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 many of the key elements of a connected health neighbourhood:
- Collaborating 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;
- Providing care coordination and system navigation to help people access acute or specialist care when necessary;
- Providing the highest-quality preventive care and chronic disease management; and
- Serving as neighbourhood health home - a place where clients and community members feel a sense of belonging and are supported throughout their life course as whole people with unique needs, assets, and goals.
Working in close partnership across sectors within a community makes comprehensive primary health care - health promotion, disease prevention, and chronic disease management as well as episodic care - accessible to more people in the community. It is also an essential step towards ensuring that people access the care they need from the right organization, in the right place, at the right time.
The strategies and case examples listed in this chapter exemplify how Alliance members work in partnership with others to build connected health neighbourhoods. They illustrate how a comprehensive primary health care team makes an ideal "hub" where clients directly access comprehensive primary health care and are seamlessly connected to other resources and partner agencies when needed.
However, access is only the beginning. It helps stabilize people and keep them out of hospital, and it lays the foundation for deeper relationships of trust, but attachment is essential for care continuity, relationship-building, and ongoing access to care across the life course. In Chapter 9, we will showcase examples that illustrate how to begin the shift from access to attachment.
# Strategies for Collaboration and Integration
The Alliance and our members have long recognized the value of local partnerships and organic integration of health and social care services in communities. The initiatives described below are examples of how Alliance members and their local partners have innovated to address gaps and ensure that people can access the care they need.
- Accountable Care Communities are a model of locally integrated care that was developed to help Alliance members work with their OHT partners to advance equity-driven approaches to population health and to support accountability and learning through the collection and sharing of data among partners. The development of this framework was foundational to the Connected Health Neighbourhood model.
- Vision for a Health Home outlines a vision of primary health care based on our Model of Health and Wellbeing - health homes nestled within neighbourhoods, serving people who are connected by geographical proximity or as members of priority populations. In this vision, every person has barrier-free access to an interprofessional primary care team.
- The Community Vaccination Project emerged in response to the COVID-19 pandemic as an approach to lowering barriers to vaccination for marginalized people and communities across the country. Here in Ontario, eleven Alliance members led CVP projects with their local partners to ensure that people had timely access to accurate and culturally tailored vaccine information, delivered by people they trusted.
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 six 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.
- Be sure to highlight and measure activities that will achieve health outcomes but focus on processes that are community-centred.
These are followed by case studies from the US and the UK.
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.
# The "Spokes": Streamlined Access to Other Service Providers
Connected Health Neighbourhoods and intersectoral collaborations can also improve access to social supports and specialist care beyond the primary health care team. System navigators, link workers, and others can help coordinate and streamline referral processes and systems, reducing wait times, lost referrals, and duplication.
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Seamless Care Optimizing the Patient Experience (SCOPE) and TeamCare - by its many names - were designed to help primary health care providers connect directly with specialists, interprofessional teams, system navigators, diagnostic services, and more.
- SCOPE operates a central hub through which over 1900 clinicians can access specialists and other health care professionals for referrals, consultations, and system navigation support. Family physicians and nurse practitioners access SCOPE through a central contact point (the SCOPE Hub), and that provider and their patient are connected with with appropriate expertise and care.
- TeamCare enables solo providers to connect their clients to team-based care at a CHC or other organization that offers comprehensive primary care services. The relationship between the client and their usual primary care provider is preserved; clear communication and feedback allows the provider to monitor the client's journey and see the impacts of the team-based care they access.
- SCOPE and TeamCare are complementary programs, connecting clinicians and clients to different kinds of care and support. This infographic from 2019 demonstrates the impact the two programs were already having at that time.
- Social Prescribing is a worldwide phenomenon that took root in the United Kingdom in the early 2000s. The Alliance and eleven of our members brought Social Prescribing to Canada beginning in 2018 with Rx:Community, a pilot program of our made-in-Ontario take on the model. Social Prescribing establishes and formalizes linkages between primary health care providers and social care services that support the determinants of health: Food security, social connectedness, access to nature, and more. Social Prescribing includes internal linkages between clinical and non-clinical programs and services within the same comprehensive primary health care team as well as external ones between primary care providers and other agencies in their communities.
Team Care
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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began as a partnership between a community FHT and a CHC. It is now wholly a project of the Windsor Family Health Team.
- 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 Transformative 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 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.
