Nav-CARE – Navigating life and aging with chronic illness

Nav-CARE (Navigation – Connecting, Accessing, Resourcing, Engaging)

Navigating life and aging with chronic illness

The overall goal of the Nav-CARE program is to improve the quality of life of adults living at home with serious illness. Community organizations across Canada are project partners. View the Nav-CARE brochure.

This project builds upon five years of collaborative work with knowledge partners in which we developed the conceptual and theoretical foundations; created, tested, and refined curriculum for volunteer navigators; and conducted three incremental pilots to determine the feasibility and acceptability of the Nav-CARE model.

Why is Nav-CARE important?
Adults living at home with serious illness, particularly those who do not yet qualify for home-based nursing care, often live with unmet needs and heavy symptom burden resulting in poor quality of life. Many do not know the services that are available to assist them.  Our previous research (see below) has demonstrated the value of using trained navigators to visit in the home to provide psychosocial support, education, guidance on advance care planning and connection to community and health resources. These navigators engage older adults to identify the services and resources available and to connect them to those resources using a best-fit, client-centred approach.

To read more, click on:

Interested in how your community organization can get involved? 
Contact us for more information! 

Barb Pesut, PhD, RN
Canada Research Chair, Health, Ethics and Diversity
Associate Professor,
School of Nursing
University of British Columbia 
Ph. 250-807-9955

Wendy Duggleby, PhD, RN, AOCN
Professor and Nursing Research Chair in Aging and Quality of Life University of Alberta, Faculty of Nursing 
Ph. 1-877-692-5909

Read our most recent document: Findings From a Knowledge Translation Study at  … -method evaluation of a volunteer navigation intervention for older persons living with chronic illness (Nav-CARE): findings from a knowledge translation study

A Billion Reasons to Care – Office of the Seniors Ombudsman

Click on the bold text to access the full report: A Billion Reasons to Care


A Billion Reasons to Care is the first provincial review of the $1.4 billion-dollar contracted long-term care sector in British Columbia. The review examined industry contracts, annual audited financial statements and detailed reporting on revenue and expenditures for the years 2016/17 and 2017/18.

Report Highlights 
– financial reporting systems were inconsistent between health authorities and they lacked openness and transparency
– there was insufficient detail for significant expenditures related to management fees, head office allocation and some administrative costs
– the method to report direct care hours was based on self-reported unaudited expense reports prepared by the care home operators with no ability to verify the reported worked hours
– less than half of care home operators are required to make their audited financial statements available to the public and no care homes publicly report their expense statements

The report found that while receiving, on average, the same level of public funding:
– not-for-profit care homes spend $10,000 or 24% more per year on care for each resident
– for-profit care homes failed to deliver 207,000 funded direct care hours
– not-for-profit care homes exceeded direct care hour targets by delivering an additional 80,000 hours of direct care beyond what they were publicly funded to deliver

The importance of community health centres in BC’s primary care reforms: What the research tells us

Mar 1, 2019
By Andrew Longhurst and Marcy Cohen 

Community health centres (CHCs) have been an effective but under-valued model for delivering primary health care1 for decades in Canada and the US. One of the unique features of the model is its strong focus on the social determinants of health and preventing acute illness among groups who are more likely to experience poor health and suffer from chronic conditions, including low-income people, ethno-cultural communities, Indigenous peoples, and frail seniors.

So what are community health centres? CHCs are non-profit primary care organizations that provide integrated health care and social services, with a focus on addressing the social determinants of health.

To read the full report, click on the Download button Download

Rural Site Visit Project

For more information, click on: RCCbc Rural Site Visit Project

Fifth report: June 2017 – November 2020 (PDF)
Fourth report: June 2017 – May 2020  (PDF)
Second report: June 2017 – June 2019 (PDF)
Third report: June 2017 – December 2019(PDF)
First report: June 2017 – December 2018 (PDF)

Please note that each report encompasses feedback from all rural communities engaged since the beginning of the Project.


