education, and engages in law reform activities. ACE services and activities are in relation to areas of law of special importance to the seniors’ population. ACE is funded through Legal Aid Ontario.
Legal Clinical of Guelph and Wellington County
The Legal Clinic of Guelph and Wellington County provides free legal services for low-income people in Guelph and Wellington County.
Legal Support Resources & Links
Elder Mediation
Community Justice Initiative (CJI)
Community Justice Initiative (CJI) utilizes a restorative justice approach to provide conflict resolution for seniors who are friends, family members, and neighbours in Waterloo Wellington. They also work with victims and offenders. During a mediation, trained facilitators ensure that everyone has a chance to speak and listen. Participants discuss how a situation impacted them and ask questions. All are encouraged to take responsibility for their actions and repair harm. Participants leave with a mutually acceptable plan to move forward.
Home and Community
For the purposes of this guide, we have included the following programs/services within the Home and Community sector:
Guelph Wellington Seniors at Risk
Seniors at Risk Clinical Consultant – CMHA WW
This service is not intended to be a crisis response and typically provides contact 3-7 days post referral. The clinical consultant provides support and consultation regarding vulnerable older adults and their families in Guelph and Wellington County. This role functions as a part of the broader Specialized Geriatric Services and HERE 24/7 team and works to build capacity of service providers to support their older adult clients with mitigating and minimizing risks. Access to emergency shelter in Guelph Wellington is also available. Referrals are directed through HERE 24/7 at 1-844-437-3247.
- HERE 24/7
- 1-844-437-3247 (HERE247) TTY: 1-877-688-5501
Guelph Wellington Seniors at Risk Consultation Team is a network of service providers working to ensure there is a coordinated community response to supporting older adults living at risk using a collaborative, multi-disciplinary approach across health and social services, legal and police services. The purpose of the consultation team is to advise service providers who are dealing with complex situations involving vulnerable older adults on available options to improve each agency’s response for support. For more information, contact the Vulnerable Seniors Lead 519-821-8089 x2105.
- Vulnerable Seniors Lead 519-821-8089 x2105
Elder Abuse Prevention Ontario
Elder Abuse Prevention Ontario (EAPO) is a provincial, registered charitable organization responsible for implementing the Ontario Strategy to Combat Elder Abuse. The framework of the strategy focuses on three priorities – community service coordination, building local capacity of front-line workers/caregivers/community networks and service professionals through training and through public education forums raising overall awareness about the complexities of elder abuse.
A Regional Consultant with EAPO is a member of the Guelph Wellington Seniors at Risk Network and supports local community services and other initiatives as required/appropriate. For more information, contact: [email protected]
LHIN Home and Community Care
Care Coordinators with the Local Health Integration Network (LHIN) are regulated health professionals who are based in the community and/or local hospitals. They conduct eligibility and service needs assessments. In collaboration with clients and families/caregivers, they develop, initiate and coordinate individualized care plans to achieve mutual goals. They also provide ongoing case management, system navigation, future planning and discharge planning to supportive settings as required.
LHIN Care Coordinators are evaluators of capacity for Long Term Care. Capacity evaluation for admission to a long-term care home involves an important and complex assessment with significant consequences for those being assessed. If a person is deemed capable, he/she retains the right to decide where they will live, including whether or not they will move to a long-term care home. If declared incapable, the individual loses that autonomy, and someone else will make the decision on their behalf.
Community Support Services
Community Support Services (CSS) are not-for-profit agencies committed to providing a continuum of services ranging from prevention to end of life care. Services benefit a full range of clients, including seniors, people of all ages with disabilities or chronic illness, and their caregivers. Funding for services are often through a combination of sources including: LHIN, client fees, private donations and/or other grant programs. For the purpose of this guide, we review local Adult Day Services, Overnight Respite and the Alzheimer Society in further detail below. For more information on additional CSS visit: wwhealthline.ca (Community Support Services – Wellington)
Adult Day Services and Overnight Respite
Adult Day Services offer full-day opportunities for clients to participate in a social/recreational program while providing respite to caregivers and families. Additionally, some programs offer direct support and health system navigation to families/caregivers. Programs can offer a full-day of support and a safe place for an older adult at risk while caregivers, family members and/or community partners work together to develop a safety plan. Referrals are made via the LHIN Home and Community Care.
Programs are offered through:
Short-term overnight respite services are also available through the Regional Overnight Stay Program (a collaborative model between St Joseph’s Health Centre Guelph and Sunnyside Seniors Services) . This service can provide an older adult at risk temporary safe shelter to allow caregivers, family members and/or community partners time to plan for a more permanent or longer term housing solution. This is an opportunity to remove the client from the identified risk environment, while providing supervision and ensuring the client’s basic needs are met. Contact the programs directly for consultation to determine suitability and availability.