Case Example: Central Specialist Intake at the Waterloo Wellington Regional Coordination Centre
Barriers to health care can be worsened by inefficient intake and waitlist management processes. Referrals are often rejected if they don’t align with the provider’s scope of practice or get lost in the system because wait times are too long. This leads to providers send duplicate referrals to multiple specialists in search of the shortest wait times, which worsens gridlock and increases the administrative burden. To address this, the Waterloo Wellington Regional Coordination Centre (WWRCC), hosted at Langs Community Health Centre, offers a central intake process with a single pathway to care. This process improves referral processes by:
- Helping to ensure even referral distribution across specialists
- Maintaining detailed wait-time information
- Reducing duplicate referrals
- Ensuring the right specialist is selected
- Maintaining consistent data monitoring
- Ensuring continuity of care
The WWRCC offers central intake pathways for diabetes, orthopedics, cataracts, and Ontario Seniors Dental Care across Waterloo Region and Wellington County. The service provides navigational support for patients and expedited access for those on waitlists. Diabetes Central Intake allows for improved access to care through self-referral, and central intake for dental care provides phone support to help seniors living with low incomes navigate the application process. Cataract Central Intake helps reduce wait times for non-surgical cataract procedures.
To help spread and scale this model, WWRCC has developed a Framework for the Development and Implementation of a Regional Central Intake for organizations looking to develop a similar process in other regions. It outlines strategies for developing, scaling, and spreading a central intake model. They are also working with organizations in neighbouring regions to help them develop and implement models like theirs.
Check out their poster presentation from the June 2025 Alliance Conference to learn more about this project and its outcomes so far, and watch this space for updated outcome data in Fall 2025.
# Primary Healthcare Access for People who are Uncertainly Attached.
Creating low- and no-barrier access points to primary health care is an essential first response. It creates the conditions for people to be stabilized and reduces hospitalizations and emergency department visits for episodic care. It also lays the groundwork for ongoing attachment to primary health care by connecting clients to the providers, teams, and partner organizations that can best meet their needs. When barriers are lowered and eliminated, any door can lead to a health care team, whether it's the door to a solo provider's office, a shelter, or even a bus.
Thorncliffe Park Community Hub and the East Effort Collaborative
Case Example: Thorncliffe Park Community Hub and the East Effort Collaborative
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.
The Hub grew out of East Effort, a collaborative, local response to COVID-19 that was sponsored by the Flemingdon Health Centre. The work began with tenants in the Flemingdon Park highrises supporting each other during lockdowns by distributing supplies, sharing public health information, and helping each other access vital services. Recognizing the value of this community-led work, staff at the Flemingdon Health Centre launched the Community Health Ambassadors (CHA) program. Together, Flemingdon staff and the CHAs hosted pop-up clinics in the buildings and helped connect people to health and social care services.
More organizations became involved, and the scope expanded to cover a large portion of East Toronto and include STI testing and meningococcal vaccine information, food distribution, a community hotline, community-based social programming, and more. In 2024, East Effort and the Community Health Ambassadors received a Transformational Change award from the Alliance for Healthier Communities; the award video at right showcases the project and its impact.
Access Clinics and MobileCare at Chatham-Kent OHT
The rural community of Chatham-Kent has the second-highest material deprivation score in Ontario and some of the province’s highest rates of chronic disease. With a single walk-in clinic and over 30,000 residents who didn’t have access to a primary care provider, many people were left to rely on the emergency department for care. In 2024, the Chatham-Kent Ontario Health Team (CHOHT) launched two initiatives to address this gap in access:
- BridgeCare is a weekend walk-in primary care clinic serving unattached people in the community.
- MobileCare, a walk-in clinic on wheels, travels to various locations to provide access to primary care and care for mental health and addictions, for people who may have difficulty travelling to access care.
In just under a year, BridgeCare and MobileCare have seen over NUMBER people. This has relieved pressure on the local hospital and has provided options for referral pathways after hospital discharge. Chatham-Kent Community Health Centre (CKCHC), one of the CKOHT partners, has been able to access more resources for rostering high-needs clients, and the OHT has been able to provide a greater focus on providing primary care as well as care for mental health and addictions to underserved community members.
In addition to being part of the BridgeCare and MobileCare initiatives, CKCHC operates “First Five,” preventative health promotion services for children aged 0-5 who do not have access to a primary care provider. People do not have to live in Chatham-Kent to access the program.
