Seniors Healthy Aging Strategy

Report to/Rapport au:
Ottawa Board of Health
Conseil de santé d’Ottawa
January 20, 2014
20 janvier 2014
Submitted by/Soumis par:
Dr./Dr Isra Levy,
Medical Officer of Health/Médecin chef en santé publique
Contact Person / Personne ressource:
Sherry Nigro, Manager/Gestionnaire
Health Promotion and Disease Prevention/
Promotion de la santé et prévention des maladies
Ottawa Public Health/Santé publique Ottawa
613-580-2424, ext./poste 28971, [email protected]
CITY WIDE/ À L’ÉCHELLE DE LA VILLE
Ref N°: ACS2014-OPH- HPDP-0002
SUBJECT:
SENIORS’ HEALTHY AGING STRATEGY UPDATE
OBJET :
MISE À JOUR SUR LA STRATÉGIE POUR LE VIEILLISSEMENT
SAIN DES AÎNÉS
REPORT RECOMMENDATIONS
That the Board of Health for the City of Ottawa Health Unit receive this report for
information.
RECOMMANDATIONS DU RAPPORT
Que le Conseil de santé de la circonscription sanitaire de la ville d’Ottawa prenne
connaissance du présent rapport à titre d’information.
EXECUTIVE SUMMARY
The proportion of Ottawa’s population aged 65 years or older is currently 14 per cent
(129,000), which is predicted to increase to 21 per cent (266,000) over the next twenty
years, with the fastest growth anticipated in the age group of 85 years and older.
In 2011, the Board of Health adopted the Seniors Healthy Aging Strategy to support key
program and service areas for Ottawa’s aging population. The Strategy, which is
aligned with and funded in part by the City of Ottawa’s Older Adult Plan (OAP), includes
enhanced programming for at-risk seniors, caregivers and falls prevention.
Program and service achievements since implementation of the Seniors Healthy Aging
Strategy include:

Enhanced programming to support healthy aging that includes awareness of falls
prevention, screening clinics, partnerships with agencies that provide services to
seniors, and education targeted to clinicians and policy makers

Expanded support for at-risk seniors. Seniors who experience social isolation due to
language, geography, income or lack of family are more vulnerable to declining
health. OPH provides a home visiting service through the Community Connect team
to those in deteriorating circumstances. In 2013, OPH launched a major outreach
component to train non-traditional referral sources that have regular contact with
older adults to identify and link isolated or at-risk older adults to OPH for support and
services. By the end of 2013, OPH had trained over 2,100 people in the community
to better serve at-risk seniors.

Improved outreach to caregivers of seniors. OPH has published an e-guide with tips
and information to help those caring for an older adult, which can be found on the
Older Adult Portal and OPH website
Seniors programming is now a recognized priority at different levels of government; the
Ministry of Health and Long-Term Care, the Champlain Local Health Integration
Network and the City are actively planning and implementing seniors-related initiatives.
This is in addition to community and health groups in Ottawa, such as the Council on
Aging, that have long been champions and leaders in seniors programming. To
optimize public health contributions, in 2014, Ottawa Public Health (OPH) will focus on
reducing falls among seniors and improving access to services for older adults. This will
involve engaging primary care providers, increasing physical activity opportunities for
older adults and working with municipal partners as part of the OAP. Each year in
Ottawa, about 6,300 seniors aged 65 years and older visit the emergency room for a fall
and approximately 1,700 are hospitalized. Falls are a factor in 40 per cent of nursing
home admissions and lead to 70 deaths of Ottawa seniors every year.
In the coming years, OPH will evaluate and reassess how this organization, as one of
many agencies serving older adults, can best contribute to healthy aging in Ottawa.
RÉSUMÉ
À l’heure actuelle, 14 % des résidents d’Ottawa sont âgés de 65 ans et plus
(129 000 personnes). On prédit que cette proportion grimpera à 21 %
(266 000 personnes) au cours des vingt prochaines années, et que le groupe d’âge qui
connaîtra la croissance la plus rapide sera celui des 85 ans et plus.
En 2011, le Conseil de santé a adopté la Stratégie pour le vieillissement sain des aînés
afin de soutenir des types de programmes et des secteurs de service essentiels pour la
population vieillissante d’Ottawa. La Stratégie, qui s’inscrit dans le Plan relatif aux
personnes âgées (PRPA) de la Ville d’Ottawa et qui est financée en partie par celui-ci,
propose des programmes améliorés pour les personnes âgées vulnérables et les
aidants naturels, ainsi que des programmes améliorés en matière de prévention des
chutes.
Parmi les réalisations accomplies depuis la mise en œuvre de la Stratégie pour le
vieillissement sain des aînés, mentionnons les suivantes :

Amélioration des programmes favorisant le vieillissement sain et comportant un
volet de sensibilisation à la prévention des chutes, des cliniques de dépistage, des
partenariats avec des organismes qui fournissent des services aux personnes âgées
ainsi que de l’information destinée aux cliniciens et aux décideurs.

