The Alliance and our members have always been committed to population health as a fundamental part of our Model of Health and Wellbeing. This includes:
- Providing the highest-quality preventive care and chronic disease management
- Collaboration with community and system partners
- Providing low- and no-barrier health and wellbeing programming for community members who receive primary health care elsewhere
- Tailoring programs, services, and outreach to the communities each member serves
These principles inform all aspects of health and social care provided by our members. The initiatives listed below exemplify how our members work in partnership with system and community partners to create locally integrated health neighbourhoods, enable community members to access their programs and services even if they are not ongoing primary care clients, and connect both clients and community members to a wide array of health and social supports both within and beyond the walls of the organization.
TeamCare
TeamCare and its regional variants (SPIN, PINOT, and PACT) provide a pathway for solo providers to connect their clients to interprofessional teams. This ensures that their most medically and socially complex clients can get the comprehensive supports they need without losing their relationship with the family doctor or nurse practitioner they've known for years. TeamCare isn't just a referral program; it’s a collaborative care team. The client's usual primary care provider and the interprofessional team stay in contact so that everyone is kept up-to-date on the client's care and progress. A member of the interprofessional team does a full assessment with the client, and the team works with the client and their provider to develop a care plan.
Every TeamCare program is unique. They vary according to local needs and resources. The case examples below were shared by Alliance members to illustrate the range of possibilities:
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Team Care in East London allows primary care providers in the community to access the full suite of clinical and social services at the London InterCommunity Health Centre (LIHC). This program uses a registration model, in which local primary care providers sign up for access. LIHC conducted extensive outreach to physicians in their community prior to launching the program publicly. System navigators at LIHC assess the circumstances of each client and connect them to LIHC's internal programs and services as well as external resources, at no cost.
- For more information, check out this presentation slide deck (LIHC, 2019)
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The Windsor Team Care Centre is a co-housed team centre offered by partners from the Windsor Family Health Team and the Canadian Mental Health Association Windsor-Essex.
- See their multi-media presentation about the team and the project here.
- See their infographic 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 Care. You can see the writeup here.
- In June 2020, they received a Transformatice Change award from the Alliance for Healthier communities. Watch an excerpt of the award video, showing TeamCare in action, at right.
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At People Accessing Care Teams (PACT) in Toronto’s Black Creek community, system navigators from the Black Creek Community Health Centre are embedded right in the ER of the Humber River Hospital.
- For more information, check out their presentation slides here (Black Creek CHC, 2019).
- People Accessing Care Teams (PACT) at Vaughn CHC's at Vaughn CHC’s Keswick and Vaughan locations is available to people experiencing barriers to health and health care. It can be accessed through a referral from their family physician or nurse practitioner.
- Team Care In Thunder Bay is available at multiple locations through a partnership with NorWest Community Health Centres and several local health clinics. The CHC’s psychotherapy, foot care, and dietitian services available at each of the clinic sites for people who face challenges accessing health care services or who have multiple and/or complex health care needs. It is available by referral only.
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Teamcare - formerly People in Need of Teams (PINOT)) - at South East Grey CHC (SEGCHC) enables local family physicians to refer their patients to the CHC’s interprofessional team. The SEGCHC also works with the hospital to make sure everyone in their community gets primary-care follow-up within 24 hours of leaving the hospital, and they have partnered with the Alzheimer’s Society to offer community memory clinics to pre-Alzheimer's patients.
- In 2017, this program won the South West LHIN’s 2017 quality award. Watch the award video here.
- CarePoint Health in Mississauga is a collaborative program that brings together interprofessional providers and primary care clinicians. Providers can register on their website to begin referring their clients; individuals without a primary care provider can connect directly to the program throug CarePoint Connects.
Social Prescribing
Social prescribing is a holistic approach to health care that brings together the social and medical models of health and wellbeing. It provides a formal pathway for health providers to address the diverse determinants of health, using the familiar and trusted process of writing a prescription. Each social "prescription" is tailored to the goals, needs, and gifts of the client and is developed through a co-design process, thus supporting the client's sense of autonomy and self-determination. This has been shown to support self-management and reduce repeat clinical visits, thereby reducing demands on providers' time.
Programs and services accessed through social prescribing are developed with the sociodemographics of the clients and community in mind. This helps to ensure that they are culturally appropriate and accessible and that they support the health of the whole community. Numerous organizations have even reported that their social prescribing programs have bolstered community capacity.