In 2017, the Joint Standing Committee on Rural Issues (JSC) tasked the Rural Coordination Centre of BC (RCCbc) with visiting every Rural Subsidiary Agreement (RSA) community between 2017 and 2020. These visits will connect with rural practitioners and communities to hear about the context of rural practice and health care delivery (what innovations exist, what works well, what the biggest challenges are) and feed this information back to the JSC to better support feedback loops between rural practitioners and the programs that support them.

The Rural Site Visits Project will engage Health Partners (Health Professionals, Health Administration, Policy Makers, First Nations, Community, and Academic Institutions) within each community. From these community meetings, information is collected, anonymized and analyzed to identify the major themes affecting health care delivery in rural communities in BC. As a commitment to the communities, RCCbc sends a bi-annual Community Feedback Report to provide project updates and share the learnings from innovative solutions found throughout the visits. This is the fifth Community Feedback Report to date. To view previous reports please visit our website (

Due to Covid-19, the Rural Site Visits Project has postponed trips since March 16, 2020. Other areas of focus have been redirected to:

Launching a Site Visits and Innovations website featuring searchable innovations collected around the province to help address health care issues and connect community contacts to one another
Writing research papers on the Site Visits project process and overarching themes, and cultural safety and racism

Improving the communication and engagement processes for Indigenous community visits Trialing virtual Site Visits and reviewing their effectiveness and sustainability

The hope to resume trips will be dependent on each community and ensuring all parties are safe and comfortable with our visits before we start reaching out again.

Thank you again for all your support.

Dr. Stuart Johnston and Krystal Wong

Community Feedback Reports
The Rural Site Visits Project engages health partners (health professionals, health administration, policy makers, community, and academic institutions) within each community visited. From these meetings, information is collected, anonymized and analyzed into themes to identify the major themes affecting health care delivery in BC rural communities. 

As a commitment to the communities, RCCbc is providing bi-annual Community Feedback Reports to provide updates on project progress and share learnings from innovative solutions found throughout the visits.

&&&&&&&&&&&&&&&&&&&&&&&& launched on September 11, 2020 to all participants and stakeholders with over 100 innovations posted.

Some of the key features include:
– Browsing by either categories or key word searches
– Submitting your own innovations
– An Innovations Concierge to help connect users or find the most relevant innovations for them
– Joining a mailing list to keep up to date
– A whiteboard YouTube video overviewing the innovations inventory

Every 2-months a new batch of approximately 40 innovations will be added. The next focus will be an engagement and marketing strategy to raise awareness about the innovations inventory and Innovations Concierge. Some ideas and opportunities include finding venues to share information such as conferences, symposiums, meetings; collaborating with partners to cross-share information; creating a podcast; hosting open forums for communities.


This open-ended guide provides a sample of questions that may be asked during the Site Visits meetings.


Two and a half years after its inception, the RCCbc Site Visit project has reached its half-way point with over 100 rural BC communities visited.

101 Rural Subsidiary Agreement (RSA) communities representing all corners of the province have been visited, more than 350 meetings with the Health Care partners recorded and over 4,000 pages of valuable transcribed feedback generated. 

We would like to express our thanks with all those who have been a part of our process and for help us reaching out to rural communities across BC.

We look forward to the next 100 communities of the Rural Site Visits project!

Dr. Stuart Johnston
Director, Rural Site Visits Project

Krystal Wong
Program Coordinator, Rural Site Visits Project


How can rural community-engaged health services planning affect sustainable health care system changes? – A process description and qualitative analysis of data from the Rural Coordination Centre of British Columbia’s Rural Site Visits Project

C Stuart Johnston, Rural Co-ordination Centre of British Columbia, Canada
Erika Belanger, Rural Co-ordination Centre of British Columbia, Canada
Krystal Wong, Rural Co-ordination Centre of British Columbia, Canada
David Snadden, University of British Columbia Faculty of Medicine, Northern Medical Program, Prince George, BC, Canada. (Corresponding Author:


The objectives of the Rural Site Visit Project (SV Project) were to develop a successful model for engaging all 201 communities in rural British Columbia, Canada, build relationships and gather data about community health care issues to help modify existing rural health care programs and inform government rural health care policy.

