WrapAround for Older Adults

WrapAround is a type of care model that involves coordinating the efforts of various community service providers to “wrap” older adults in community supports so you can:

  • Have a voice in choices that affect your care
  • Experience better supports and more involvement in your community
  • Benefit from the support of a team who help you build on your strengths

WrapAround assists with the following life domains: Housing, Safety, Financial, Spiritual, Health, Family, Social, Recreation, Culture/Values, Mobility & Legal.

“I have participated in the WrapAround process in multiple capacities over the past 4 years.  Each has met with participant defined success. The experience is challenging, and one that needs to be adaptable to individual needs and capabilities, but it is amazing how the application of a focused process can improve a life!”

- C. Rice, Volunteer Facilitator

Supported by:

Volunteers are trained (4-Day Session) to deliver a consistent and prescribed method of support, known as WrapAround.

The older adult and the volunteers will work together, using the WrapAround method, to form a team of support around the older adult.  These teams will support the participant to battle social isolation and build on their strengths to find ways to address their needs and goals.

Ontario Health Team of Northumberland (OHT-N) Projects:

“WrapAround has been a wonderful experience for me. I have connected with my volunteers and always know they are there to support me when needed. For once, I have been left feeling like I have control of my own care and the services I have been connected with. My volunteers created a list of all my strengths, and I was brought to tears knowing I am a valued member of my community and I have purpose. I look at this list often when I am feeling low. Without the support & encouragement of my volunteer facilitators, I would feel overwhelmed by the services in the community and would be hesitant to accept help.”

– Volunteer Peer Support Program Participant

Volunteer Peer Support (VPS)

This initiative will match trained volunteers with people in our community who require informal support, broadening their social network and assisting them to navigate and access the health care services they need. 

Community Paramedicine Program

The OHT-N has partnered with Northumberland Paramedics to expand the reach of the Community Paramedicine program, supporting more people who are frail/elderly, live in rural areas, are experiencing mental health and addictions challenges, or are experiencing homelessness. Leveraging the skills and training of Northumberland Paramedics, the Community Paramedicine program provides proactive services for patients who use 9-1-1 services due to system gaps/challenges/ access to community care, such as onsite assessments and remote patient monitoring. 

Rural Outreach Clinics

Multiple OHT-N partners will bring services to rural community locations to reduce barriers to care experienced by patients in small, rural areas, such as access, transportation and outreach challenges. The Colborne Rural Outreach Clinic, opened April 6, 2021. Located at 34 Victoria St. in Colborne.

 The population served, as well as the scope of services provided, will expand over time.

Learn More about OHTN:

Email: info@ohtnorthumberland.ca

Phone: 905-396-6486

CLICK THIS TAB to be directed to the OHTN website.

Goal of the VPS Initiative

  • The OHT-N Volunteer Peer Support initiative will match skilled volunteers with vulnerable older adults experiencing persistent complex needs and conditions.
  • The volunteers will be trained (4-Day Session) to deliver a consistent and prescribed method of support, known as WrapAround.
  • The older adult and the volunteers will work together, using the WrapAround method, to form a team of support around the older adult. These teams will support the participant to battle social isolation and build on their strengths to find ways to address their needs and goals.
  • It is expected that older adults who participate in a WrapAround process will have developed greater capacity to navigate the service systems and be less reliant on the service systems, due to their larger, informal, social support circle.


Expected Impact of the VPS Program

  • Improved experience of vulnerable individuals and families by providing volunteer-based supports to contribute to timely access and more effective transitions
  • A new referral option for primary care providers/health care teams
  • Community and inter-personal connections that mitigate social isolation and loneliness which can contribute to system delays through unnecessary, repeat and frequent use of primary care/ED/EMS services and can prolong hospital stays
  • Increased rich volunteer opportunities across the County

WrapAround Core Values and Practice Principles

Life Domains that WrapAround Assists with:

Housing, Safety, Financial, Spiritual, Health, Family, Social, Legal, Recreation, Mobility, etc.