This video on “Respite Care in Waterloo Wellington” may be helpful to you when suggesting this option to your client:
Alzheimer Society Waterloo Wellington (ASWW)
ASWW works with care partners and people who are living with dementia to identify possible risks with memory related changes that impact one’s ability to function in their home and to develop safety plans that help the person living with dementia to live safely in the community. We might do this through an education session, telephone support, care partner support groups or through individual or family counselling.
Behaviour Supports Ontario
A multi-disciplinary team of clinicians who assess older adults with cognitive impairment for specific responsive behaviours arising from dementia, mental health and/or addictions. The clinicians work collaboratively with identified caregivers on strategies to manage the behaviour and/or associated risk.
A multi-disciplinary team of clinicians who provide assessment on specific responsive behaviours arising from dementia, mental health and/or addictions in order to facilitate a positive and successful transition across sectors (i.e. from Community to Long Term Care or Hospital to Community).
In Waterloo Wellington, BSO is hosted by St. Joseph’s Health Centre Guelph and is an integrated extension of Specialized Geriatric Services (SGS) working closely with the primary care practitioner or geriatric specialist. It is preferred that a thorough geriatric assessment is completed and pharmacotherapy reviewed/optimized, prior to BSO involvement.
Referrals can be made by healthcare professionals via the Specialized Geriatric Services Referral Form.
Wellington Guelph Hoarding Response
The Wellington Guelph Hoarding Response (WGHR) represents a committed group of organizations in Guelph Wellington that have come together to provide support and resources for persons with hoarding challenges. Together they continue to build capacity to support each other and situations where home safety is compromised due to clutter. A coordinator is available for consultation.
Health Care
This section includes the following programs and services as part of the older adult’s health care team:
Primary Care
Primary care is the day-to-day healthcare given by a health care provider. Typically this provider acts as the first contact and principal point of continuing care for patients within a healthcare system, and coordinates other specialist care that the patient may need. Primary care is seen as a “gatekeeper” and as a patient’s medical “home”, helping patients navigate throughout their whole care journey. Primary care could be seen as the best place within the health system to identify, provide and coordinate care for at-risk older adults (Reference: University of Waterloo – Geriatric Health Systems Research Group)
Specialized Geriatric Services (Medicine/Psychiatry)
Specialized Geriatric Services (SGS) is a community based network of interdisciplinary teams (geriatricians, geriatric psychiatrists, specialized nurses and social workers, intensive geriatric service workers). SGS completes a comprehensive holistic assessment of a client which promotes improved health/wellbeing, improved function and decreased risk. Ongoing assessments, treatments, monitoring as well as support and education are available to clients and their families. A physicians’ referral is required.
Community Paramedicine – Guelph Wellington Paramedic Service
Community paramedicine is an evolving model of community-based health care in which paramedics function outside of their traditional emergency response and transport roles. The program aims to support individuals to access collaborative resources in order to reduce dependency on 911 and possible transports to the local emergency department.
Paramedic Referrals: Frontline Paramedics can refer directly to the LHIN Home and Community Care or HERE 24/7 advising when an older adult could benefit from additional support and intervention.
Paramedic Home Visits: For clients with frequent calls to 911, the community paramedics can provide home visits to determine an alternate support plan for the individual (i.e. supported referrals).
Community Health Assessment Program (CHAP): Paramedics also offer health monitoring clinics in Wellington County Housing buildings. Monitoring includes social determinants, food security, blood pressure monitoring, blood sugar checks, and falls risk assessment.
Remote Patient Monitoring: People that suffer from congestive heart failure (CHF), diabetes (DM) and/or chronic obstructive pulmonary disease (COPD) will be monitored remotely through technology to recognize exacerbations and trends to improve patients health awareness and decrease dependency on emergency services and hospitals admissions. Paramedics work collaboratively with LHIN Rapid Response Nurses and Primary Care to provide wrap around care for unstable patients.
For more information about access and referrals to the Community Paramedicine Program, contact the Coordinator at 519-822-1260 x3379.
Community Paramedicine Resources & Links
- HERE 24/7
- 1-844-437-3247 (HERE247) TTY: 1-877-688-5501
- Community Paramedicine Program
- Coordinator – 519-822-1260 x3379
Acute Care
Care for older adults at risk often begins with a Geriatric Emergency Management (GEM) nurse assessment in the Emergency Department. A GEM nurse is a specially trained nurse in geriatric medicine and can assess older adults for geriatric syndromes. GEM nurses work in collaboration with Specialized Geriatric Services to create comprehensive treatment plans and liaise with community supports to allow for community based follow up to further address safety concerns for seniors at risk.
