November 21, 2025
A Safer Tomorrow at Home: How Care Coordination Helps Canadians Age in Place
Discover how care coordination helps Canadians age in place by reducing falls, easing hospital-to-home transitions and improving quality of life.
Discover how care coordination helps Canadians age in place by reducing falls, easing hospital-to-home transitions and improving quality of life.
Even in the warmth of a holiday gathering, small signs can raise big questions. A loved one stumbles on the front steps. Another repeats the same story twice at dinner. Someone returns home from a hospital stay but looks thinner, more confused, less steady. These are not just isolated moments; they are reflections of a larger challenge in Canada’s aging journey.
As our population grows older, the cracks in the system become more visible. Falls, dementia, rushed hospital discharges, and fragmented care all take a toll on older adults and their families. Yet this story doesn’t need to be one of decline. With the right connections in place—care coordination that links hospitals, community supports, families and preventive programs—helps older Canadians age safely and independently at home.
Canada is aging quickly. As of 2024, adults aged 65 and older make up nearly 19 percent of the population, and that share is projected to climb steadily over the next two decades (Statistics Canada).
One of the most pressing challenges linked to aging is dementia. The number of Canadians living with dementia is expected to reach close to one million by 2030, with even greater increases projected by mid-century (Alzheimer Society of Canada). Encouragingly, research shows that nearly half of dementia risk is attributable to modifiable factors such as physical inactivity, hypertension, hearing loss and social isolation (Journal of Prevention of Alzheimer’s Disease, 2024).
Alongside dementia, frailty and falls are among the biggest threats to aging in place. In 2022, there were 78,076 fall-related hospitalizations among older adults in Canada, accounting for nearly 90 percent of all injury hospitalizations in this age group. Emergency departments were equally burdened, with more than 200,000 fall-related visits in Ontario and Alberta that same year (Government of Canada Health Infobase). Behind each statistic is a Canadian who simply wanted to stay in their own home, but whose safety and support fell short.
A fall can alter an older adult’s ability to age in place overnight. One in three fall-related hospitalizations involves a hip fracture, and recovery can take months of rehabilitation. Some never fully regain their mobility or independence (Government of Canada Health Infobase).
The impact is not only physical. After a fall, fear of falling again often leads to inactivity and isolation, which further weaken muscles and confidence. For people living with dementia, the risk is even greater. In Canada, about 15 percent of emergency department visits by people with dementia are fall-related, compared to 9 percent among older adults without cognitive impairment (PubMed, 2023).
Effective falls prevention, including home safety checks, strength and balance training, and medication review, can help prevent injuries and support older adults in remaining safely at home.
If falls represent one kind of risk, the transition from hospital to home represents another. Each year, thousands of older Canadians face complex discharges, often returning to homes that are not prepared for their recovery or mobility needs.
According to the Canadian Institute for Health Information (CIHI), the 30-day risk-adjusted urgent readmission rate for medical patients across Canada remains substantial, with national data showing persistent trends. Broader indicators covering all patient groups confirm that many hospital discharges are followed by a return visit within 30 days (CIHI, 2023).
Recent research shows that between 11 percent and 15 percent of Canadians discharged from hospital end up back within a month (Salimian et al., 2024). Without proper discharge planning, timely follow-up or home supports, many older adults find themselves caught in a revolving door of hospital stays.
The challenge is worsened by Canada’s growing shortage of family doctors. In provinces like New Brunswick, health ministers have acknowledged that a lack of accessible primary care leaves thousands of residents without a family physician—forcing older adults to rely on emergency departments or manage post-hospital recovery alone (Canadian Broadcast Corporation (CBC), 2025). For those trying to age in place, this gap can be the tipping point between independence and institutional care.
Care coordination helps bridge these cracks by guiding hospital-to-home transitions. Coordinators ensure medications are reconciled, follow-ups are scheduled and home supports are in place. With a dedicated care coordinator, older adults recover in familiar surroundings rather than returning to hospital.
Unlike a fall, dementia doesn’t happen in a single moment. Its early signs—forgetting a name, getting lost on a familiar route, repeating a question—develop gradually and often go unnoticed until a crisis. Even when families suspect dementia, getting assessed and connected to care can take years. Nationally, the average time from first symptoms to a formal diagnosis is between 21 and 28 months, and post-diagnosis supports still vary widely by province (Brainwell Institute, 2025).
A 2024 review found that older adults with dementia face significantly higher 30-day hospital readmission risks, particularly when living with multiple chronic conditions, and that up to 40 percent of these readmissions could be prevented with stronger care transitions (BioMed Central (BMC) Geriatrics, 2024). Coordinated care through ongoing contact, caregiver education and community resources, helps Canadians with dementia live safely at home longer and delays the need for residential care.
The most hopeful part of Canada’s aging story is that prevention works. Fall-prevention programs combining exercise, vision care and medication review reduce injury risk in older adults (Public Health Agency of Canada (PHAC), 2024).
Similarly, nearly half of dementia risk is linked to modifiable factors (Journal of Prevention of Alzheimer’s Disease, 2024). Yet access remains unequal. Rural and remote seniors face greater travel times and fewer providers (CIHI, 2025), and Canada faces a shortage of more than 22,800 family physicians (Canadian Medical Association (CMA), 2025).
Care coordination connects prevention with people. Coordinators link older adults to community and virtual programs that promote exercise, socialization and cognitive health, helping them maintain their independence and age in place safely.
Instead of each fall, diagnosis or hospital stay being treated as an isolated event, care coordination brings these experiences into one connected story. Care coordinators work alongside older adults and their families to spot risks early, support smooth care transitions and make prevention part of everyday life.
The examples below show how care coordination closes the gaps that often disrupt safe and independent living at home.
This isn’t just about logistics—it’s about preserving independence. When care is connected, older adults are less likely to fall, less likely to return to hospital, and more likely to remain active and confident in their own homes.
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At Serefin Health, we know that many seniors and their families don’t need another app or hotline. They need a trusted point of contact. That’s what our Care Concierge provides: a single hub where health and social needs come together.
Through a secure portal, families can view care plans, appointments and assessments in real time. Care coordinators check in regularly, noticing subtle cues—a slower talking pace during a call, a change in mood or a missed appointment—and act before a small concern becomes a crisis.
When a hospital discharge is approaching, care coordinators ensure every detail is covered: medications reconciled, physiotherapy arranged, primary care looped in and families fully informed. For dementia, they act as educators and advocates, walking alongside families from assessment through long-term planning.
Most importantly, the Care Concierge model recognizes that aging in place is not just a medical goal; it is a human one. It’s about helping people stay in the comfort of home, surrounded by familiarity, connection and peace of mind.
Aging should not be viewed as decline. It is a stage of life that can be rich with purpose, routine and connection. With the right supports, Canadians can stay active, safe and engaged where they most want to be—at home.
No one should have to navigate aging alone or fall through the cracks of a fragmented system. Care coordination can bridge hospital and home, link prevention with treatment, and help Canadians age independently, confidently and with dignity in the place they call home.
Visit Serefin Health Care Coordination and our Public Access Program to learn how we’re helping Canadians live longer, safer and more connected lives at home.
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