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Model of Health and Wellbeing

The Alliance is committed to research that can advance our collective vision of the best possible health and wellbeing for everyone living in Ontario.

Out now! Interactive report and narrative report about Mental Health & Addictions clients at the centre and sector levels.

This interactive tool and the accompanying narrative report use data from BIRT that was sent to CIHI for data linkage in 2018. The interactive report includes a sociodemographic profile that can help you understand and plan care for the people in your community who experience challenges with mental health and/or addiction. It also includes linked data which profiles the client journey at the CHC, the ED, and at the hospital.

The interactive report lets you examine your own CHC’s data and compare your centre to similar organizations. This will help you better plan mental health & addictions care for your communities, facilitate knowledge-sharing and peer support, and show you where you have successes to celebrate and opportunities to improve. It is accompanied by a narrative report, Patterns of Community Care for Mental Health and Addictions, which summarizes key findings at the sector level.

What’s next? We recognize that seeing all this data can make you feel like you’re drinking from a firehose, so we’re developing a suite of tools and education to help you navigate, understand, and use it. These tools will be co-designed with a small group of CIHI staff and CHC EDs and clinical directors. If you are interested in joining this group, please reach out to

This is the second of two proof-of-concept projects done in partnership with CIHI. The first interactive report, produced in 2018, profiled CHC clients with COPD and included a review of data quality and completeness. We supported it with a webinar, which was well-received. We’re pleased with the success of our partnership with CIHI so far, and we plan to continue it with more data extractions and interactive reports. This was approved by a majority of EDs at the fall EL network meeting, and the data-sharing agreements are being signed now.


Want to participate in a research project with us or request data for your academic or community-based research? Email

Our research program interacts with the Model of Health and Wellbeing in two ways: The model informs our research questions and methods, and the knowledge generated by our research provides insights into how best to operationalize the model and adapt it to local contexts. Research helps us to understand the populations we serve; to recognize emerging health challenges, such as loneliness and isolation; and to evaluate new and ongoing programs and services so we know what’s working and where there are opportunities for improvement.

Research also helps us to tell our story. We know our members’ work is immensely valuable to the communities and individuals they serve. In order to ensure that our partners and stakeholders recognize this, we need clear data. This includes quantitative data – numbers – that demonstrate this value at a system and population level, as well as qualitative data – stories – that show how our work impacts individual patients, caregivers, and providers. Sharing our knowledge through conferences, presentations and publication in peer-reviewed journals helps us reach as many people as possible.

The Alliance’s research program is spearheaded by Dr. Jennifer Rayner, our Director of Research and Evaluation. Dr. Rayner is also an adjunct research professor at the Schulich School of Medicine and Dentistry at Western University. However, like our members’ work, our research portfolio is collaborative and crosses sector lines. We work with over 50 research partners from academia, primary care, and public health.  

Here are some recent research highlights:

  • Impact of comprehensive care on health care use among a cohort of marginalized people living with hepatitis C in Toronto. This study by researchers at South Riverdale CHC, the University of Toronto, ICES, and several hospital and community health partners, provides evidence that comprehensive, community-based care, including harm reduction, leads to better health outcomes for people who use drugs and have chronic Hepatitis C infection. Participants in the study received comprehensive HCV care and harm-reduction support from South Riverdale CHC, Regent Park CHC, and Sherbourne Health. Published November 12, 2019.
  • Attachment to primary care and team-based primary care.  This study by researchers at the University of Toronto, ICES, the Ontario Department of Corrections, and other research institutions provides evidence that CHCs are fulfilling their mandate of providing care for people who experience marginalization and barriers to health and wellbeing. The study finds that people who experience incarceration are less likely than others to be attached to a primary care provider, both before incarceration and after release, but those who are attached to primary care are much more likely to be attached to a CHC than to a FHT or other model of primary care. Published October 1, 2019.
  • Using Equity Data to Improve Cancer Screening in Ontario CHCs. This poster by the Alliance research team, Access Alliance, and TAIBU CHC provides evidence that CHCs are fulfilling their mandate of improving health equity. Generally, racialized women and women with low incomes are at a high risk of not undergoing regular cervical cancer screenings. Women who are attached to CHCs are much more likely than the general population to be up-to-date with their screenings, despite the fact that a much larger percentage of CHC clients are from "high risk" populations. Using health equity data allows CHCs to tailor interventions to their local populations to improve screening rates. Presented at the 47th NAPCRG Annual Meeting in November 2019.
  • Rx Community: Social Prescribing in Ontario Community Health Centres. This poster by the Alliance research and social prescribing teams demonstrates the effectiveness of the Rx: Community social prescribing programPresented at the 47th NAPCRG Annual Meeting in November 2019.
  • Advancing Access to Team-Based Care in Ontario. This poster by the Team Care research team demonstrates the effectiveness of Team Care for advancing access to team-based care with positive outcomes for both providers and clients. Presented at the 47th NAPCRG Annual Meeting in November 2019.