An adapted version of Boelen’s health partnership model was used to identify each community’s Health Care Partners: health providers, academics, policy makers, health managers, and community representatives. Qualitative data was gathered using a semi-structured interview guide. Major themes were identified through content analysis, and this information was fed back to the government and interviewees in reports every six months.

The 107 communities visited thus far have health care services that range from hospitals with surgical programs to remote communities with no medical services at all. The majority have access to local primary care.

Participants were recruited from the Health Care Partner groups identified above using purposeful and snowball sampling.

Primary and secondary outcome measures
A successful process was developed to engage rural communities in identifying their health care priorities, whilst simultaneously building and strengthening relationships. The qualitative data was analysed from 185 meetings in 80 communities and shared with policy makers at governmental and community levels.

36 themes have been identified and three overarching themes that interconnect all the interviews, namely Relationships, Autonomy and Change Over Time, are discussed.

The SV Project appears to be unique in that it is physician led, prioritizes relationships, engages all of the health care partners singly and jointly in each community, is ongoing, provides feedback to both the policy makers and all interviewees on a 6-monthly basis and, by virtue of its large scope, has the ability to produce interim reports that have helped support system change.

Article Summary

  • This study process has adapted Boelen’s health partnership model and is unique in that it is physician led, prioritizes relationships, engages all of the health care partners singly and jointly in each community, is ongoing, provides feedback to both the policy makers and all interviewees on a 6-monthly basis.
  • A successful method of engaging with rural communities and building relationships and trust across multiple stakeholder groups is described that contributed to influencing positive health care system changes.
  • As all communities in one province are being visited a picture of rural health care initiatives and challenges is highly comprehensive and therefore able to influence policy.
  • One of the main limitations in this study is that because the interviewers were experienced health care providers, power differentials may have existed which may have introduced bias in the discussions.
  • A potential limitation is the enormous amount of data to handle and analyze in a rigorous way, which was mitigated by having two full time analysts working together to ensure consistency with frequent meeting with the research team to consider and agree emerging themes.

How to Establish Intergenerational Groups in Your Community

Lee Reid, Member of Community First Health Co-Op. 
February 4, 2020

      “In a few years, our generation of youth will have the most power, which we are not ready for. It is important to have people who are already experienced in life to guide us. It is important to know about history, so that we don’t repeat the mistakes.”  
This comment by a sixteen-year-old emerged from one of several conversation groups that brought seniors and youth together at LV Rogers Secondary School in Nelson, B.C.  Her comment represents an invitation for seniors to go back to school, albeit fifty or so years after they left. She is inviting seniors, aged 55-95+ to engage with a generation of teens that many, regretfully, have very little connection to. Hers is a voice that represents the global rise of youth activism and leadership around issues such as climate change and gun control, and their request for all ages to care, get involved and work together.  Youth slogans voice a shared, if ironic, vulnerability with seniors: “You will die of old age, but we will die from climate change.” As we confront a growing number of global crises, youth are asking us to grow together.

 In their research article on Mindfulness and Compassion training in Adolescence, Portland State University authors Robert W. Roeser PhD, and Cristi Pinela, MS, remind us that, “In essence, insuring that young people realize the unique, non-transferable, and very precious nature of their existences during adolescence is an inter-generational project.” ***(p.2). They go on to say, “We propose that adolescents have a need for wisdom concerning how to be fully human. Through provisions of wise mentors with embodied life experience; use of wisdom texts, myths, poems and stories, and philosophical debate and discussion, adults can help youth address this need in healthy, life-giving ways.”***(#27, p. 4). Grandmother Margaret Wheatley, a global activist and coach for social change, suggests that the gift that seniors can bring to other generations is, ‘the memory of what it means to be a wholehearted human being.’** 

When I asked youth what they wanted to discuss with seniors, they said, “We want to talk about climate change and Me Too. Will you tell us about death, because the media scare us with violent, gory and grotesque images. We need to know if love is an unreal infatuation at our age, and what love means for older people. Can we talk about loneliness? How can we know if  technology makes loneliness worse or better?”The teens invited the seniors to open up, “Tell us about your spirituality, your hope. What are the skills you learned to get you through hard times?” To the surprise of many seniors, youth affirmed, “After all you seniors have been through, you are still growing. How can we be strong like you?” And the seniors’ voices replied, “We need conversations; we need to hear the way forward from youth.”*(Growing Together. Pg 17. Phyllis, age 85).