Treatment for older adult patients while residing in hospital is based on a multidisciplinary approach to care. A team of physicians, allied health professionals (social work, therapy), nurse practitioners, specialists (i.e. geriatricians, psychiatry) work to create comprehensive assessments and treatment plans during the stay as well as contributing to safety plans as necessary when older adult living at risk are returning back to reside in the community.
Homewood Health Centre
The Program for Older Adults supports those dealing with depression, anxiety, dementia, or other mental health needs through a multidisciplinary clinical team, led by physicians and offers three treatment streams to meet the diverse needs of patients. All three streams provide a comprehensive assessment, individualized treatment and recommendations for the continued management of care after discharge.
Grand River Hospital
Both the Geriatric Assessment Unit (GAU) and Neuro-Behavioural Unit (NBU) are located in the Grand River Terrace Building at the Freeport Campus. The Geriatric assessment unit inpatient service is designed for frail seniors who need an inpatient admission. They have a number of health professionals working together to give patients comprehensive geriatric assessment and treatment. The neurobehavioural unit offers specialized assessment and treatment for adults living with age-related conditions that may include dementia.
There is also a specialized mental health unit for seniors who have a cognitive impairment typically related to dementia. Patients may have responsive behaviours such as aggression, wandering, physical resistance or agitation. The behaviour is termed “responsive” because the person is responding to something negative, frustrating, or confusing in his or her environment.
The PRC provides consultation, education and training to Long Term Care (LTC) Homes and Acute Care settings regarding older adults who exhibit complex responsive behaviours associated with physical and mental health needs. PRCs collaborate to bring together the right people and resources to meet the changing needs of clients. If you are supporting an older adult at risk with an upcoming transition to LTC or hospital, consider how a referral to the PRC can support the staff in the new setting as they prepare for the arrival of your client. The Guelph-Wellington PRC role is hosted by the Canadian Mental Health Association WW in partnership with Home and Community Care.
Acute Care Resources & Links
Grand River Hospital
Guelph Wellington PRC
Sexual Assault/Domestic Violence Treatment Centres
Sexual Assault/Domestic Violence Treatment Centres (SADVTC) are 35 hospital-based centres that provide 24/7 emergency care to women, children and men who have been sexually assaulted or who are victims or survivors of domestic violence by an intimate partner.
Services include
- Emergency medical/ nursing care
- Crisis intervention
- Collection of forensic evidence
- Follow-up and counselling
- Referral to community resources
- Safety planning
Sexual Assault/Domestic Violence Treatment Centres Resources & Links
Crisis Services
For the purposes of this guide for service providers, crisis resources include:
If your client is experiencing a medical or mental health crisis with imminent risk of harm, consider calling 911.
Crisis Call Centres
HERE 24/7
Here 24/7 is the front door to the addictions, mental health and crisis services provided by partner agencies across Waterloo – Wellington. A HERE 24/7 staff members completes crisis intervention, intake, mental health/addictions assessment, referral, and brief support functions.
- HERE 24/7
- 1-844-437-3247 (HERE247) TTY: 1-877-688-5501
Guelph Wellington Women in Crisis
The Crisis Line is a 24-hour telephone and TTY support and referral line in Guelph and Wellington County offering support to those who have experienced or are experiencing physical, sexual, emotional or financial abuse and/or stalking. They also speak to concerned friends and family members of abused women, service providers and other professionals in contact with abused women.
- Guelph Wellington Women in Crisis
- 519-836-5710 or 1-800-265-7233
Support Services for Male Survivors of Sexual Abuse
The Support Services for Male Survivors of Sexual Abuse program provides help for male survivors of sexual abuse, both recent and historical. The program is the first of its kind in Canada and is delivered by agencies across the province. Survivors also have access to a 24-hour, multilingual, toll-free phone line for immediate crisis and referral services at 1-866-887-0015.
- Support Services for Male Survivors of Sexual Abuse
- 1-866-887-0015
Emergency Shelter
Retirement Home Placement Program
Three Retirement Homes located in Guelph and Wellington County agree to provide temporary, emergency placement for older adults who are victims of abuse. Abuse can include financial, emotional, physical and sexual mistreatment as well as neglect. Accommodation will be provided for a minimum period of 48 hours with additional provision to be determined in consultation with the Wellington County Special Services Unit. Note that for this purpose emergency placement is intended to be of short term duration and that a follow-up case conference and a housing plan will be required within one week of the placement. To access this service, any requests are to be directed to the seniors at risk clinical consultant, vulnerable seniors lead, or via the supportive housing caseworker with the County of Wellington.
Marianne’s Place – GW Women in Crisis
Marianne’s Place is an accessible emergency shelter where all women and their children who are experiencing physical, sexual, emotional or financial abuse and/or stalking are welcome. Staff provide support and information so the individual can make informed choices about their safety. All services are free and interpreters can be arranged when necessary. You can contact the shelter by calling the 24-hour Crisis Line at 1-800-265-7233 for immediate and confidential support.
