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Background: Seniors living in subsidized housing have lower income, poorer health, and increased risk for cardiometabolic diseases and falls. Seniors also account for more than one third of calls to Emergency Medical Services (EMS). This study examines the effectiveness of the Community Health Assessment Program through EMS (CHAP-EMS) in reducing blood pressure, diabetes risk, and EMS calls.Methods: Paramedics on modified duty (e.g. injured) conducted weekly, one-on-one drop-in sessions in a common area of one subsidized senior's apartment building in Hamilton, Ontario. Paramedics assessed cardiovascular, diabetes, and fall risk, provided health education, referred participants to local resources, and encouraged participants to return to CHAP-EMS for follow-up. Reports were faxed to the family physician regularly. Blood pressure was collected throughout the one year intervention, while diabetes risk was assessed at baseline and after 6-12 months. EMS call volumes were collected from the Hamilton Paramedic Service for two years pre-intervention and one year during the intervention.Results: There were 79 participants (mean age = 72.2 years) and 1,365 participant visits to CHAP-EMS. The majority were female (68%), high school educated or less (53%), had a family doctor (90%), history of hypertension (58%), high waist circumference (64%), high body mass index (61%), and high stress (53%). Many had low physical activity (42%), high fat intake (33%), low fruit/vegetable intake (30%), and were current smokers (29%). At baseline, 42% of participants had elevated blood pressure. Systolic blood pressure decreased significantly by the participant's 3rd visit to CHAP-EMS and diastolic by the 5th visit (p < .05). At baseline, 19% of participants had diabetes; 67% of those undiagnosed had a moderate or high risk based on the Canadian Diabetes Risk (CANRISK) assessment. 15% of participants dropped one CANRISK category (e.g. high to moderate) during the intervention. EMS call volume decreased 25% during the intervention compared to the previous two years.Conclusions: CHAP-EMS was associated with a reduction in emergency calls and participant blood pressure and a tendency towards lowered diabetes risk after one year of implementation within a low income subsidized housing building with a history of high EMS calls.Trial Registration: Retrospectively registered on May 12th 2016 with clinicaltrials.gov: NCT02772263. [ABSTRACT FROM AUTHOR]

Background: The consideration of unique social housing needs has largely been absent from the COVID-19 response, particularly in tailoring strategies to improve access to testing and vaccine uptake among vulnerable and high-risk populations in Ontario. Given the growing population of social housing residents, this study aimed to compare SARS-CoV-2 testing, positivity, and vaccination rates in a social housing population with those in a general population cohort in Ontario, Canada., Methods: This population-based cohort study used administrative health data from Ontario to examine SARS-CoV-2 testing, positivity and vaccination rates in social housing residents compared with the general population from 1 January 2020 to 31 December 2021. All comparisons were unadjusted, stratified by sex and age and evaluated using standardised differences., Results: The rates of SARS-CoV-2 PCR testing were lower among younger age groups and higher among older adults within the social housing cohort, compared with the general population cohort. SARS-CoV-2 test positivity was higher in social housing than in the general population among individuals aged 60-79 years (7.9% vs 5.3%, respectively) and 80 years and older (12.0% vs 7.9%, respectively). Overall, 34.3% of social housing residents were fully vaccinated, compared with 29.6% of the general population cohort. However, a smaller proportion of social housing residents had received a booster vaccine (36.7%) compared with the general population (52.4%)., Conclusion: Improved and targeted outreach strategies are needed to increase the uptake of COVID-19 booster vaccines among social housing residents., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Importance: Community Paramedicine at Clinic (CP@clinic) is a chronic disease prevention program that decreases 911 calls for emergency medical services, but its wider system effects are unknown., Objective: To evaluate the effects of CP@clinic vs usual care on individual-level health service utilization outcomes., Design, Setting, and Participants: This open-label, pragmatic cluster randomized clinical trial evaluated all residents 55 years or older in 30 social housing buildings in Ontario, Canada, that had (1) a unique postal code, (2) at least 50 apartments, (3) 60% or more residents 55 years or older, and (4) a similar building for pairing (15 intervention and 15 control buildings, pair-matched randomization). The 12-month intervention had a staggered start date from January 1, 2015, to December 1, 2015, and ended between December 31, 2015, and November 30, 2016. Administrative health data analysis was conducted in May 2022., Intervention: CP@clinic was a health promotion and disease prevention program led by specially trained community paramedics who held weekly drop-in sessions in social housing buildings. These paramedics conducted 1-on-1 risk assessments, provided health education and referrals to relevant community resources, and, with consent, sent assessments to family physicians. Control buildings received usual care (universal health care, including free primary and specialty medical care)., Main Outcome and Measures: Individual-level health service utilization was measured from administrative health data, with ED visits via ambulance as the primary outcome; secondary outcomes included ED visits for any reason, primary care visits, hospitalizations, length of hospital stay, laboratory tests, receipt of home care, transfer to long-term care, and medication initiation. Generalized estimating equations were used to estimate intervention effects on individual-level health service utilization, accounting for trial design and individual-level baselines., Results: The 30 social housing buildings had 3695 residents (1846 control and 1849 intervention participants; mean [SD] age, 72.8 [9.1] years; 2400 [65.0%] female). Intention-to-treat analysis found no significant difference in ED visits by ambulance (445 of 1849 [24.1%] vs 463 of 1846 [25.1%]; adjusted odds ratio [AOR], 0.97; 95% CI, 0.89-1.05) but found higher antihypertensive medication initiation (74 of 500 [14.8%] vs 47 of 552 [8.5%]; AOR, 1.74; 95% CI, 1.19-2.53) and lower anticoagulant initiation (48 of 1481 [3.2%] vs 69 of 1442 [4.8%]; AOR, 0.68; 95% CI, 0.53-0.86) in the intervention arm vs the control arm. CP@clinic attendance was associated with higher incidence of primary care visits (adjusted incidence rate ratio, 1.10; 95% CI, 1.03-1.17), higher odds of receiving home care (AOR, 1.07; 95% CI, 1.01-1.13), and lower odds of long-term care transfers (AOR, 0.32; 95% CI, 0.13-0.81)., Conclusions and Relevance: In this cluster randomized clinical trial of CP@clinic, the intervention did not affect the rate of ED visits by ambulance; however, there were increased primary care visits and connections to home care services, which may have increased antihypertensive medication initiation and reduced long-term care transfers from social housing. Health policymakers should consider CP@clinic's impact as an upstream approach to improve care for older adults with low income., Trial Registration: ClinicalTrials.gov Identifier: NCT02152891.