Accroissement du soutien aux personnes âgées vulnérables. Les aînés isolés
socialement pour des raisons linguistiques, géographiques, familiales ou liées à leur
revenu sont le plus à risque de voir leur état de santé se détériorer. Par
l’intermédiaire de l’équipe de Connexion communautaire, SPO offre un service de
visites à domicile aux personnes dont la santé décline. En 2013, il a lancé un
important volet de sensibilisation pour apprendre aux sources d’aiguillage non
traditionnelles qui sont fréquemment en contact avec des aînés comment repérer les
personnes âgées isolées ou à risque et les diriger vers SPO afin qu’elles obtiennent
des services de soutien. À la fin de 2013, plus de 2 100 personnes dans la
communauté avaient été formées pour mieux répondre aux besoins des personnes
âgées vulnérables.

Amélioration de la sensibilisation des aidants naturels des aînés. SPO a publié un
guide électronique comprenant des conseils et des renseignements pour épauler les
aidants; vous le trouverez sur le Portail des aînés et sur le site Web de SPO.
Les différents ordres de gouvernement reconnaissent maintenant les programmes à
l’intention des aînés comme une priorité; le ministère de la Santé et des Soins de
longue durée, le Réseau local d’intégration des services de santé de Champlain et la
Ville jouent un rôle actif dans la planification et la mise en œuvre d’initiatives liées aux
personnes âgées. S’ajoutent à ces organismes les groupes communautaires et les
groupes œuvrant dans le domaine de la santé d’Ottawa, comme le Conseil sur le
vieillissement, qui se posent depuis longtemps en champions et en chefs de file des
programmes destinés aux aînés. Pour optimiser les contributions en santé publique
relativement aux personnes âgées, SPO mettra l’accent en 2014 sur la réduction des
chutes et sur l’amélioration de l’accès aux services. Pour ce faire, il devra mobiliser les
fournisseurs de soins de première ligne, augmenter les possibilités pour les aînés de
faire de l’activité physique et collaborer avec les partenaires municipaux dans le cadre
du PRPA. Chaque année, à Ottawa, environ 6 300 personnes âgées de 65 ans et plus
visitent les urgences à la suite d’une chute, et environ 1 700 sont ensuite hospitalisées.
Les chutes représentent un facteur dans 40 % des admissions en maison de soins
infirmiers et entraînent le décès de 70 aînés d’Ottawa chaque année.
Dans les années à venir, SPO réévaluera comment il peut, parallèlement aux nombreux
autres organismes au service des personnes âgées, contribuer de manière optimale au
vieillissement sain à Ottawa.
BACKGROUND
The Board of Health 2011 Seniors Healthy Aging Strategy highlighted several key
program and service areas to support Ottawa’s aging population. These initiatives are
aligned with the objectives of the Board of Health’s 2011-2014 Strategic Priority of
responding to demographic changes:
 Enhance programming to support healthy aging
 Improve outreach and support to caregivers
 Expand supports for at-risk seniors
Ottawa’s aging population
The proportion of Ottawa’s population aged 65 years or older is currently 14 per cent
(129,000), which is an increase from 11 per cent in 2003. Over the next twenty years,
the proportion of seniors is predicted to increase to 21 per cent (266,000),1 with the
fastest growth anticipated in the age group of 85 years and older. In Ottawa, seven per
cent of seniors live with low income, 26 per cent of seniors live alone, and two out of
three older adults living in poverty live alone. 2 3 4 Recent older adult immigrants are
three times more likely (25 per cent) to have a lower income than the rest of the
immigrant older adult population (nine per cent).5
Overall, 23 per cent of seniors need help with one or more activities of daily living, but
among those who are socially isolated, this proportion jumps to 33 per cent.6 Almost
three-quarters (72 per cent) of the health care that seniors receive at home is provided
by family or friends and 20 per cent of caregivers are seniors themselves. Almost onethird (28 per cent) of employed Canadians are caring for an elderly dependent.7 Older
caregivers face an increased risk of injury, and this can also worsen pre-existing chronic
