# Change Ideas for Equitable Attachment

Helping unattached or uncertainly attached people access primary health care services is a start, but for population health and a sustainable health system, people need an ongoing relationship with a trusted team of primary care and interprofessional health care providers. Attachment, like access, needs to be grounded in equity in order to ensure that the people who are most at risk of poor health outcomes have the first opportunity for connection to primary health care.  The case examples on this page illustrate a variety of pathways to attachment. Each of them draws from several of the change ideas listed below, and all of them are grounded in health equity, population health, and a commitment to deep collaboration and integration.

  • Population Health Clinics are interprofessional health care clinics that specialize in meeting the needs of particular populations, for example people experiencing or at risk of homelessness, newcomers, or 2SLGBTQ+ youth. These groups often have a greater need for ongoing primary health care and are overrepresented among those who aren't attached to a primary care provider or team.
  • Community Access Points are places where  an embedded system navigator is available to meet with people who are receiving episodic health or social care and connect them with a primary health care team for intake and ongoing care. Access points may be lcoated in  health care facilities such as hospitals  or specialist clinics; community settings, such as schools; or social care settings, such as shelters and drop-in centres.
  • Outreach Services include mobile clinics, visits to shelters and encampments, and home visits from peer ambassadors. They may work with unattached or uncertainly attached individuals for a longer period while they develop a trust-based relationship that can lead to attachment for ongoing care.
  • System Navigators, Link Workers, and others in similar roles can play an essential part in connecting individuals with ongoing primary health care. They work in partnership with individuals to determine the best health care home for them based on their health goals, strengths, and needs, and matching those to assets in the community.
    • This handout describes the vital role of Social Prescribing Link Workers and provides evidence  of their contribution so system sustainability, client self-efficacy, and workflow improvement.
  • Group Medical Visits can facilitate efficient intake processes. In these expanded appointments, clients with similar conditions meet together with multiple healthcare providers for longer, interdisciplinary sessions. For example, a chiropodist, a dietitian, and diabetes nurse educator may work alongside a clinician in a group visit focused on diabetes management. It can help you manage the balance of supply and demand by reducing the total number of appointments needed. It can also minimize the need for the client to repeat their story, which then shortens wait times and makes intake processes more efficient and equitable.  
  • Using population health statistics, sociodemographic data, and asset maps can help direct access, intake, and attachment efforts to the areas of highest need within a community and inform collaborative strategies for population health. 

# Case Examples

A Primary Care Neighbourhood Network with Centralized Intake and Triage | Wellfort CHS

The Primary Care Neighbourhood Network, envisioned and established by WellFort Community Health Services (CHS) and its partners, has increased attachment and access to primary care for over 3600 patients in just its first three months. 

Nine primary care organizations are partners in this project, with WellFort CHS providing backbone support. It began with coordinated sharing of resources, including interprofessional support for primary care providers in the community. After this, they implemented a new Population Health Clinic for unattached people, where individuals can be screened, assessed, and supported. It includes a centralized intake and assessment process and allows for clients to be transferred between organizations according to their health complexity. On a broader level, population health-based assessments are being used to identify care needs for unattached population in the neighbourhood network.   

# Key Steps to Implementing the Model 

  • Identifying unmet needs
  • Getting buy-in from partners
  • Creating the vision
  • Considering risks

# Key Facilitators of the Model

  • Trust
  • Leadership
  • Model of Health and Wellbeing

 This case study describes the Neighborhood Network model and how it delivers team-based primary health care. 

Heart Health Screening Supporting Long-Term Attachment for At-Risk Seniors | Seaway Valley CHC

Seaway Valley Community Health Centre (CVCHC), located in Cornwall, ON, is currently collaborating with the University of Ottawa Heart Institute (UOHI) to screen individuals without a primary care provider for heart valve disease. 

Using its existing waitlist of over 3,000 people seeking primary care, SVCHC contacted individuals aged 65 and older to invite them to participate in a voluntary heart valve screening event.  Based on screening results, SVCHC has developed a priority pathway to ensure that individuals requiring urgent follow-up are rostered with a primary care provider. This is especially critical given the severity of some findings and the limited access to walk-in services in the community.

The first clinic will take place on July 17, with additional clinics scheduled on a monthly basis. UOHI and SVCHC also plan to expand the initiative to include heart health risk factor screening for individuals aged 40 and older, following a similar process.  

This marks the first in a series of preventative screening initiatives for unattached designed to offer expedited access to primary care. Watch this space for more stories and outcomes!