As social prescribing has matured within our sector, the range of "prescribers" has expanded to include not only clinicians, but other members of the interprofessional team. Many organizations find that having a dedicated link worker is a key ingredient for success.
To learn more about how to start or expand a social prescribing program at your organization, check out these links:
- Webinar: The future is social prescribing: Why it's key to an integrated, accessible, resilient health system. (Alliance, 2024)
- Online Social Prescribing Course (Alliance, 2024)
- Video Series: What Social Prescribing looks like across Ontario (Alliance and members, 2023-2024)
To learn more or access coaching supports (available to Alliance members only), email SocialPrescribing@AllianceON.org.
Accountable Care Communities for Population Health
This report and Toolkit for Action articulates a vision for connected, regional health care systems. It was created to support Alliance members who were involved in Ontario Health Teams (OHTs) in ensuring that their OHTs were designed for health equity and community involvement. It includes a list of seven actions to consider, with detailed descriptions, examples, and links to relevant resources:
- Partner with newly forming Primary Care Networks and expand access to TeamCare and Social Prescribing through existing team models.
- Understand the characteristics of the population, including social, economic, and health inequities.
- Involve the community in shaping and improving services by working together.
- Ensure an equity-driven approach is included and social and systemic determinants of health are addressed by partnering with organizations, such as municipalities, who may not be part of your existing OHT.
- Work with community partners and share back office activities to support the future envisioned financial payments and accountabilities.
These are followed by case studies from the US and the UK.
Case Example: Thorncliffe Park Community Hub
The Thorncliffe Park Community Hub, in northeast Toronto, will opening in February 2025. Co-led by the Flemingdon Health Centre (FHC) and The Neighbourhood Organization (TNO), The Hub is a community-driven initiative that will provide a wide array of of community, social, and health services. Every day, more than 3000 people will have local access to integrated primary health care, dental services, midwifery services, legal aid, child care, language classes, homework help, and more.
The Hub was not built in a day. FHC has over 50 years of experience serving and collaborating with two neighbouring communities: Flemingdon Park and Thorncliffe Park. FHC's main site is located in Flemingdon Park, and Thorncliffe Park is connected to it by a bridge. Staff at FHC heard from Thorncliffe Park community members that having to cross this bridge was often a barrier for them, so in 2011, FHC and TNO jointly launched Health Access Thorncliffe Park (HATP) - an experimental "test of change" that began integrating health and social services in a new way. Community health ambassadors, who live in the neighbourhoods, help make HATP (and soon The Hub) even more accessible by doing direct outreach and providing system navigation. The Hub is the next evolution of HATP, incorporating a wider array of services and supports, with space contributed by the United Way.
One key learning from HATP is that while co-location can be an essential way to remove barriers and support integration, organizations can successfully partner in this work without needing to merge. When clients enter the facility, they may encounter staff from FHC, TNO, or even the Michael Garron Hospital.
However, this is seamless to the clients. A consistent HATP logo and "look and feel" visually erase the distinctions between the organizations, and linked health records ensure that clients will not have to re-tell their stories to multiple providers.In this video, FHC's CEO Jen Quinlan reflects on the evolution of HATP into The Hub, and she shares her goals and vision for the future of The Hub. This video was produced by the Canadian Association of Community Health Centres (CACHC) as part of their Community Matters podcast and used with their permission. Check out other episodes of Community Matters to learn more about the work CACHC is doing federally, including advocacy for CHCs and integrated health care.
Learnings from the Community Vaccination Promotion Project
At the height of the COVID-19 Pandemic, the Alliance partnered with four national and provincial community primary health care associations to develop a pan-Canadian strategy for reducing barriers to vaccination for marginalized people in Canada. Although developed and funded at the national level, the strategy was realized locally, in partnership with community ambassadors, public health units, churches, social organizations, and and trusted community leaders. Here in Ontario, eleven Alliance member organizations led tailored, culturally informed Community Vaccination Promotion (CVP) projects that featured door-do-door outreach; local, ethnic media coverage; partnerships with religious and community leaders; multi-lingual literature and in-person interpretation; and peer support. All of this work was informed and enabled by Alliance members' deep connections to their communities and rich understanding of those communities' unique assets, priorities, and needs.
Want help applying some of these learnings to support connected care in your community? Email QI@AllianceON.org to access more resources and coaching support.