health conditions.8
Health issues in older adults
In Canada, 25 per cent of older adults aged 65 to 79, and 37 per cent of those aged 80
and older report four or more chronic conditions.9 Many (approximately 86 per cent)
Ottawa seniors (65+ years) reported having at least one chronic condition in 2009/2010.
The top five most common chronic conditions among seniors are arthritis, high blood
pressure, back problems, diabetes and heart disease.10 In Ottawa, 54 per cent of
seniors experience participation or activity limitation because of a chronic health
problem.11
In Ontario, 10 per cent of older adults – those who are experiencing the most complex
health issues – account for 60 per cent of annual health care spending for this
population.12 The release of Ontario’s Living Longer Living Well in 2013 described the
challenges of dealing with multiple health issues and the demands on the health
system. Subsequently, the Ministry of Health and Long-Term Care (MOHLTC) has
launched a provincial initiative called Health Links to improve service and coordination
of care for patients with complex, chronic health conditions. The intention is to provide
coordinated and comprehensive primary and tertiary care while ensuring positive patient
outcomes with the best return on investment. Locally, the Champlain Local Health
Integration Network (LHIN) leads the integration of services for this medically-fragile
population.
Falls remain a health concern for older adults. In Ottawa, each year approximately
6,300 seniors aged 65 years and older visit the emergency room for a fall and close to
1,700 are hospitalized.13 14 Falls are a factor in 40 per cent of nursing home admissions
and lead to 70 deaths of Ottawa seniors every year.15 16
To better understand the knowledge and attitudes of seniors about falls, OPH undertook
the Older Adults Falls Prevention Survey by telephone with 1,050 Ottawa adults aged
65 years and older living at home. Results reveal that although nine of 10 seniors agree
that falling is a major health concern and is preventable, many are not taking necessary
steps to prevent falls. For example, only half of seniors have a grab bar or rail installed
in their bathtub or shower. Additionally, fewer than half of older adults are getting the
right amount or right kind of physical activity to help protect them from falls. Many
seniors (43 per cent) take multiple medications that may increase their risk of falls, and
only one in four seniors are getting enough daily calcium.
There are a number of factors that can protect, or conversely, increase risk for falls and/
or complications of chronic disease. The prevalence of chronic disease and falls is
highest among older adults on low incomes, who are living alone or who are from
language or cultural minorities.17 In Ottawa, older adults who are Francophone,
Aboriginal and new immigrants are more likely to experience social, cultural and
economic barriers in accessing health services.18
OPH programming and contribution to the City of Ottawa’s Older Adult Plan
In 2011, OPH re-allocated resources to enhance services for seniors. As well, OPH
identified several shared priorities with the City’s Older Adult Plan (OAP) following the
consultations that took place through the Seniors Summit in 2011. The City has
invested $203,200 in OPH programs to support increased access to health promotion
services (healthy aging) and targeted programming for at-risk seniors (dental services
and Community Connect). As well, OPH receives funding from Community Care Access
Centre for services in Aging in Place buildings.
Enhance programming to support healthy aging
With a focus on falls prevention, OPH has implemented a robust Healthy Aging
Program that includes awareness of falls prevention, screening clinics, partnerships with
agencies that provide services to seniors, and education targeted to clinicians and
policy makers. In addition, OPH is using a multi-media approach to promote six key
ways to prevent falls:
 Periodic health exams
 Annual vision check
 Annual medication review
 Regular physical activity, including strength and balance components