Objective: Social housing programs are integral to making housing more affordable to Canadian seniors living in poverty. Although the programs are similar across Canada, there may be inter-provincial differences among the health of residents that could guide the development of interventions. This study explores the health of low-income seniors living in social housing in Quebec and compares it with previously reported data from Ontario., Results: 80 responses were obtained in Quebec to compare with the previously reported Ontario data (n = 599) for a total of 679 responses. More Ontario residents had access to a family doctor (p < 0.001). Quebec residents experienced less problems with self-care (p = 0.017) and less mobility issues (p = 0.052). The visual analog scale for overall health state was similar in both provinces (mean = 67.36 in Ontario and 69.23 in Quebec). Residents in Quebec smoked more cigarettes per day (p = 0.009). More residents in Ontario participated in moderate physical activity (p = 0.09), however, they also spent more time per day on the computer (p = 0.006)., (© 2024. The Author(s).)

Background: Community Paramedicine (CP) is an emerging model of care addressing health problems through non-emergency services. Little evidence exists examining the integration of an app for improved patient, CP, and family physician (FP) communication. This study investigated FP perspectives on the impact of the Community Paramedicine at Clinic (CP@clinic) program on providing patient care and the feasibility and value of a novel "My Care Plan App" (myCP app)., Methods: This retrospective mixed-methods study included an online survey and phone interviews to elucidate FPs ' perspectives on the CP@clinic program and the myCP app, respectively, between January 2021 and May 2021. FPs with patients in the CP@clinic program were recruited to participate. Survey responses were summarized using descriptive statistics, and audio recordings from the interviews thematically analyzed., Results: Thirty-eight FPs completed the survey and 10 FPs completed the phone interviews. 60.5% and 52.6% of FPs reported that the CP@clinic program improved their ability to further screen and diagnose patients for hypertension, respectively (in addition to their regular screening practices). The themes that emerged in the phone interviews were grouped into three topics: app benefits, drawbacks, and integration within practice. Overall, FPs described the myCP app as user-friendly and useful to improve interprofessional communication with CPs., Conclusions: CP@clinic helped family physicians to screen and monitor chronic disease. The myCP app can impact health service delivery by closing the gap between primary, community, and emergency care through an eHealth information-sharing platform., (© 2024. The Author(s).)

Objective: This study describes cardiometabolic diseases and related risk factors in vulnerable older adults residing in social housing, aiming to inform primary care initiatives to reduce health inequities. Associations between sociodemographic variables, modifiable risk factors (clinical and behavioural), health-related quality of life and self-reported cardiometabolic diseases were investigated., Design, Setting, and Participants: This was a cross-sectional study with an interviewer-administered questionnaire. Data was collected from residents aged 55 years and older residing in 30 social housing apartment buildings in five regions in Ontario, Canada., Outcome Measures: The proportion of cardiometabolic diseases and modifiable risk factors (e.g., clinical, behavioural, health status) in this population was calculated., Results: Questionnaires were completed with 1065 residents: mean age 72.4 years (SD = 8.87), 77.3% were female, 87.2% were white; 48.2% had less than high school education; 22.70% self-reported cardiovascular disease (CVD), 10.54% diabetes, 59.12% hypertension, 43.59% high cholesterol. These proportions were higher than the general population. Greater age was associated with overweight, high cholesterol, high blood pressure and CVD. Poor health-related quality of life was associated with self-reported CVD and diabetes., Conclusions: Older adults residing in social housing in Ontario have higher proportion of cardiovascular disease and modifiable risk factors compared to the general population. This vulnerable population should be considered at high risk of cardiometabolic disease. Primary care interventions appropriate for this population should be implemented to reduce individual and societal burdens of cardiometabolic disease., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Agarwal et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Community paramedicine (CP) is an extension of the traditional paramedic role, where paramedics provide non-acute care to patients in non-emergent conditions. Due to its success in reducing burden on hospital systems and improving patient outcomes, this type of paramedic role is being increasingly implemented within communities and health systems across Ontario. Previous literature has focused on the patient experience with CP programs, but there is lack of research on the paramedic perspective in this role. This paper aims to understand the perspectives and experiences, both positive and negative, of paramedics working in a CP program towards the community paramedic role., Methods: An online survey was distributed through multiple communication channels (e.g. professional organizations, paramedic services, social media) and convenience sampling was used. Five open-ended questions asked paramedics about their perceptions and experiences with the CP role; the survey also collected demographic data. While the full survey was open to all paramedics, only those who had experience in a CP role were included in the current study. The data was qualitatively analyzed using a comparative thematic analysis., Results: Data was collected from 79 respondents who had worked in a CP program. Three overarching themes, with multiple sub-themes, were identified. The first theme was that CP programs fill important gaps in the healthcare system. The second was that they provide paramedics with an opportunity for lateral career movement in a role where they can have deeper patient connections. The third was that CP has created a paradigm shift within paramedicine, extending the traditional scope of the practice. While paramedics largely reported positive experiences, there were some negative perceptions regarding the slower pace of work and the "soft skills" required in the role that vary from the traditional paramedic identity., Conclusions: CP programs utilize paramedic skills to fill a gap in the healthcare system, can improve paramedic mental health, and also provide a new pathway for paramedic careers. As a new role, there are some challenges that CP program planners should take into consideration, such as additional training needs and the varying perceptions of CP., (© 2024. The Author(s).)