Here are some of our ongoing research projects:

  • Rx: Community: A social prescribing pilot currently being implemented at 11 CHCs across Ontario. An essential component of this is implementation evaluation research that will help us understand the effectiveness of social prescribing in Ontario as well as the contextual factors that enable or hinder its implementation. A concurrent study by research partners from ICEs and Women’s College Hospital is exploring the impact of loneliness and social isolation in older adults on their health outcomes and the health system.
  • TeamCare: Nearly 30 teams are currently participating in TeamCare projects, under various names including SPiN, PINOT, PACT, and Expanding Team-Based Care. While these projects differ in funding, structure, and scope, they all have two things in common: Increasing access to interprofessional heal care for patients of family physicians in the community and participating in an ongoing evaluation program to track the impact of the projects and help us understand what makes them successful. A concurrent investigation with ICES is underway to help us get a better understanding of where there are gaps in access to interprofessional primary care as well as the demographic risks and needs among Ontario’s population.
  • Organizational Attributes Associated with Quality Care: Together with partners from ICES and the University of Ottawa, we are examining the relationships between organizational attributes identified from the organizational survey of Ontario primary care practices and the quality of care they provide. This will help us advocate with funders and stakeholders for appropriate investments in primary care. A concurrent study with ICES seeks to analyze the characteristics of providers and recipients of team-based primary care at 72 CHCs.
  • Refugee and Newcomer Health: We are currently participating in or providing data access for six concurrent studies on immigrant health and access to health care among immigrants and refugees in Ontario. With research partners from Centre for Addiction and Mental Health, the University of Toronto, Ryerson University, the Dalla Lanna School of Public Health, ICES, and the Wellesley Institute, we are examining health system utilization, inequities in cancer screening rates and access to care for chronic conditions among immigrants and refugees in Ontario. We are also exploring whether the so-called “Healthy Immigrant Effect” still holds and whether it extends to mental health care. This research will help us advocate for equitable and effective policies to support the health needs of newcomers to Canada.
  • Complex health needs, mental health, and addiction: In addition to the studies described above under Rx: Community and Immigrant Health, we are involved in a number of studies that explore the intersection of medical complexity, mental health, and health services utilization. With partners from ICES, CIHI, SickKids Hospital, Western University, and the University of Toronto, we are examining how people in Ontario access the mental health care system, what barriers they face, and how effectively interprofessional team-based primary care can help dismantle these barriers and improve the health of clients with complex needs. With our ICES research partners, we are also exploring how effectively the health system is supporting the mental health needs of people in First Nations communities.
  • Social Determinants of Health and Health System Utilization: Numerous partners are working with CHC data to explore how the social determinants of health affect health system usage and health outcomes. Specific social determinants being explored include disability, history of incarceration, HIV and Hepatitis C status, social isolation, and age.
  • Climate Change and Health Equity: Co-authored literature reviews on climate change and health equity. One is a contribution to a Climate Change Health Assessment chapter on Health Equity for Health Canada. Another is a report for the Greenbelt Foundation on Climate Change and Health Equity for Women, Newcomers, and Youth.

A new element of this research program is knowledge translation. In addition to presenting our learnings at conferences and publishing them in journals, we are developing tools that will help us communicate them with policymakers, Alliance members, and the public in ways that are meaningful and accessible. This will allow our members to turn information into action and will help us to continue advocating for healthier public policy.

Watch for a series of themed weeks over the next year; each one will highlight knowledge that we can all use to advance health and wellbeing in our communities. These will include “lunch-n-learn” webinars; keep an eye on the space below for video recordings! And check out our research library, where we post links to studies as they come out, or our 2016-18 Research Report.

If you would like to learn more about our research program, participate in a research project with us, or wish to request data for your academic or community-based research, please email Jennifer Rayner at