Eating calcium-rich foods and consuming a daily vitamin D supplement
Addressing environmental hazards in the home.
Highlights include:
 More than 700 seniors screened, with 12 per cent referred for falls risk and 24 per
cent for other health issues, such as hypertension
 Television interstitials in June 2013 with over 3.1 million views during air times
 Publication of low literacy resources, including recipe cards and infographics
 Falls Prevention Forum with Canadian expert Vicki Scott as a key note speaker
 Presentations to national, provincial and local organization to share the findings of
OPH’s falls prevention survey
 Considerations in the Official Plan, Transportation Master Plan, Pedestrian, and
Cycling Plans
OPH has significantly expanded partnerships with agencies serving seniors. This has
increased the number of locations where health information and activities are being
delivered beyond original targets. For example, staff are now in 17 Aging in Place
buildings, four municipal seniors centres and eight community locations where seniors
gather.
Expand supports for at-risk seniors
Seniors who experience social isolation due to language, geography, income or lack of
family are more vulnerable to declining health and becoming part of the 10 per cent who
need the most health care. OPH provides a home visiting service through the
Community Connect Team to those in deteriorating circumstances to assist them in
accessing support and prevent further decline. In 2013, OPH launched a major outreach
component to this program by training non-traditional referral sources who have regular
contact with older adults in order to identify and link isolated or at-risk older adults to
OPH for support and services. Training began in June with the expected reach to be
500 people in 2013. By the end of last year, OPH had trained over 2,100 people in the
community to identify and refer at-risk seniors.
Increasing evidence shows an association between oral health and general health. For
example periodontal disease is linked to cardiovascular disease, diabetes and
respiratory disease.19 Only 68 per cent of Ontarians report having dental insurance and
among older Ontarians and those with lower income and less education, there is a
significant drop in coverage rates.20 To improve and promote oral health among older
adults, OPH initiated a short-term project to provide free oral health education, dental
screening and fluoride applications for seniors in 10 Ottawa Community Housing Aging
in Place sites, 14 Community Health and Resource Centre locations and four municipal
long-term care homes:
 A new dental referral process was developed and implemented with the City of
Ottawa’s Long-Term Care Branch to identify and treat, when appropriate, urgent
dental needs among institutionalized, high-risk older adults
 In 2012, 274 screenings were completed with 128 needing further follow-up. Case
management was provided to older adults with urgent dental treatment needs to

help them access care, such as low-cost preventive services at hygiene colleges, to
use dental plans if they had coverage or to apply to the City of Ottawa’s Essential
Health and Social Supports program to be able to access dental services.
In 2013, more than 450 seniors received dental screenings and half (51 per cent)
were identified as having urgent dental needs. Over 200 of these seniors were linked
to dental treatment services and received treatment, such as restorations,
extractions and dentures. All seniors received oral health information to help them
improve and maintain their oral health.
Improve outreach and support to caregivers
OPH has provided workshops and resources to caregivers for over 15 years. In 2012,
the Caring for a Senior Community Resource Guide was revised and continues to be
used at events and workshops delivered through workplaces and various community
locations. As well, a caregiver forum, held in 2012, reached 165 caregivers with
services, tailored information and workshops, and opportunities for ongoing support.
Over 1,780 caregivers have been reached through sessions and displays. Most
recently, OPH has published an e-guide with tips and information to help those caring
for an older adult, which can be found on the Older Adult Portal and OPH website.
DISCUSSION
Seniors’ programming is now a recognized priority at different levels of government; the
Ministry of Health and Long-Term Care, the Champlain LHIN and the City are actively
planning and implementing seniors-related initiatives. This is in addition to community
and health groups in Ottawa, such as the Council on Aging, that have long been
champions and leaders in seniors programming. To minimize duplication of services
and optimize public health contributions, in 2014, OPH will focus on reducing falls
among seniors and improving access to services for older adults.
Optimize community capacity for falls prevention among seniors
In 2011, the MOHLTC introduced the Public Health Accountability Agreement target to
reduce fall-related emergency visits in older adults aged 65 years and older. In Ottawa,
the target set was 5,233 fall-related ER visits per 100,000 adults aged 65 years and
older. The rate of fall-related ER visits among Ottawa seniors 65 years and older has
increased five per cent from 5,379 per 100,000 in 2009 to 5,648 per 100,000 in 2012.21
For more detailed information, please refer to Document 1. Fall-related ER visits have
also increased in three of seven urban centre peers in Ontario (Peel, WellingtonDufferin-Guelph and Windsor-Essex). Data suggest there is much work to be done to
reduce falls among seniors. OPH will continue with a multi-prong approach that
recognizes that individuals, clinicians, planners and policy makers are all important
partners in effecting change. Activities planned for 2014 include:
 Continued dissemination of survey results to promote consistent messaging to the
public and to raise awareness of opportunities to prevent falls
 Leverage Ontario’s new physiotherapy funding model through a partnership with the
Community Health and Resource Centres and a local physiotherapy agency that has