WrapAround Process


  • Referral made by organization, family member, friend or older adult
  • Intake meeting completed by the Coordinator. Once intake is completed the Coordinator will match the participant with two volunteer facilitators to begin the WrapAround process.

Four Phases of WrapAround

1)Engagement: following referral process

  • Listen to their story and reflect it back
  • 2-4 meetings to complete the “Strengths/Needs/Culture Discovery”, a list of the participants strengths, culture, hopes and dreams, needs and the people they may want on their WrapAround team.
  • Opportunity for the participant to connect with volunteers & form a strong relationship

2)Team-Based Planning

  • Identify potential formal & informal team members with the help of the trained volunteers
  • Hold team meetings: 1-2 per month


  • Follow up with the participant and each team member after the first team meeting at least once and more often as necessary
  • Continuously reviewing the plan and making changes as needed


  • When goals have been achieved, begin to assist the participant to transition out of WrapAround.
  • Summarize success, do anticipatory planning for future challenges with participant and, in some case, their team members
  • Follow up as necessary and as agreed upon

How Does The WrapAround Process Work?

  • An older adult/caregiver driven, team based and holistic planning process that develops one individualized and integrated plan
  • Develops strategies that the entire team takes on to effectively address the needs identified by the older adult/caregiver on a daily basis
  • Key to the success of WrapAround is that the older adult pick who will be on their team, what they want to work on, the strategies that they want in their Action Plan and how fast they want to work on that plan.

In using the WrapAround process, we are implementing a facilitated team-based practice model designed to integrate natural, community and professional supports, with the older adult in the driver’s seat.  Together they develop one plan that integrates everybody’s efforts.

  • Another reason for its success is that the service system supports the local community and the neighborhood that the older adult lives in to get involved and take charge of this initiative

The reason that this is important is that the community will always be there to support its members, no matter their level of need, while formal services are usually both time and quantity limited and come and go in the lives of the people we serve in that community.

Participation in the WrapAround process has ranged from 3-4 months to 18-24 months, although the average is between 1 and 2 years.

    WrapAround in Action

    WrapAround Scenarios:

    • An older gentleman living in a rural community who had been hospitalized frequently due to mental health concerns, had received several eviction notices, no food security, no financial stability, and very limited family supports. Does not have a family doctor. His apartment was not accessible, there was no elevator and he lived on the 3rd floor. His daughter in law lived out of town and was heading to Florida for the winter and was worried about leaving her father. We were able to get him on the Meals on Wheels Program & friendly visits with CCN, St. Elizabeth was set up to offer home care to assist in his home twice a week and Home & Community Support Services supported him with getting on the emergency list for LTC. He has since moved into a long-term care home and has been doing well with this transition. His stepdaughter was happy with the support we offered.
    • Gentleman recently had a stroke, struggled with post-stroke depression & recent mental health hospitalization, minimal social connections & lifestyle changes following stroke. His brother lives with him but their relationship has been struggling since his return from the hospital, due to the extra care he is requiring. He has requested more supports be in place for his recovery as well as help with his personal care. He does not feel confident enough to make his own meals anymore due to physical limitations.  He gets a long well with his social worker from the hospital, but he is unsure of how long she will stay on board.
    • Participant lives in a rural community, decline in mobility/chronic pain/falls. Struggles with depression and isolation. Requires support filling out forms (CPP & ODSP).  She has been declined ODSP x3 and has a hearing coming up.  She has not completed an intake with Home & Community Support Services and is unsure she wants to move in to LTC. Her son moved closer to her to be an active support in her live.  She had many friends but has lost touch with them throughout COVID. She does not drive and requires assistance getting to medical appointments.
    • Participant has complex physical & mental health needs. Risk of homelessness. Rent arrears and cell phone debt. Family doctor is out of town, and she does not meet with him regularly.  Lives in an apartment and gets a long well with her neighbours.  She is always paranoid that someone will enter her room at night.  Struggles with severe anxiety and physical mobility concern- uses a walker. Main income source is Ontario Works.  Unsure if she has applied for Northumberland Rent Geared to Income Housing. Has family that lives in the area, but they do not get a long.
    • Currently unhoused, living in a motel. Separated from his wife a few years ago and his children are unhappy with how he treated his wife. He has 4 children but does not have regular communication with them. Financial limitations. Used to play hockey & loves to play Euchre but doesn’t have anyone that will play with him.  Needs help renewing his health card and needs new glasses, he has not had an eye exam in many years & would like a haircut. The help centre & Transition House are involved to help him with his housing challenges. He would like to reconnect with his daughter but is not hopeful for a reconciliation.   He would also like a small table in his room so he can play cards.  He would like food to be delivered to his apartment if possible as he doesn’t have any way to cook meals in his room. Participant was wondering about any laundry services in town, he would like his towels cleaned.
    • Participant has a seasonal house; in the winter she resides in an accommodation arranged through the Help Centre & Transition House. Significant financial difficulties. She had a heart attack & stroke approx. 3 years ago. Moderate left side paralysis, has not received any follow-up Occupational Therapy or Physiotherapy treatments. Very limited family involvement, she has two friends that check in often. She is feeling isolated and would like to engage in social activities when possible. She had her own business but that has stopped during COVID-19 due to the nature of the business. Her health has changed significantly in the past couple years. CPP & Old Age Pension (guaranteed income). Concerned that she cannot afford to eat because groceries are so expensive. Often indicates she is “lonely & poor” and recognizes she needs help but doesn’t always like to ask for it.

    How to Access the Volunteer Peer Support Service


    Individuals can:


    2)Be referred by a family, friend or caregiver

    3)Be referred by a doctor, primary care provider or another community service provider


    • Older adults residing in Northumberland County, and
    • Are experiencing complex and persistent needs/conditions or are caring for someone with multiple complex and persistent needs/conditions, and
    • Are agreeable to a WrapAround process, and
    • Have not effectively had their needs addressed by the efforts of service providers


    There is no fee for the services we provide in the Volunteer Peer Support Program

    Volunteer Opportunities

    WrapAround Facilitator Position: The volunteer facilitator will be matched with a participant and co-facilitate.  They will help older adults navigate the system to find the care and support they need. They will take a 4-day comprehensive training in the WrapAround process. The training will prepare volunteers to support the participant and help them form a team of supports (informal & formal) that will help them achieve their goals and support their needs.

    Skills and experience the program would consider as helpful for volunteers

    • Experience supporting seniors (e.g. as friend/family caregiver)
    • Excellent communication and listening skills
    • Ability to form professional and comfortable working relationships with a wide range of people
    • Empathetic and caring
    • General knowledge of:

    oCommunity support groups (may include faith communities, senior’s programs and centres, service clubs); and

    oHealth care services and social services available throughout Northumberland County.



      Kelly Peterson, Volunteer Peer Support Coordinator

      Office: (905) 372-7356 x 102

      Cell: (905) 373-2998


      “As a volunteer co-facilitator for the WrapAround program, I am learning a lot about our community and am seeing many varied and caring supports within it. While the challenges that WrapAround participants face can be daunting, they know they are not alone, and they can choose supports that help them move forward with hope.”

      – W. Sheppard, Volunteer Facilitator

      “I am grateful to be a volunteer for the WrapAround program. It is rewarding and a much-needed service to our senior community. I am extremely thankful to be paired up with another volunteer that has the same commitment to help our seniors who are making their best efforts to live independently. I feel we were successful in determining our clients needs and creating a helpful team. We had a lot of support from our Volunteer Peer Support Coordinator, which made this experience very worthwhile.”

      – M.L. Secord, Volunteer Facilitator

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