In intergenerational groups, both seniors and youth tend to unite around pressing global issues, such as abuse of women and abuse of racial or gender minorities. They feel deeply troubled about climate-related disasters, or mass shootings that target schoolchildren and civilians. “How can we work together on climate action? How can we help each other in a world where the future seems scary and uncertain?” They ask how to stay present with despair when they see overwhelming suffering in our world. They ask about leadership and compassion when violence and bullying seem the norm. 

What can we tell them?

From spring 2018 to autumn 2019, I facilitated a series of 4-8 week intergenerational groups at our local secondary school. The 2018 groups, which were scheduled into double blocks of English writing class, generated fruitful creative writing by the teens. Writing was a course requirement. For me, however, the writing evolved into a book. In order to summarise the conversations and provide a ‘how to’ roadmap for other communities, we compiled and published, Growing Together: Conversations with Seniors and Youth.*

Last November, we completed the final intergenerational group for 2019 at LV Rogers Secondary School. With this group, youth filmed the relationships and personal reflections that developed from the conversations with seniors.  In May 2020, their film will be featured in a community forum to be held at the Civic Theatre in Nelson, B.C. This forum, titled Make Learning Visible, will host panels and speakers who will explore the health and education benefits of intergenerational groups for the whole community, as well as for the school systems. If you would like to attend the forum, contact Carla Wilson at school district #8:  or   Phone 250-505-5783.

What, Why and How to Shape Intergenerational Groups in your Community

Over the past two years, I have grown and learned about younger generations, and I have learned how generative and creative seniors can be. Generativity means the willingness to contribute our cumulative life experience to the community, so that future generations might thrive. I learned to weather the excitement and anxiety that comes with facilitating teen and senior groups within tight school schedules. Groups where the only agenda was meaningful conversation about life. In a class of 20-30 teens, we 6-12 elders were in the visible yet undaunted minority. Although more seniors wanted to participate, space was limited due to classroom size, and to allow everyone the time needed to speak and be heard.

Most seniors attended groups with the hope to communicate and connect with youth and with each other.  ‘Back to school’ was not exactly the comfort zone that many seniors envisioned after retirement, and it took courage for some of them to attend.  My greatest fear and concern was, “What if the generations have nothing in common or nothing to say to each other?” OR, as one senior said in a group, “I am scared that youth will just ignore me or discount me, because that’s what happens with seniors on the streets.” When the youth responded that sometimes seniors can look critical or rejecting on the street, Mike, an athletic senior aged 55, said,  “… If you see us seniors on the street, and we have this ‘resting bitch face,’ we’re not angry or sad underneath. Our faces settle into that look, but don’t think that people don’t want a sense of true connection.”* (Growing Together, pg 72.)  Mike also acknowledged that he, like many men, would not have been ready for vulnerable conversations earlier in his life. He regretted the lack of real conversation when he was a school student.

While encouraging the seniors to hold an attitude of curiosity and open-mindedness towards whatever might arise in the groups, I learned how to be resilient. In fact, the unifying conversation theme throughout the 2019 groups was ‘exploring our resilience.’ With the teens, we explored qualities of resilience such as persevering through hard times, or keeping a sense of humor despite adversity, or cultivating the ability to witness but not defend against uncomfortable emotions. The discussions revealed that all ages share similar challenges. Through the conversations, seniors and youth discovered they had more in common than they realised. I was surprised to hear how many youth had gone through a death in the family, or death of friends. They asked us, the seniors, how to grieve. How to let go. 