The views of community Elders and health care providers in a rural remote First Nation community in Ontario, Canada on their health care landscape and adapting the Community Paramedicine at Clinic (CP@clinic) Program to their community are presented. Key informant interviews took place between September 2020 and March 2021, and were thematically analysed using the Framework Hierarchical Analysis. There were seven themes that emerged with many subthemes: available services in the community, health care access, health challenges in community, causes of frailty, health care and community appreciations, community-specific benefits of CP@clinic, and CP@clinic program considerations for adaptation. CP@clinic program considerations for adaptation included defining the role of CP, refining referral processes to capture the target population, advertising and promoting, ensuring community awareness, determining clinic setting and composition, focusing on advocacy and timely continuity, adding to the program through time, managing resistance, engaging community and partners, deploying cultural training and language accommodations, leveraging community assets, and ensuring sustainability. Focusing on continuity, engagement, and leveraging available resources may support the success of the CP@clinic program implementation. Findings from this study may be useful to other underserved communities in Canada seeking health programming.

Objectives: Community Paramedicine (CP) is increasingly being used to provide chronic disease management for vulnerable populations in the community. CP@clinic took place in social housing buildings to support cardiovascular health and diabetes management for older adults. The purpose of this study was to examine participant perceptions of their experience with CP@clinic as well as potential ongoing programme benefits., Design: This descriptive qualitative study used focus groups to understand resident experiences of the CP@clinic programme. Groups were facilitated by experienced moderators using a semistructured guide. An inductive coding approach was used with at least two researchers taking part in each step of the analysis process., Setting: Community-based social housing buildings in Ontario, Canada., Participants: Forty-one participants from four CP@clinic sites took part in a focus group. Convenience sampling was used with anyone having taken part in a CP@clinic session being eligible to attend the focus group., Results: Analysis yielded six themes across two broad areas: timely access to health information and services, support to achieve personal health goals, better understanding of healthcare system (Personal Benefits); and sense of community, comfortable and familiar place to talk about health, facilitated communication between healthcare professionals (Programme Structure). Participants experienced discernible health changes that motivated their participation. CP@clinic was viewed as a programme that created connections within the building and outside of it. Participants were enthusiastic for the continuation of the programme and appreciated the consistent support to meet their health goals., Conclusions: CP@clinic was successful in creating a supportive and friendly environment to facilitate health behavioural changes. Ongoing implementation of CP@clinic would allow residents to continue to build their chronic disease management knowledge and skills., Trial Registration Number: Trial registration number: NCT02152891, Clinicaltrials.gov., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: The Community Paramedicine at Home (CP@home) program is a health promotion program where community paramedics conduct risk assessments with frequent 9-1-1 callers in their homes, with a goal of reducing the frequency of 9-1-1 calls in this vulnerable population. The effectiveness of the CP@home program was investigated through a community-based RCT conducted in four regions in Ontario, Canada. The purpose of this current recruitment study is to examine the challenges met when recruiting for a community randomized control trial on high frequency 9-1-1 callers., Methods: Eligible participants were recruited from one of four regions participating in the CP@home program and were randomly assigned to an intervention group (n = 1142) or control group (n = 1142). Data were collected during the recruitment process from the administrative database of the four paramedic services. Whether they live alone, their parental ethnicity, age, reason for calling 9-1-1, reason for not participating, contact method, and whether they were successfully contacted were recorded. Statistical significance was calculated using the Chi-Squared Test and Fisher's Exact Test to evaluate the effectiveness of the recruitment methods used to enroll eligible participants in the CP@home Program., Results: Of the people who were contacted, 48.0% answered their phone when called and 53.9% answered their door when a home visit was attempted. In Total, 110 (33.1%) of people where a contact attempt was successful participated in the CP@home program. Most participants were over the age of 65, even though people as young as 18 were contacted. Older adults who called 9-1-1 for a lift assist were more likely to participate, compared to any other individual reason recorded, and were most often recruited through a home visit., Conclusions: This recruitment analysis successfully describes the challenges experienced by researchers when recruiting frequent 9-1-1 callers, which are considered a hard-to-reach population. The differences in age, contact method, and reason for calling 9-1-1 amongst people contacted and participants should be considered when recruiting this population for future research., (© 2023. BioMed Central Ltd., part of Springer Nature.)