These initiatives are now ready to scale up and to spread to other communities. Because the model is flexible, it can be adapted for diverse and evolving needs. CKOHT plans to expand both initiatives and adapt them to serve additional community members.
Access Clinics at Thames Valley FHT
Thames Valley Family Health Team (TV-FHT) offers comprehensive primary health care services across a large geography spanning London, Oxford, Middlesex, Elgin, and the Strathroy-Caradoc municipality. Recently, the team has been expanding its services and group programs in a shift towards a population health model based on deeper integration with community partners. This case study describes how TVFHT’s two Interprofessional Primary Care Team (IPCT) projects are facilitating access and attachment to team-based primary health care for individuals living within Elgin County and the city of London.
Key elements of their expanded services in Elgin County include:
- An Unattached Population Clinic in Elgin County that opened its doord in September 2024 and has served close to 5000 unattached individuals as of July 2025.
- Increased collaboration and integration with other funded models in the community, including recruitment and funding of staff for Central CHC's mobile healthcare clinic; creating a direct referral pathway from the St. Thomas - Elgin General Hospital for unattached people visiting the Emergency Department for primary care services; and partnerships with pharmacies in Elgin who can provide low-barrier care for minor ailments.
In London, TV-FHT has expanded primary care access by creating a new, low-barrier primary care team in partnership with the London InterCommunity Health Centre (LIHC). This team is housed in a Community Hub along with other service organizations, so clients can access primary care and social services in a single location. The team also conducts outreach to clients in shelters, supportive housing, and encampments. One of their outreach partners, the Salvation Army Centre of Hope - has seen a 50% reduceion in ambulance calls since TV-FHT's primary care team began making biweekly visits.
As the expansion moves into Year Two, the team at TV-FHT will be shifting their focus to move from access to attachment, using a stepped-care approach.
The Mission United Program in Durham
The Mission United Program in Durham Region is a centralized, low-barrier health hub that offers integrated primary health care, mental health supports, crisis counselling, housing, and addiction services. It also serves as a rest centre where individuals can receive a daily meal between 10 a.m. and 1 p.m. It is led by CMHA Durham and housed at the Back Door Mission; numerous other social care agencies also offer services at the hub.
Through this innovative model, CMHA Durham has had over 14,000 clinic visits and 7500 harm reduction interactions, and it has provided essential care to over 1100 clients, including nearly 250 first-time visitors.
The hub has facilitated over 31000 visits and over 56000 food security visits. It has prevented over 400 emergency department visits and supported over 1300 unhoused individuals.The Mission United Program received a 2025 Transformative Change Award from the Alliance for Healthier Communities. Watch their award video at right to learn more about the program.
Care Bus in Thunder Bay
The Care Bus is a low-barrier transportation service and mobile service hub in Thunder Bay, spearheaded by NorWest Community Health Centres and supported by numerous system partners. The Care Bus fosters strong ties with Indigenous organizations,
including the Ontario Native Women's Association, to provide crucial health and social support services during winter months. It is staffed by individuals with lived experience, which helps to make it one of the most vital winter services in the community, In 2023-24, the Care Bus served over 5800 clients.The Care Bus received a 2025 Transformative Change Award from the Alliance for Healthier Communities. Watch their award video at right to learn more about the program.
Lower Limb Wound Prevention and Treatment Clinic in Windsor
The Lower Limb Wound Prevention and Treatment Clinic in Windsor is led by the Windsor Family Health Team in collaboration with the Windsor Regional Hospital, Windsor Essex Community Health Centre, City of Windsor, Canadian Mental Health Association (Windsor-Essex Branch) and Windsor-Essex Ontario Health Team. The clinic offers interprofessional care aimed at preventing amputations in high-risk populations, including those with diabetes, vascular disease, or experiencing homelessness.
Supported by the Windsor Essex CHCs' specialized foot care services, the clinic applies best practices in wound management while addressing social determinants of health. Partnering with the CoW and CMHA, the clinic extends outreach to homeless hubs by equipping non-clinical staff with wound care training and essential supplies, ensuring
clients’ needs are met promptly. Patients gain access to vital resources, primary care, and free transportation. It also offers education for patients and providers.The Lower Limb Wound Prevention and Treatment Clinic received a 2025 Transformative Change Award from the Alliance for Healthier Communities. Watch their award video at right to learn more about the program.
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.