A Multi-Sectoral Clinic and New Pathways to Ongoing Primary Care | Midtown Kingston Health Home

The Midtown Kingston Health Home - cited by Jane Philpott as a living example of her Health Home Model - attaches and provides access to equitable and sustainable, comprehensive, ongoing primary health care. It consists of an entirely new clinic site and a newly hired multi-disciplinary team, community access points, access clinics and expansion of regional programs. 

A site of the Kingston Community Health Centre (KCHC), the Health Home was created when several partner organizations came together to co-design a response to the growing population of individuals within the Kingston area who were not attached to primary care (approximately 20,000 individuals). Within three months of receiving funding, they set up an entirely new clinic. It began operating with only a few new staff on board; the majority were hired later, in a staggered fashion, due to the ongoing human health resource crisis. By the end of February 2025, seven months after opening its doors, the Health Home team had over 30 staff and had already recorded 13,377 encounters with 3,742 unique clients. More than 1,700 previously unattached people are now attached to and actively receiving ongoing primary care there. 

A key element of success for the Health Home was the establishment of formal partnerships and over a dozen referral pathways between KCHC and key pressure points within the health care system. Pressure points and referral sources include:

  • Sexual, reproductive, and perinatal care
  • School board partnership for youth mental health
  • Transgender Health program
  • Community Paramedics program
  • Regional Lung Health program
  • Health Care Connect list of medically complex unattached people from the K7K and K7L postal codes
  • Emergency Departments
  • Kingston Health Sciences Centre specialists
  • Local OHT priority pathways

In addition to the new clinic site and the multiple referral sources within the community, the Health Home has extended its reach with on-location primary care in partner organization sites as well as a mobile health unit. 

Check out this case study to learn more about the Midtown Kingston Health Home and how it is improving access and attachment to care for marginalized people in the community.

Building Capacity and Streamlining Equitable Intake with Group Medical Visits | Merrickville District CHC

This report describes how the Merrickville District Community Health Centre (now part of Rideau Community Health Services) provided attachment to team-based primary health care for thousands of patients who had been "orphaned" by the loss of three family physicians in Smiths Falls.

Some of the changes they implemented: 

  • Implementing group medical visits.
  • Moving clients towards self-management.
  • Building a collaborative multi-disciplinary primary health care team.
  • Collecting and reviewing data to measure impact of changes. 

Key enabling principles:

  • Responsiveness to individual and community needs.
  • Working collaboratively.
  • Integrating with other services.
  • Engaging clients to be active participants in their care.  .

Through these efforts, the CHC made primary health care services available to those most in need in ways that benefited not only those individuals but the whole community and the health care system. Benefits included: 

  • High attendance and client satisfaction scores at group medical visits.
  • Fewer emergency department visits and medication errors.
  • Increased number of people with access to a primary health care provider.

Appendix A in this document and this 2011 news article provide additional details.

Connecting Homeless/Precariously Housed and Newcomer Populations to Ongoing Primary Care | Grand River CHC

In Brantford Brant Norfolk, high rates of unattachment, socioeconomic deprivation, and unattachment signaled a need for innovation. The Grand River Community Health Centre collaborated with partner agencies to launch specialized access clinics that both improved access to care and led to numerous marginalized individuals being attached to a primary care provider. 

In the area covered by the Brantford Brant Norfolk Ontario Health Team (BBNOHT), there were over 17,000 individuals without a primary care provider (PCP) in 2022 – an increase of over 4,000 from two years earlier. Rates of mental illness and other chronic conditions in the region exceed the provincial average. People in the region who lack access to a PCP are disproportionately affected by low income and/or housing instability, and they are more likely than those with a PCP to be newcomers to Canada. 

In response to these disparities, the Grand River Community Health Centre (GBCHC) developed an Interprofessional Primary Care Team (IPCT) in 2024 to provide accessible, person-centred health care to underserved populations, including those living with low incomes, experiencing homelessness, facing mental health or addiction challenges, or who are newcomers to Canada. They  worked with partner agencies, including primary care groups and hospitals, to identify gaps in health care and opportunities for collaboration. Based on what they learned, the IPCT launched two specialized primary care clinics: An outreach clinic for people who are homeless or precariously housed, and a clinic tailored to newcomers. 