public health nurses deliver the health education component of the Stand Up
program to seniors living in the community
Continue to offer falls screening clinics that provides assessment and referrals for
individuals
Multi-media awareness campaigns on the six key ways to prevent falls
Co-chair the Champlain LHIN Falls Prevention Steering Committee. This committee
includes members from community and acute care sectors. Progress to date
includes the set up of a governance structure, an inventory of existing falls
prevention activities across the Champlain LHIN and the development of an
algorithm for primary care providers to be piloted in 2014.
Participate in Public Health Ontario’s Locally Driven Collaborative Projects. The goal
of this project is to identify strategies that public health units can implement to
increase non-health service providers’ knowledge, attitudes, and use of evidencebased falls preventing activities.
Improving access to services through partnerships
Seniors that do not have reliable support systems not only have more health problems,
they also have more difficulty navigating health systems and accessing community
resources. OPH will continue to reach out to the most vulnerable through partners to
identify seniors who potentially are at risk as well as provide screening and referral
services. Through the Ottawa Public Health Information Line and the Community
Connect Team, efforts to reach seniors who are isolated by geography and/or language
will be made with focus on:
 Communities with the highest older adult density, including outreach to rural and
outlying areas
 “Building an Age-Friendly Business” project through the Council on Aging
 Multicultural and newcomer/immigrant communities through resources translated
into five additional languages (Chinese, Vietnamese, Arabic, Somali, and Spanish),
as well as through English as a Second Language and French as a Second
Language classes, and with Community Health and Resource Centres .
 Low-income seniors by expanding OPH programming for all 21 Ottawa Community
Housing seniors buildings. Presently, OPH offers services at 17 sites. In addition to
training for tenant community workers, support staff and volunteers, OPH is currently
working with the Ottawa Community Housing Corporation to develop a policy to
address safety features in Aging in Place buildings, such as adequate lighting in
common areas and installation of hand rails.
 Reaching caregivers through workplaces, churches and faith organizations and
through City facilities and programs
In addition to partnerships related to the above activities, OPH also supports and
contributes to several other community and City initiatives for seniors:
 Participate in various committees of the Council on Aging as it leads the
implementation of Age-Friendly City designation
 Support other municipal departments on OAP projects:
o Health promotion programming for the Older Adult Activity Guide
o Paramedicine Outreach Program with Ottawa Paramedic Service

