Sarnia-Lambton Community Support Services

The Sarnia-Lambton project was developed to support the needs of residents who need access to home and community care in Lambton County. A key objective is to increase awareness of, and access to, community supports and health services that enable Lambton County residents to "age-in-place". This objective arose because community members had indicated the need for increased awareness and communication of services, as well as improved connectivity of service providers.

This research project is a collaboration of investigators in Ontario, Quebec, and Alberta to support stronger primary care for older adults living with frailty. Effective assessment of frailty will allow older adults to remain in their homes and communities. Primary care clinicians will use the Assessment Urgency Algorithm tool, which uses a scale of one to six, to determine frailty level. This ensures a client is connected to the right type of service, at the right time.

Caredove has configured services to display results in 3 main categories:

  • Prevention & Health Promotion for scores 1 & 2
  • Community Support Services for scores 3 & 4
  • Specialized Geriatric Services for scores 5 & 6
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Funded ByProject Sponsor

Ontario Ministry of Health and Long Term Care

Network Search SiteAlberta Network Waterloo Wellington Network

Find and book from 10 Agencies and 87 services

Lead Agency

County of Lambton, Lambton Elderly Outreach

Funded ByProject Sponsor

Ontario Ministry of Health and Long Term Care


  • Reintegration Care Units (RCU)
    These units support patient transitions from the hospital to short-term transitional care units in the community that provide a safe and supportive place to help patients increase strength, mobility and endurance to support their transition home or into an alternative care setting.
  • Caregiver ReCharge Programs
    These programs provide caregiver relief and improve their capacity to transition their loved one home and continue to provide care for the client while promoting their own wellbeing.  These services include in-home respite (day/night), away from home overnight respite, and/or supervised programming in a group setting during the day (i.e. Adult Day Programs).
  • The Process
    The Centralized Referral Management Team members will confirm eligibility and the client will be matched to a health service provider (of the selected program) by their unique needs and availability, with consideration given to geography where possible.
    The Health Service Provider Team members will then work with the caregiver and/or the clients’ families on a plan for service provision.
  • Sites
    Bellwoods, Hillcrest Reactivation Centre, LOFT Community Services, Pine Villa Sprint, Reconnect Community Health Services, Rekai Centre Transitional Care Unit, St. Hilda’s Towers Senior Care Unit, The Neighbourhood Group


December 2018 project performance

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An effective referral management system helping caregivers and care providers access the range of community supports and health services available in our community. By connecting all of the available services in our community, we can deliver better coordinated care, closer to home.

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