Background: Older adults living in social housing are a vulnerable population facing unique challenges with health literacy and chronic disease self-management. We investigated this population's knowledge of cardiovascular disease and diabetes mellitus, and self-efficacy to make health behaviour changes (for example, physical activity). This study characterized the relationship between knowledge of health risk factors and self-efficacy to improve health behaviours, in order to determine the potential for future interventions to improve these traits., Methods: A cross-sectional study (health behaviour survey) with adults ages 55+ (n = 599) from 16 social housing buildings across five Ontario communities. Descriptive analyses conducted for demographics, cardiovascular disease and diabetes knowledge, and self-efficacy. Subgroup analyses for high-risk groups were performed. Multivariate logistic regressions models were used to evaluate associations of self-efficacy outcomes with multiple factors., Results: Majority were female (75.6%), white (89.4%), and completed high school or less (68.7%). Some chronic disease subgroups had higher knowledge for those conditions. Significant (p < 0.05) associations were observed between self-efficacy to increase physical activity and knowledge, intent to change, and being currently active; self-efficacy to increase fruit/vegetable intake and younger age, knowledge, and intent to change; self-efficacy to reduce alcohol and older age; self-efficacy to reduce smoking and intent to change, ability to handle crises, lower average number of cigarettes smoked daily, and less frequent problems with usual activities; self-efficacy to reduce stress and ability to handle crises., Conclusions: Those with chronic diseases had greater knowledge about chronic disease. Those with greater ability to handle personal crises and intention to make change had greater self-efficacy to change health behaviours. Development of stress management skills may improve self-efficacy, and proactive health education may foster knowledge before chronic disease develops., (© 2022. The Author(s).)

Background: Older adults face greater risk of social isolation, but the extent of social isolation among low-income older adults living in social housing is unknown. This study aims to explore the rate of, and risk factors contributing to, subjective social isolation or loneliness among older adults in social housing., Methods: We conducted a cross-sectional study of data collected from a community program held in the common rooms of 55 social housing buildings in 14 communities across Ontario, Canada, from May 2018 to April 2019. Participants were program attendees aged 55 years and older who resided in the buildings. Program implementers assessed social isolation using the 3-Item Loneliness Scale from the University of California, Los Angeles and risk factors using common primary care screening tools. We extracted data for this study from the program database. We compared the rate of social isolation to Canadian Community Health Survey data using a 1-sample χ 2 test, and evaluated associations between risk factors and social isolation using univariate and multivariate logistic regressions., Results: We included 806 residents in 30 buildings for older adults and 25 mixed-tenant buildings. Based on the 3-Item UCLA Loneliness Scale, 161 (20.0%) of the 806 participants were socially isolated. For those aged 65 and older, the rate of social isolation was nearly twice that observed in the same age group of the general population (36.1% v. 19.6%; p < 0.001). Risk factors were age (65-84 yr v. 55-64 yr adjusted odds ratio [OR] 1.99, 95% confidence interval [CI] 1.01-3.93), alcohol consumption (adjusted OR 2.45, 95% CI 1.09-5.54), anxiety or depression (adjusted OR 6.05, 95% CI 3.65-10.03) and income insecurity (adjusted OR 2.10, 95% CI 1.24-3.53). Protective factors were having at least 1 chronic cardiometabolic disease (adjusted OR 0.44, 95% CI 0.24-0.80), being physically active (adjusted OR 0.47, 95% CI 0.30-0.73) and having good to excellent general health (adjusted OR 0.60, 95% CI 0.39-0.90)., Interpretation: The high rate of social isolation in low-income older adults living in social housing compared with the general population is concerning. Structural barriers could prevent engagement in social activities or maintenance of social support, especially for older adults with income insecurity and anxiety or depression; interventions are needed to reduce subjective social isolation in this population., Competing Interests: Competing interests: None declared., (© 2021 CMA Joule Inc. or its licensors.)

Objectives: This study aimed to describe the risk of developing diabetes and the probable prevalence of diabetes and prediabetes in residents of subsidized or social housing who were 55 years of age or older., Methods: We conducted a cross-sectional study using data collected from an ongoing community health program in social housing buildings-the Community Paramedicine at Clinic (CP@clinic) program. Community paramedics staffing the CP@clinic program conducted lifestyle-related modifiable risk factor assessments of participating social housing residents who were 55 years of age or older. The Canadian Diabetes risk assessment (CANRISK) tool was administered to all participants, and those with moderate-to-high risk of developing diabetes were asked to return for a fasting capillary blood glucose (CBG) measurement. Data were collected from program participants who attended the sessions between December 2014 and May 2018., Results: There were 728 participants. Most were women (80.5%), aged 65 to 84 (68.1%), white (85.4%) and educated to the high school level or less (69.2%). At baseline, 71.3% were identified as having overweight or obesity, and 12.5% were diagnosed with diabetes. Of participants not diagnosed with diabetes (N=632), 66.6% were at high risk of developing diabetes, and 30.1% were categorized as moderate risk. The CBG assessments showed that 37.7% (N=158) of those with high risk and 22.0% (N=42) of those with moderate risk had blood glucose readings indicating impaired fasting glucose or probable diabetes., Conclusions: This study shows that 96.7% of low-income older adults in social housing buildings had moderate-to-high risk of developing diabetes and that the probable prevalence of undiagnosed prediabetes and diabetes was 32.0%., (Copyright © 2020 Canadian Diabetes Association. Published by Elsevier Inc. All rights reserved.)

