The ACHRU-CPP five core components
| Intervention components | Goals |
| 1. Home/virtual visits (up to 3 home visits) and unlimited follow-up phone calls by an RN and/or RD or nutritionist | To assess older adults’ and caregivers’ needs and goals using standardised tools to support a coordinated care plan |
| 2. Monthly group wellness sessions (up to 6 sessions) at a local community centre led by the RN, RD or nutritionist and community programme coordinator | To provide older adults and caregivers with gentle progressive physical activity, self-management education for diabetes and other chronic conditions, and healthy lunches and snacks |
| 3. Monthly team case conferences which include an RN, RD or nutritionist and community programme coordinator | To discuss the health and social care needs of older adults and caregivers, develop and revise the coordinated care plan, and plan topics for group wellness sessions |
| 4. Collaboration with the primary care interprofessional team and other specialists (eg, family physicians, nurse practitioners, kinesiologists, social workers, home care and social service providers, pharmacists, endocrinologists) | To support primary care and community providers in working collaboratively to develop care plans for older adults, and connect older adults and caregivers to specialists and community resources |
| 5. Nurse-led care coordination/system navigation | To facilitate linkages to other primary healthcare providers, specialists and community care services for older adults and caregivers |
ACHRU-CPP, Aging, Community and Health Research Unit-Community Partnership Program; RD, registered dietitian; RN, registered nurse.