In response to these emerging themes, the group facilitator can assign homework for everyone to do. My homework aimed to nurture resilience through exercises that would build empathy and self reflection, exercises that would invite transparency in the conversations. I assigned homework that encouraged random acts of kindness toward strangers, or that suggested people could choose to react with compassion and empathy toward the challenges they shared with the group. Many youth did not do the homework, or chose not to talk, and others were willing to share their homework experiences in group. With each group, I learned to trust that a core group of 6-12 youth would always come forward to engage with seniors. 

In 2019, the teens wanted to talk about gender issues: gender neutral language, gender abuse, gender transition, cultural prejudices toward trans or queer youth. The seniors wanted to discuss toxic masculinity, and the impact of feminism on their identity.  The elder men wanted to share the skills that allowed them to show vulnerability. Weaving the groups together through a common theme such as ‘resilience’ encouraged diversity in conversations while acknowledging the courage and resourcefulness of the participants.

Combat Loneliness

Intergenerational groups bring seniors and youth together in a learning process that invites everyone to be honestly human. The groups engender rich social connections among seniors and youth, with beneficial impact on the health of the community. According to health reports from Isobel Mackenzie, the B.C. Seniors Advocate, loneliness and isolation are well known barriers to health for seniors. ****  However, many teens in the groups told us that their overreliance on technology and social media were deterrents to face-to-face social engagement for their generation. They felt sad about the lack of human connection. 

The crisis in loneliness is not just a seniors’ issue. It is an intergenerational issue that undermines community health.  What does that look like? It is masked in depression, obesity, anxiety, heart disease, violence and cyber bullying, teen and senior suicide, or negative stereotypes about both seniors and youth. In her book Braving the Wilderness, author Brene Brown PhD states that living in loneliness increases our chances of dying early by 45% (p. 55). In my groups, a popular and gregarious seventeen-year-old boy admitted, “Most of the boys are lonely. We don’t even know how to talk to girls. I think that teens and seniors are pretty separated and I think this is a good way to bring us back together. *(Growing Together, p. 40)

Planning and developing intergenerational groups is rewarding work that connects people from all walks. It invites collaboration with school administration and teaching staff, as well as with seniors-service agencies, hospice and compassionate care societies, gerontology students and gerontology/nursing/social work programs, and with Elder Education groups in the community and college. 

My Evolving Recipe for Intergenerational Success

1) You will need funding. You will need funding for the facilitators, for time invested in planning, and for any intergenerational productions such as a book or a film, a forum or a photo gallery. Invite a community group or a society to sponsor and perhaps co-fund the groups. In our case, we applied for a variety of school or youth grants, and in 2018 we were sponsored by Nelson CARES Society who successfully achieved a federal grant under the New Horizons for Seniors program. In 2019, we also received generous funding and support from Nelson and area School District #8. 

2) Invite partnerships with school administration, school counseling team, school district, community youth services and networks, and seniors service societies or health and recreation centres for seniors. Invite partnerships with seniors’ assisted-living and extended-care residences. Hospice societies and associated compassionate care programs are also interested in intergenerational work as highly relevant to the human continuum of life, aging, and death.

3) Hire a coordinator to do the community engagement. I agreed to take on this leadership role as well as facilitating the groups. I thoroughly enjoyed both positions, which I saw as complementary. Although it is a lot of work, it is helpful for the facilitator to form community alliances in order to succeed with both founding and funding the groups. As the groups grow a solid foundation that is anchored in continuity with funding, then the partnerships and networking can be done separately by contracting a community liaison coordinator.

4) Contract and fund a groups facilitator with skills (including counseling expertise) to engage both seniors and youth.

5) Create short, seniors-only sessions that meet right after each group and within the school setting. Our meetings occurred in the open media room, where many youth could see us as they passed in the halls. It was clear that some of them wanted to join us, or felt reassured and intrigued by our presence.  These 30-minute follow-up sessions provided the opportunity for seniors to share their responses from the conversation group, and to bond with each other. De-brief sessions are essential for community-building with seniors.

