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TeamCare

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

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 social 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.

Image of Susitha's smartphone showing TeamCare contacts

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 upon 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.

INNOVATIONS IN ACTION

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, Canadian Mental Health Association Windsor, and the Windsor Community Family Health Team.

At People in Need of Teams  in London, primary care providers in the community can use teamcare to access the full suite of clinical and social services at the London InterCommunity Health Centre.

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.   

TEAMCARE IN THE NEWS

MEMBER RESOURCES

Note: You will need to be logged into the Alliance member portal to access these resources.

FOR MORE INFORMATION

Jennifer Rayner
Director, Research and Evaluation
Alliance for Healthier Communities
jennifer.rayner@allianceON.org