To inform community members about these new services, the team partnered with BBNOHT Primary Care Council, the BBNOHT Navigation Community of practice, and various community agencies to distribute flyers and social media posts. Within just a few months, the PCPs were rostering clients, and interprofessional providers were offering individual appointments as well as delivering group educational programs. Since then, there have been:

  • 596 individuals newly attached to a nurse practitioner or family physician (as of August 31, 2025)
  • 54,029 individual encounters with PCPs, nurses, and interprofessional providers (March 1 - August 31, 2025)
  • 14,816 participants in group programs (March 1 - August 31, 2025)

Over the next [TIME PERIOD], the IPCT aims to attach 750 people to a PCP who currently don’t have one, and to serve another 5774 individuals through services such as primary care appointments, mental health counselling, nutrition counselling, and social prescribing.  

Embedding Health Intake and System Navigation into Access Points | Flemingdon HC & Health Access Thorncliffe Park

The dense, urban neighbourhoods of Flemingdon Park and Thorncliffe Park are home to vibrant and diverse communities that include many newcomers, people living with low incomes, and an exceptionally high number of young children. Community members experience significant barriers in accessing primary care and social services, resulting in increased reliance on emergency departments for non-urgent care, as well as gaps in access to preventative care, such as cancer screening and immunizations. 

In response to these challenges, Flemingdon Health Centre (FHC) and Health Access Thorncliffe Park (HATP) have expanded and diversified their team-based primary health care programs to provide access to comprehensive, wraparound services for unattached and uncertainly attached individuals. As the program matures, clients will be able to access these clinics through multiple points of entry, including: 

  • Referrals from the Emergency Department at Michael Garron Hospital (MGH)
  • Direct referrals to HATP and FHC
  • Ontario Health Team (OHT) Integrated Clinical Pathways
  • Health Care Connect
  • OHT-led home care projects

Between April 2024 and July 2025, the program has successfully rostered 331 clients. 

A key element of the program is the presence of Holistic Intake and Navigation Counsellors (HINCs) at each access point. HINCs establish personalized connections between clients and the primary care providers at HATP, FHC, and other providers in the East Toronto Family Practice Network (EasT-FPN). They also provide culturally sensitive services, including client intake, waitlist management, and orientation. Key duties include maintaining documentation, triaging calls, coordinating referrals, and collaborating with service providers to streamline care. The position also supports clients through personalized plans, crisis counseling, and community connections, while contributing to outreach, advocacy, and local community events.

Using geographic data to design an equitable attachment strategy | Ottawa Health Team/ Équipe Santé Ottawa

Over 170,000 people in Ottawa don’t have access to a primary care provider. The Ottawa Health Team/ Équipe Santé Ottawa (OHT-ESO) developed a process to identify neighbourhoods in the city with low attachment rates and connect individuals in these neighbourhoods to primary care providers.

In order to ensure an equitable and evidence-based approach to matching resources to needs, the OHT conducted a cross-sectional study of attachment rates. They collaborated with the Ottawa Neighbourhood Study to look at variations in access to primary care and the social determinants of health among the city’s “natural” neighbourhoods. They found that while Ottawa’s overall rate of primary care unattachment is 15.6%, neighbourhood-level unattachment rates range from 7.4% to 27.7%. They found strong correlations between unattachment rates and measures of neighbourhood deprivation, as well as with sociodemographic factors such as proportion of residents living with low incomes, young adults aged 20-34, people living alone, unemployed people, and racialized people. When limiting consideration to areas determined by statistics (census tracts), administrative boundaries (wards or ridings), or postal designations (forward sortation areas), some of these differences were obscured by the proximity of less-resourced neighbourhoods to highly resourced ones. 

Having identified priority neighbourhoods and developed an understanding of their characteristics, the OHT-ESO has implemented a plan of action to increase primary care attachment in those neighbourhoods. This includes implementing a neighbourhood model of care, expanding access to teams, and centralizing access to after-hours and urgent care, as well as finding ways to recruit and retain clinicians and reduce administrative burden. Key to this strategy was identifying two family health teams (FHTs) – the Bruyère Academic FHT and the Byward FHT – who were  willing to implement an equity-based approach to rostering and had the capacity to take on clients with greater complexity. Forming an action table with these two FHTs as well as Ottawa Public Health and various local social and health service agencies, the OHT-ESO has been able to connect NUMBER residents in areas of greatest need to primary care providers. 

# A Multi-Pronged Approach to Increasing Access & Attachment

Equitably increasing both access and attachment depends on concepts explored in earlier chapters of this toolkit: 

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8 | Connecting Care: Building a Health Neighbourhood

8 | Connecting Care: Building a Health Neighbourhood

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