- Marianne’s Place
- 1-800-265-7233
Drop In Centre – Shelter Program
The Drop In Centre’s shelter programs provide homeless individuals with a shelter bed and access to basic needs, such as meals, hygiene items, and showers. These emergency shelters offer individuals a safe place to stay as they search for housing and pursue their goals. Many of the shelters may not be suitable or accessible for your older adult client, contact the Drop In Centre for more information. Note: all shelter residents are encouraged to utilize The Drop In Centre during the day, when the shelter is closed. Meals are provided twice daily at the Drop In Centre and are free of charge to anyone utilizing the shelter program.
Treatment Centres
Sexual Assault/Domestic Violence Treatment Centres
Sexual Assault/Domestic Violence Treatment Centres (SADVTC) are 35 hospital-based centres that provide 24/7 emergency care to women, children and men who have been sexually assaulted or who are victims or survivors of domestic violence by an intimate partner.
County of Wellington – Social Services
The central offices of the County of Wellington, Social Services Department are located in downtown Guelph. An Ontario Works and Settlement Services office located in Fergus provides full support for these programmes, and appointments can be made for other social services in Fergus as well as in Mount Forest.
Social Services: May include support with housing and social assistance programs. Financial assistance may be available to assist Social Assistance recipients (Ontario Works and/or Ontario Disability Support Program) who are homeless obtain housing, or who are at risk of becoming homeless remain housed. The emergency housing and energy supports available through the Housing Stability program can assist with last month’s rent deposits, hydro arrears and moving costs.
Housing services: All applications for Rent-Geared-to-Income (RGI) assistance for subsidized housing located in GuelphWellington are managed by the County of Wellington through the Centralized Waiting List. This “one-stop” centralized approach means applicants only need to complete one application form to apply to multiple housing providers for RGI assistance.
Settlement Services: This programme is funded through Immigration, Refugees and Citizenship Canada (IRCC). The mandate of this programme is to assist newcomers to Canada access community services and adjust to life in their new community. All services are available at no cost to those with Permanent Resident, Convention Refugee, or Live-In Caregiver status in the County of Wellington and City of Guelph.
County of Wellington – Social Services Resources & Links
Lutherwood
Lutherwood is a progressive, not-for-profit health and social service organization that strengthens people’s lives in our community by providing mental health, employment and housing services in Waterloo Region and Wellington County. Lutherwood’s housing services support clients in the search to find permanent, safe and affordable housing.
Drop In Centre Guelph
The Drop In Centre (also called The Welcome In Drop In Centre) is a community space in downtown Guelph that offers a multitude of services, especially for those living on a limited income. It provides a place to meet with friends and have a meal, access shelter if needed, and connect with support services to improve quality of life. The Centre welcomes all individuals, offering a sense of community, friendship, happiness and hope to everyone who walks in the door. The Drop In Centre is a place for everyone — regardless of gender, socioeconomic status, sexual orientation, or any other factor. Supports available include meals, emergency pantry, financial assistance, as well as access and referral to outreach, emergency shelter, mental health and addictions supports, medical assessment, housing and legal services.
Women in Crisis
Guelph-Wellington Women in Crisis (G-W WIC) supports seniors affected by domestic or sexual violence through safe shelter, crisis line response, individual and group counselling, accompaniments, advocacy, risk assessment and safety planning. Additionally, G-W WIC offers community consultation on incidents involving seniors at risk and elder abuse.
Developmental Services
Developmental Services Ontario
Developmental Services Ontario is the central access point for all adult developmental services in Ontario. They determine eligibility for ministry funded services that may be available in Guelph Wellington.
Community Networks of Specialized Care – Health Care Facilitator
The refreshed mandate of the Community Networks of Specialized Care (CNSC) is to improve access to healthcare for individuals with a developmental disability that have High Support and Complex Care Needs. Referrals can be made from community or residential services. The Health Care Facilitators support and educate primary health care providers and non-developmental services agencies about people with complex and multiple needs and develop linkages between health care professionals and share knowledge with the existing developmental services community. For more information on programs in the Central West Region, visit the Central West Specialized Developmental Services.
Family and Children’s Services
Family and Children’s Services is mandated to protect children in our community. If a person has reasonable grounds to suspect that a child is or may be in need of protection, the person must promptly report the suspicion and the information to Family and Children’s Services.
The duty to report is an ongoing obligation and cannot be delegated to someone else. If a person has made a previous report about a child and has additional grounds to suspect that the child is or is likely to suffer harm, that person must make another report. For more information visit the section on privacy and reporting.
If you are uncertain about reporting you can contact Family and Children’s Services at 1-800-265-8300 to discuss the questions and concerns to determine if it is reportable.