Objectives: To evaluate the cost-effectiveness of the Community Paramedicine at Clinic (CP@clinic) programme compared with usual care in seniors residing in subsidised housing., Design: A cost-utility analysis was conducted within a large pragmatic cluster randomised controlled trial (RCT). Subsidised housing buildings were matched by sociodemographics and location (rural/urban), and allocated to intervention (CP@clinic for 1 year) or control (usual care) via computer-assisted paired randomisation., Setting: Thirty-two subsidised seniors' housing buildings in Ontario., Participants: Building residents 55 years and older., Intervention: CP@clinic is a weekly community paramedic-led, chronic disease prevention and health promotion programme in the building common areas. CP@clinic is free to residents and includes risk assessments, referrals to resources, and reports back to family physicians., Outcome Measures: Quality-adjusted life years (QALYs) gained, measured with EQ-5D-3L. QALYs were estimated using area-under-the curve over the 1-year intervention, controlling for preintervention utility scores and building pairings. Programme cost data were collected before and during implementation. Costs associated with emergency medical services (EMS) use were estimated. An incremental cost effectiveness ratio (ICER) based on incremental costs and health outcomes between groups was calculated. Probabilistic sensitivity analysis using bootstrapping was performed., Results: The RCT included 1461 residents; 146 and 125 seniors completed the EQ-5D-3L in intervention and control buildings, respectively. There was a significant adjusted mean QALY gain of 0.03 (95% CI 0.01 to 0.05) for the intervention group. Total programme cost for implementing in five communities was $C128 462 and the reduction in EMS calls avoided an estimated $C256 583. The ICER was $C2933/QALY (bootstrapped mean ICER with Fieller's 95% CI was $4850 ($2246 to $12 396)) but could be even more cost effective after accounting for the EMS call reduction., Conclusion: The CP@clinic ICER was well below the commonly used Canadian cost-utility threshold of $C50 000. CP@clinic scale-up across subsidised housing is feasible and could result in better health-related quality-of-life and reduced EMS use in low-income seniors., Trial Registration Number: Clinicaltrials.gov, NCT02152891., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: The South Asian population in Canada is growing and has elevated risk of cardiovascular disease and diabetes. This study sought to adapt an evidence-based community risk assessment and health promotion program for a South Asian community with a large proportion of recent immigrants. The aims were to assess the feasibility of implementing this program and also to describe the rates of cardiometabolic risk factors observed in this sample population., Methods: This was a feasibility study adapting and implementing the Community Paramedicine at Clinic (CP@clinic) program for a South Asian population in an urban Canadian community for 14 months. CP@clinic is a free, drop-in chronic disease prevention and health promotion program implemented by paramedics who provide health assessments, health education, referrals and reports to family doctors. All adults attending the recreation centre and temple where CP@clinic was implemented were eligible. Volunteers provided Hindi, Punjabi and Urdu translation. The primary outcome of feasibility was evaluated using quantitative process measures and a qualitative key informant interview. For the secondary outcome of cardiometabolic risk factor, data were collected through the CP@clinic program risk assessments and descriptively analyzed., Results: There were 26 CP@clinic sessions held and 71 participants, predominantly male (56.3-84.6%) and South Asian (87.3-92.3%). There was limited participation at the recreation centre (n = 19) but CP@clinic was well-attended when relocated to the local Sikh temple (n = 52). Having the volunteer translators was critical to the paramedics being able to collect the full risk factor data and there were some challenges with ensuring enough volunteers were available to staff each session; as a result, there were missing risk factor data for many participants. In the 26 participants with complete or almost complete risk factor data, 46.5% had elevated BP, 42.3% had moderate/high risk of developing diabetes, and 65.4% had an indicator of cardiometabolic disease., Conclusion: Implementing CP@clinic in places of worship is a feasible approach to adapting the program for the South Asian population, however having a funded translator in addition to the volunteers would improve the program. Also, there is substantial opportunity for addressing cardiometabolic risk factors in this population using CP@clinic.

Background: Poverty and food insecurity have been linked to poor health and morbidity, especially in older adults. Housing is recognized as a social determinant of health, and very little is known about subjective poverty and food insecurity in the marginalized population of older adults living in subsidized social housing. We sought to understand poverty and food insecurity, as well as the risk factors associated with both outcomes, in older adults living in social housing in Ontario., Methods: This was a cross-sectional study using data collected from the Community Paramedicine at Clinic (CP@clinic) program. A total of 806 adult participants residing in designated seniors' or mixed family-seniors' social housing buildings attended CP@clinic within 14 communities across Ontario, Canada., Results: The proportion of older adults reporting poverty and food insecurity were 14.9 and 5.1%, respectively. Statistically significant risk factors associated with poverty were being a smoker (AOR = 2.38, 95% CI: 1.23-4.62), self-reporting feeling extremely anxious and/or depressed (AOR = 3.39, 95% CI: 1.34-8.62), and being food insecure (AOR = 23.52, 95% CI: 8.75-63.22). Statistically significant risk factors associated with food insecurity were being underweight (AOR = 19.79, 95% CI: 1.91-204.80) and self-reporting experiencing poverty (AOR = 23.87, 95% CI: 8.78-64.90). In those who self-reported being food secure, the dietary habits reported were consistent with a poor diet., Conclusion: The poverty rate was lower than expected which could be related to the surrounding environment and perceptions around wealth. Food insecurity was approximately twice that of the general population of older adults in Canada, which could be related to inaccessibility and increased barriers to healthy foods. For those who reported being food secure, dietary habits were considered poor. While social housing may function as a financial benefit and reduce perceived poverty, future interventions are needed to improve the quality of diet consumed by this vulnerable population.