o Falls prevention program for seniors who ride the bus
o Development of a safety and well-being screening checklist for use by all
City staff who conduct home visits with older adults
o Work with Ottawa Police Services on preventing elder abuse
o Design and content for the Older Adult Portal on the City’s web site
Collaborate with the United Way and several community agencies, such as on a joint
communications initiative entitled “Plan Your Aging” to be launched in 2014.
Conclusion
In 2014, OPH will focus on increasing community capacity to reduce falls in Ottawa,
particularly through outreach to primary care providers, through increasing physical
activity opportunities and through engaging municipal partners as part of the OAP. The
City’s efforts with the Older Adult Portal offer new possibilities to integrate with other
City services and leverage technology.
OPH will consider how to maximize the reach and build in sustainability for the most
effective programs. As a new cohort moves into retirement, there is growing interest in
more upstream health promotion and policy development. These are items that were
identified in the OAP development and may well be areas for future attention.
In the coming years, OPH will evaluate and reassess how this organization, as one of
many agencies serving older adults, can best contribute to healthy aging in Ottawa.
LEGAL IMPLICATIONS
There are no legal impediments to receiving the information in this report.
FINANCIAL IMPLICATIONS
There are no financial implications associated with this report.
TECHNOLOGY IMPLICATIONS
There are no technology implications associated with this report.
BOARD OF HEALTH STRATEGIC PRIORITIES
The report supports the Board of Health Strategic Priorities: Enhance programming to
support healthy aging (D1); Improve outreach and supports for caregivers (D2); Expand
supports for at-risk seniors (D3).
TERM OF COUNCIL PRIORITIES
This report supports the Term of Council Priority: Healthy and Caring Communities.
SUPPORTING DOCUMENTATION
Document 1 – Fall-related emergency department visits among older adults
DISPOSITION
Ottawa Public Health will continue to implement the Seniors Healthy Aging Strategy, as
described in this report.
1
Ontario Population Estimates and Projections 2011-2033, Based on 2006 Census
Data, Intellihealth, Extracted October 11, 2012.
2
Statistics Canada. 2013. National Household Survey (NHS) Profile. 2011 National
Household Survey. Statistics Canada Catalogue no. 99-004-XWE. Ottawa. Released
September 11, 2013. Retrieved October 10, 2013 from:
http://www12.statcan.gc.ca/nhs-enm/2011/dp-pd/prof/index.cfm?Lang=E
3
Statistics Canada. 2013. National Household Survey (NHS) Profile. 2011 National
Household Survey. Statistics Canada Catalogue no. 99-004-XWE. Ottawa. Released
September 11, 2013. Retrieved October 10, 2013 from:
http://www12.statcan.gc.ca/census-recensement/2011/dppd/prof/details/page.cfm?Lang=E&Geo1=CSD&Code1=3506008&Geo2=CD&Code2=3
506&Data=Count&SearchText=ottawa&SearchType=Begins&SearchPR=01&B1=Famili
es%20and%20households&Custom=&TABID=1).
4
Social Planning Council of Canada (2010). Poverty Profile of the City of Ottawa. Based
on 2006 Census. Ottawa.
5
Social Planning Council of Canada (2009). Immigrants’ Economic Integration:
Successes and Challenges. A Profile of Immigrants in Ottawa. Based on the 2006
Census. Ottawa
6
Successful Aging Ottawa, 2004 Seniors Survey Report of Results. Prepared by Social
Data Research Ltd. June 15, 2005
7
Duxbury L, Higgins C, Schroeder B. Balancing paid work and care giving
responsibilities: A closer look at family caregivers in Canada. January 2009. Canadian
Policy Research Networks: Ottawa.
8
Health Council of Canada. (2012). Seniors in need, caregivers in distress: What are
the home care priorities for seniors in Canada? Toronto: Health Council of Canada.
9
Public Health Agency of Canada. 2010. The Chief Public Health Officer’s Report on
the State of Public Health in Canada, 2010: Growing Older-Adding Life to Years. Her
Majesty the Queen in Right of Canada: 2010
10
Canadian Community Health Survey (2009/2010). Retrieved October 16 from:
http://ottawa.ca/calendar/ottawa/citycouncil/obh/2012/01-16/NEW%20%205864%20Ottawa%20Mortality%20and%20Morbidity%20Report%20Eng%20PRES
S%20Jan%2013-12.pdf
11
Statistics Canada, Canadian Community Health Survey (CCHS) 2009-2010. CANSIM
table 105-0502 is an update of CANSIM table 105-0400.
12
Sinha, Samir (2012). Living Longer, Living Well. Report Submitted to the Minister of
Health and Long-Term Care and the Minister Responsible for Seniors on
recommendations to Inform a Seniors Strategy for Ontario. Ministry of Health and LongTerm Care. Extracted Jan 2013. Government of Ontario.
13
Ambulatory Emergency External Cause 2009 to 2011 fiscal years, National
Ambulatory Care Reporting System.IntelliHEALTH Ontario, MOHLTC. Extracted August
28, 2013. Falls (ICD-10: W00-W19)
14
Ontario inpatient discharges 2009 to 2011 fiscal years, Discharge Abstract Database.
IntelliHEALTH Ontario, MOHLTC. Extracted January 18, 2013. Falls (ICD-10: W00W19).
15
Scott,V. (2012). Fall Prevention Programming: Designing, Implementing and
Evaluating Fall Prevention Programs for Older Adults. Raleigh, North Carolina: Lulu
Publishing
16
Ontario Mortality Data 2007 to 2009 calendar years, IntelliHEALTH Ontario,
MOHLTC. Extracted September 14, 2012. Falls (ICD-10: W00-W19)
17
Public Health Agency of Canada. 2010. The Chief Public Health Officer’s Report on
the State of Public Health in Canada, 2010: Growing Older-Adding Life to Years. Her
Majesty the Queen in Right of Canada:2010
18
Social Planning Council of Canada (2009). Immigrants’ Economic Integration:
Successes and Challenges. A Profile of Immigrants in Ottawa. Based on the 2006
Census. Ottawa
19
Azarpazhoo, A & Tenenbaum, H (2012) Separating Fact from Fiction: Use of HighLevel Evidence from Research Syntheses to Identify Diseases and Disorders
Associated with Periodontal Disease. Journal of Dental Association
20
Dr Arlene King (April 27, 2012) Oral Health – More Than Just Cavities. A Report by
Ontario’s Chief Medical Officer of Health
21
Ambulatory Emergency External Cause 2009 to 2011 calendar years, National
Ambulatory Care Reporting System. IntelliHEALTH Ontario, MOHLTC. Extracted
August 28, 2013. Falls (ICD-10: W00-W19)