#TeamCare: A “plug and play” solution to connect primary care physicians with interprofessional teams 

#TeamCare News

In November 2019, the AATBC research team presented a poster, Advancing Access to Team-Based Care in Ontario to the North American Practice-Based Research Group (NAPCRG) at the 47th NAPCRG annual meeting. Check it out here!

On October 29, 2019, the AATBC research team (Jennifer Rayner, Walter Wodchis, Elana Commisso, and Jennifer Im) presented an overview of Team Care and an introduction to the research & evaluation project. Several of the participating teams also made presentations.

Ontario physicians need to be connected into our health system. There are approximately 5000 family practice physicians who currently don’t have access to the interprofessional health teams that provide the highest level of care for their most medically and socially complex patients.

Now imagine a solution that's both high tech and high touch. One that builds the confidence of patients and their primary care physicians that their local health network is responsive and there for them when and where they need it.

Introducing TeamCare, a real-time network that brings individualized medical and social care teams together for the health care users who need it most. In more than 30 communities across Ontario, local health providers are adapting the TeamCare model to meet local needs through collaboration and codesign.

Here’s how it works:

  1. CONTACT: The primary care physician contacts teamcare by phone or digitally, outlining the patient’s needs and suggesting potential directions. The physician remains the patient’s primary care provider at all times.
  2. CONNECTION: The system navigator contacts the patient directly and conducts an intake assessment. This includes a wide menu of medical and social services such as social work, dietitian, chiropody, diabetes education, community kitchens, walking groups and so on, provided by core health professionals on the team. It also includes services provided by partner organizations such as mental health and addictions, housing, food security and employment services.
  3. COLLABORATION: Ongoing collaboration between the patient, the primary care provider, the team and the partners happens throughout the patient’s journey. Points of communication are built into, but are not limited to, the point of connection with TeamCare, after the first TeamCare health service visit, upon any changes or new services on the care plan, and completion of TeamCare participation.
  4. CODESIGN: A built-in codesign approach ensures primary care providers, team members and patients create regular feedback loops aimed at real-time quality improvement and engagement.

Let’s imagine an example:

Susitha is a primary care physician operating in a small family practice clinic in the community. She's facing a challenge: her patient Jamal is not managing his diabetes well. He lives alone and doesn't get out much, and needs a specialized scan right away - complex medical and social needs that can't be solved in a 10-minute clinic visit. The waiting room is full of others waiting their turn. She needs support - fast.

Susitha connects with TeamCare and reaches Nancy, a system navigator. Susitha knows Nancy well, and she trusts Nancy's knowledge of all the interprofessional services and supports nearby.

After a brief conversation that runs through a standardized menu of options, Nancy is ready to recommend and support specific referrals to Susitha. She recommends clinical care by Avnish, a physiotherapist at the community health centre, and social support by Ben, a social prescribing link worker who can accompany Jamal to his first appointments and then connect him to the men's cooking group and diabetes self-management group in the community.

But this is not a referral program. It’s a collaborative care team. Nancy keeps Susitha and the care team updated on Jamal and helps build direct relationships between everyone on the team so everyone can stay involved throughout Jamal’s care.

Avnish and Ben know that the care they give will be communicated back to Susitha in a clear and direct way and that they can call her or Nancy directly with any questions or concerns.

Jamal trusts that the health care he needs will be available when and where he needs it, and that he will be supported throughout his transitions in care. He knows Susitha will stay his main care provider and connection to the health system and that he is welcome to keep using all the supports and services of the team, including diabetes self-management and the men’s cooking group, as long as he needs.


It all began in 2013, in the Toronto Central LHIN region. Solo Practitioners in Need (SPiN) was an idea that became a Health Links initiative, connecting vulnerable patients of solo family physicians to the range of services offered at CHCs. The initiative recognized that family physicians needed to have managed access to appropriate community-based services for their patients with the most complex medical and social needs, in order to achieve good health and well-being. It was difficult for the solo family physicians to know about and access these services for their patients, to know when they received them and how they were doing. In its first years as a proof of concept SPiN established a system that could address these needs. Today, more than 100 family physicians in Toronto utilize SPiN to access appropriate and timely inter-professional support and resources found in 16 CHCs across Toronto for their patients. 

In East London, primary care providers in the community can use Team Care to access the full suite of clinical and social services at the London InterCommunity Health Centre.

At the Windsor Team Care Centre, more than 100 physicians and 1500 patients have already connected with services in a new co-housed team centre offered by partners from the Windsor Family Health Team and the Canadian Mental Health Association Windsor. See their multi-media presentation about the team and the project here. In September 2019, they received a Bright Lights award from the Association of Family Health Teams of Ontario (AFHTO), in the category Access to Care: Improving Team-Based CareYou can see the writeup here, or watch the video of all nominees in the category here.  

Through People Accessing Care Teams (PACT) in Toronto’s Black Creek community, more than 150 physicians and patients are connecting through teamcare. PACT includes teamcare system navigators embedded right in the ER of the Humber River Hospital.

In Vaughn CHC’s Keswick and Vaughan locations, people with and without health care benefits can meet their health needs through People Accessing Care Teams (PACT).

In Thunder Bay, NorWest Community Health Centres have teamed up with three local clinics – The Port Arthur Health Centre, the Aurora Family Health Team, and the Superior Family Health Organization – to embed the CHC’s psychotherapy, foot care, and dietitian services available at each of the clinic sites.   

Since April 2018, London InterCommunity Health Centre has received about 360 referrals to their Team Care program from over 50 physicians. This number is expected to increase starting in June 2019, when they open the doors of a dedicated Team Care site in East London. 

In June 2017, the South East Grey CHC won the South West LHIN’s annual quality award for their participation in People In Need of Teams (PINOT). In addition to enabling local family physicians to refer their patients to the CHC’s interprofessional team, the SEGCHC works with the hospital to make sure everyone in their community gets primary-care follow-up within 24 hours of leaving the hospital. They have also partnered with the Alzheimer’s Society to offer community memory clinics to pre-Alzheimer's patients.



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Jennifer Rayner
Director, Research and Evaluation
Alliance for Healthier Communities