Background: Falls in older adults is a widely researched topic. However, older adults residing in public housing are a vulnerable population that may have unique risk factors for falls. This study aims to describe the prevalence and risk factors for falls, fear of falling, and seeking medical attending for falls in this population., Methods: Sociodemographic and health-related data was collected as part of a community-based health assessment program with older adults in public housing. Three pre-screening questions identified individuals at potential risk for falls; individuals who screened positive performed the objective Timed Up and Go (TUG) test. Logistic regression was used to evaluate risk factors for four outcome variables: falls in the past year, seeking medical attention for falls, fear of falling, and objectively measured fall risk via TUG test., Results: A total of 595 participants were evaluated, of which the majority were female (81.3%), white (86.7%), did not have a high school diploma (50.0%), and reported problems in mobility (56.2%). The prevalence of falls in the past year was 34.5%, seeking medical attention for falls was 20.2% and fear of falling was 38.8%. The TUG test was completed by 257 participants. Notably, males had significantly reduced odds of seeking medical attention for a fall (OR = 0.50, 95%CI 0.25-0.98) and having a fear of falling (OR = 0.42, 95%CI 0.24-0.76); daily fruit and vegetable consumption was associated with decreased odds of having a fall in the past year (OR = 0.55, 95%CI 0.37-0.83), and alcohol consumption was associated with increased odds of fear of falling (OR = 1.72, 95%CI 1.03-2.88)., Conclusion: Older adults residing in public housing have unique risk factors associated with social determinants of health, such as low fruit and vegetable consumption, which may increase their risk for falls. The findings of this study can be used to inform falls interventions for this population and identify areas for further research.

Background: The Cardiovascular Health Awareness Program (CHAP) uses volunteers to provide cardiovascular disease (CVD) and diabetes screening in a community setting, referrals to primary care providers, and locally available programs targeting lifestyle modification. CHAP has been adapted to target older adults residing in social housing, a vulnerable segment of the population. Older adults living in social housing report poorer health status and have a higher burden of a multitude of chronic illnesses, such as CVD and diabetes. The study objective is to evaluate whether there is a reduction in unplanned CVD-related Emergency Department (ED) visits and hospital admissions among residents of social seniors' housing buildings receiving the CHAP program for 1 year compared to residents in matched buildings not receiving the program., Methods/design: This is a pragmatic, cluster randomized controlled trial in community-based social (subsidized) housing buildings in Ontario and Quebec. All residents of 14 matched pairs (intervention/control) of apartment buildings will be included. Buildings with 50-200 apartment units with the majority of residents aged 55+ and a unique postal code are included. All individuals residing within the buildings at the start of the intervention period are included (intention to treat, open cohort). The intervention instrument consists of CHAP screens for high blood pressure using automated blood pressure monitors and for diabetes using the Canadian Diabetes Risk (CANRISK) assessment tool. Monthly drop-in sessions for screening/monitoring are held within a common area of the building. Group health education sessions are also held monthly. Reports are sent to family doctors, and attendees are encouraged to visit their family doctor. The primary outcome measure is monthly CVD-related ED visits and hospitalizations over a 1-year period post randomization. Secondary outcomes are all ED visits, hospitalizations, quality of life, cost-effectiveness, and participant experience., Discussion: It is anticipated that CVD-related ED visits and hospitalizations will decrease in the intervention buildings. Using the volunteer-led CHAP program, there is significant opportunity to improve the health of older adults in social housing., Trial Registration: ClinicalTrials.gov,NCT03549845. Registered on 15 May 2018. Updated on 21 May 2019.

Background: Determining the effectiveness of community-based health promotion and disease prevention programs requires an appropriate data collection tool. This study aimed to develop a comprehensive health questionnaire for older adults, called the HABiT, and evaluate its reliability, content validity, and face validity in assessing individual health-related items (e.g., health status, healthcare utilization) and five specific scales: knowledge, current health behaviors (risk factors), health-related quality of life (HRQoL), perceived risk and understanding, and self-efficacy., Methods: Iterative survey development and evaluation of its psychometric properties in a convenience sample of 28 older adults (≥ 55 years old), half from a low-income population. Following item generation, the questionnaire was assessed for content validity (expert panel), face validity (participant feedback), internal consistency of each scale (Cronbach's alpha), and test-retest reliability for each item and scale (Pearson's r and phi correlations, as appropriate)., Results: Questions were drawn from 15 sources, but primarily three surveys: Canadian Community Health Survey, Canadian Diabetes Risk Questionnaire (CANRISK), and a survey by the Canadian Hypertension Education Program. Expert consensus was attained for item inclusion and representation of the desired constructs. Participants completing the questionnaire deemed the questions to be clear and appropriate. Test-retest reliability for many individual items was moderate-to-high, with some exceptions for items that can reasonably change in a short period (e.g., perceived day-to-day stress). Of the five potential scales evaluated, two had acceptable internal consistency (Cronbach's alpha ≥ 0.60) and a subset of one scale also had acceptable internal consistency. Test-retest reliability was high (correlation ≥ 0.80) for all scales and sub-scales., Conclusions: The HABiT is a reliable and suitable comprehensive tool with content and face validity that can be used to evaluate health promotion and chronic disease prevention programs in older adults, including low-income older adults. Some noted limitations are discussed. Data collected using this tool also provides a diabetes risk score, health literacy score, and quality-adjusted life years (QALYs) for economic analysis.