6) Invite a sponsor teacher to schedule the groups into double blocks of her/his class time. This sponsor will sit in with the groups to provide support and resources for the students, as well as offering an overview on modern teen reality for the seniors. My most engaged groups consisted of grades 11 and 12, ages 16-18, and were sponsored by English teacher Carla Wilson. As a creative writing project, Carla asked her class to interview the seniors individually, and then to write up the biographies of their elder partners. I recall Peter, a Doukhobor grandfather, reporting with a huge smile, “Four young guys interviewed me about my life. They asked about my culture. It was a lot of fun.”

You can facilitate groups with ages as young as 14 or 15 (grade 10), but they require a more structured format. An example of this (for grades 10-12) would be my hope to create a series of culture-education conversation groups. Of particular relevance, I can envision a series of conversations featuring orientation to indigenous culture, indigenous world view, collective trauma through colonisation, and the meaning of reconciliation. With this example, indigenous facilitators and leaders would be invited to shape and direct the intergenerational project.

*Ideally, each group session would be allotted 90-minutes of uninterrupted conversation time during school hours. In a busy and noisy school environment that can be fraught with unexpected interruptions, this is quite the feat to pull off, but teachers like Carla work miracles every day.

*Schedule 6-8 weekly 90-minute groups. The youth will find this attractive or will at least be curious, because it happens during class time and they can get extra credits. Each senior would be asked to commit to at least 2-sessions, with the option to attend more. I recommend a screening process to ensure that seniors will be able to participate in the conversations.

*At the beginning of the groups, clarify the school counseling resources that are available to the teens. In particular, the seniors find this to be reassuring. Seniors usually need to know how the more vulnerable youth are cared for within the school system.

*Ensure that a microphone is available for each session. The microphone is passed to each speaker in the circle. This will alleviate the stress for young and old of trying to hear what people are saying. 

*Arrange the group in a fishbowl consisting of two concentric circles. The inner circle would contain all the seniors and those youth who wanted to participate in conversation. The outer circle would consist of youth who preferred to listen. They would have the option to join the inner circle at any time. Typically 6-10 youth would choose the inner circle, and usually 6-12 seniors would engage with them.

What about the silent majority?

What to do with youth who are reluctant to speak or engage? Youth who appear bored and disinterested?  In my groups, they were invited to listen, learn, and take notes from the outer circle of the fishbowl. However, it is wise for the teacher to have optional coursework choices for those youth who prefer to not be in groups.

After the entire program had completed, teacher Carla Wilson reflected on the changes she witnessed in her students. “Teens who have open and caring connections with seniors (such as in the groups), display greater maturity and ability to navigate the stresses of the world. Their capacity for clear critical thinking and communication improved. They engaged more openly in classroom discussions and took more initiative to help others whom they would previously ignore.” *(Growing Together, pg 77).

Both Carla and I observed that intergenerational groups fostered compassion and understanding among students. For example, many teens reached out to international students whom they otherwise might tend to exclude in the school. We felt hopeful that, over the long term, intergenerational work could positively reduce bullying and alienation in schools. *(Growing Together, p.77).

As for the seniors, I will close with the voice of a 68-year old retired home-and community-care nurse named Rivkah: “What I really like about this group is that it offers an opportunity to approach what I would call true communication, intimate communication, with a world different than what we seniors are used to. It’s not an easy thing to do. It takes courage and commitment.”*(Growing Together, p.72)

*Growing Together: Conversations with Seniors and Youth.  Author Lee Reid.
Owned and published in 2018 by Nelson CARES Society Press. Sold at Nelson CARES, 709A Vernon street, Nelson, B.C. V1L4G3.  To purchase this book, contact Corrine Younie:  ph 250-352-2708 ext 5247

** Warriors of the Human Spirit. CBC Interview by Mary Hynes with Margaret Wheatley on Tapestry .

***Research on mindfulness and compassion in adolescents was published in: New Directions in Youth Development, 2014. 

****Sept 15, 2017 PDF report on seniors and loneliness in care facilities. B.C. Seniors Advocate Isobel Mackenzie.

****BCCPA (B.C. Care Providers Association) article: “Suffering in Silence: Solving Seniors Isolation in B.C.” by Michael Kary and Ravin Johl