Objective: Older adults account for 38-48% of emergency medical service (EMS) calls, have more chronic diseases, and those with low income have lower quality of life. Mobile integrated health and community paramedicine may help address these health inequalities and reduce EMS calls. This study examines the effectiveness of the Community Paramedicine at Clinic (CP@clinic) program in decreasing EMS calls and improving health outcomes in low-income older adults. Methods: This was an open-label, pragmatic, cluster-randomized controlled trial conducted within subsidized public housing buildings for older adults in 5 paramedic services across Ontario, Canada. A total of 30 apartment buildings were eligible (>50 units, >60% of units occupied by older adults, unique postal code, available match for pairing). Paired buildings were randomly allocated to intervention (CP@clinic for one year) or control (usual care) via computer-generated randomization. The CP@clinic intervention is a community-based, paramedic-led, health promotion and disease prevention program held weekly in building common rooms. CP@clinic includes risk assessment with validated tools, decision support, health promotion, referrals to resources, and reports back to family doctors. All residents could participate, but only older adults (55 years and older) were included in analyses. The primary outcome was building-level EMS calls from paramedic service databases. Secondary outcomes were individual-level changes in chronic disease risk factors and quality-adjusted-life-years (QALYs). Data were analyzed using Generalized Estimating Equations to account for clustering by sites. Results: Intention-to-treat analysis showed no significant difference in EMS calls (mean difference = -0.37/100 apartment units/month, 95%CI: -0.98 to 0.24). Sensitivity analysis excluding data from 2 building pairs with eligibility changes after intervention initiation revealed a significant difference in EMS calls in favor of the intervention buildings (mean difference = -0.90/100 apartment units/month, 95%CI: -1.54 to -0.26). At the individual level, there was a significant QALY increase (mean difference = 0.06, 95%CI: 0.02 to 0.10) and blood pressure decrease (systolic mean change = 3.65 mmHg, 95%CI: 2.37 to 4.94; diastolic mean change = 2.03 mmHg, 95%CI: 1.00 to 3.06). Conclusions: CP@clinic showed a significant decrease in EMS calls, decrease in BP, and improvement in QALYs among older adults in subsidizing public housing, suggesting this simple program should be replicated in other communities with public housing. Trial Registration: Clinicaltrials.gov, Registration no. NCT02152891.

Background: Frequent users of emergency medical services for issues that could be more appropriately managed through non-urgent care deplete the limited resources of the health-care system. Community paramedicine is an emerging field that extends the role of paramedics beyond the traditional emergency response. The goal of the current study is to evaluate the impact of a community paramedicine home-visit intervention with frequent users on reducing ambulance calls, hospital visits, and admissions. The study will also provide a cross-sectional description of the characteristics of frequent users of emergency medical services., Methods/design: An open-label, pragmatic, randomized controlled trial with parallel intervention and control groups will be conducted in four paramedic services in Ontario. The sample size has been calculated as 261 per group for a 25% reduction in ambulance calls. Eligible participants will be frequent callers (three or more calls in 6 months), individuals who call for at least one lift assist, or individuals referred to the program by a paramedic. Individuals will be randomly allocated to receive either the Community Paramedicine at Home (CP@home) program intervention or their usual care (control). Intervention participants will receive up to three visits from a community paramedic, who will conduct health risk assessments, provide health promotion and education, provide referrals to local resources, and fax reports back to the family physician. Data will be collected from administrative databases (e.g., paramedic services), a custom CP@home program database, participant surveys, and key informant interviews. An intention-to-treat analysis will be conducted, including descriptive statistics and multi-level modeling to find factors predictive of primary and secondary outcomes. A thematic analysis will be used to analyze the qualitative outcomes. An economic analysis will consider the cost-effectiveness of the program., Discussion: CP@home has the potential to reduce the health-care system burden significantly by targeting current frequent users of emergency medical services. By targeting this population, CP@home aims to decrease ambulance calls and emergency department visits, reducing health-care costs and improving the quality of life of a vulnerable population. If successful, CP@home will inform the development of community paramedicine policies and the expanding role of paramedics in regions across Canada., Trial Registration: ClinicalTrials.gov, NCT02835989 . Registered on July 14 2016.

Objectives: This study aimed to assess functional health literacy levels among older adults living in subsidized housing in Hamilton, Ontario, and to assess the relationships between health literacy and other important health indicators, such as education level, age, ethnicity, body mass index (BMI), and self-reported health status., Methods: Older adults (n = 237) living in subsidized housing buildings in Hamilton, ON, were assessed using the NVS-UK as a measure of functional health literacy in addition to a health indicator questionnaire through structured interview. Health literacy levels were analyzed using descriptive statistics and logistic regression to determine relationships between health literacy levels and other health indicators., Results: Participants' mean age was 73 years, 67% were female, 70% were not educated beyond high school, and 91% were white. Over 82% of participants had below adequate health literacy levels using the NVS-UK. Multivariable logistic regression revealed significant relationships between functional health literacy and BMI, education level, and pain and discomfort levels. No significant relationships were found between health literacy level and age group, anxiety and depression levels, CANRISK (Diabetes risk) score, gender, marital status, mobility issues, self-care issues, self-reported health status, or performance of usual activities., Conclusions: As the population of older adults continues to grow, the appropriate resources must be available to both improve and support the health literacy level of the population. Future health research should gather information on the health literacy levels of target populations to ensure more equitable health service. This research provides a significant opportunity to better understand populations with health literacy barriers.

Background: Low-income older adults who live in subsidized housing have higher mortality and morbidity. We aimed to determine if a community paramedicine program - in which paramedics provide health care services outside of the traditional emergency response - reduced the number of ambulance calls to subsidized housing for older adults., Methods: We conducted an open-label pragmatic cluster-randomized controlled trial (RCT) with parallel intervention and control groups in subsidized apartment buildings for older adults. We selected 6 buildings using predefined criteria, which we then randomly assigned to intervention (Community Paramedicine at Clinic [CP@clinic] for 1 yr) or control (usual health care) using computer-generated paired randomization. CP@clinic is a paramedic-led, community-based health promotion program to prevent diabetes, cardiovascular disease and falls for residents 55 years of age and older. The primary outcome was building-level mean monthly ambulance calls. Secondary outcomes were individual-level changes in blood pressure, health behaviours and risk of diabetes assessed using the Canadian Diabetes Risk Questionnaire. We analyzed the data using generalized estimating equations and hierarchical linear modelling., Results: The 3 intervention and 3 control buildings had 455 and 637 residents, respectively. Mean monthly ambulance calls in the intervention buildings (3.11 [standard deviation (SD) 1.30] calls per 100 units/mo) was significantly lower (-0.88, 95% confidence interval [CI] -0.45 to -1.30) than in control buildings (3.99 [SD 1.17] calls per 100 units/mo), when adjusted for baseline calls and building pairs. Survey participation was 28.4% ( n = 129) and 20.3% ( n = 129) in the intervention and control buildings, respectively. Residents living in the intervention buildings showed significant improvement compared with those living in control buildings in quality-adjusted life years (QALYs) (mean difference 0.09, 95% CI 0.01 to 0.17) and ability to perform usual activities (odds ratio 2.6, 95% CI 1.2 to 5.8). Those who received the intervention had a significant decrease in systolic (mean change 5.0, 95% CI 1.0 to 9.0) and diastolic (mean change 4.8, 95% CI 1.9 to 7.6) blood pressure., Interpretation: A paramedic-led, community-based health promotion program (CP@clinic) significantly lowered the number of ambulance calls, improved QALYs and ability to perform usual activities, and lowered systolic blood pressure among older adults living in subsidized housing. Trial registration: Clinicaltrials.gov, no. NCT02152891., Competing Interests: Competing interests: None declared., (© 2018 Joule Inc. or its licensors.)

Introduction: Chronic diseases and falls substantially contribute to morbidity/mortality among seniors, causing this population to frequently seek emergency medical care. Research suggests the paramedic role can be successfully expanded to include community-based health promotion and prevention. This study implements a community paramedicine programme targeting seniors in subsidised housing, a high-risk population and frequent users of emergency medical services (EMS). The aims are to reduce EMS calls, improve health outcomes and healthcare utilisation., Methods/analysis: This is a pragmatic clustered randomised control trial in four communities across Ontario, Canada. Within each, four to eight seniors' apartment buildings will be paired and within each pair one building will be randomly assigned to receive the Community Health Assessment Programme through EMS (CHAP-EMS) intervention, while the other building receives no intervention. During the 1-year intervention, paramedics will run weekly sessions in a common area of the building, assessing risk factors for cardiovascular disease, diabetes and falls; providing health education and referrals to community programmes; and communicating results to the participant's primary physician. The primary outcomes are rate of emergency calls per 100 residents, change in blood pressure and change in Canadian Diabetes Risk (CANRISK) score, as collected by the local EMS and study databases. The secondary outcomes are change in health behaviours, measured using a preintervention and postintervention survey and healthcare utilisation, available through administrative databases. Analysis will mainly consist of descriptive statistics and generalised estimating equations, including subgroup cluster analysis., Ethics/dissemination: This study is approved by the Hamilton Integrated Research Ethics Board and will follow the Tri-Council Policy Statement. Findings will be disseminated through reports to local stakeholders, publication in peer-reviewed journals and conference presentations., Trial Registration Number: NCT02152891., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Background: Older adults have higher risk of developing cardiovascular disease, diabetes and falls, leading to costly emergency medical service (EMS) calls and emergency room visits. We developed the Community Health Assessment Program through EMS (CHAP-EMS) that focuses on health promotion/prevention of hypertension and diabetes, links with primary care practitioners, targets seniors living in subsidized housing, and aims to reduce morbidity from these conditions, thereby reducing EMS calls. In this pilot study, we evaluated the feasibility of implementing the CHAP-EMS, attendance rates, prevalence of high blood pressure and cardiovascular risk factors., Methods: In this pilot study the CHAP-EMS was implemented in the intervention site over a 12 month period. BP, lifestyle, cardiovascular risk and EMS call rates were collected and descriptive analyses performed. Participants were residents (low income seniors) of a subsidized housing complex in Hamilton, Ontario. Two paramedics provided once-weekly sessions, measuring BP, assessing diabetes/lifestyle risk (CANRISK questionnaire) and discussed prevention/local wellness activities in the intervention site. Follow up was invited., Results: A total of 1365 visits with 79 unique participants occurred; 48 (25.2%) visited at least twice; mean age was 72.2; 87.2% were 65 years of age and older and 68.1% were female; 90.3% had a family doctor. Overall, 45.2% had elevated BP initially from the total; 50.0% of participants previously diagnosed with hypertension had elevated BP while 33.3% not previously diagnosed had elevated BP. Almost 1 in 5 (19.4%) had diabetes; 66.7% had moderate to high risk of developing diabetes., Conclusion: This pilot study indicates that CHAP-EMS is a feasible program that could have impact on BP, lifestyle factors, diabetes risk and EMS calls in the buildings in which it was implemented.