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University of Toronto, King's College Circle, Toronto, ON

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Empowering unattached patients, primary care clinicians and OHTs

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Empowering unattached patients, primary care clinicians and OHTs

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For the past 11 years, we have been helping individuals across Canada find primary care clinics accepting new patients through iamsick.ca and empower.ca

This year, as Ontario focuses on primary care attachment, we’re excited to be providing multiple OHTs with:

lists of all primary care clinics & clinicians updated every 1-2 months, including detailed info about those accepting new patients

freshly launched OHT regional planning web portals (clinician portal launched in summer & OHT portal launched this month) with GIS overlays

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Empower Health - supporting multiple OHTs

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Supporting OHTs and PCNs to advance digital health use is a critical success factor for integrated patient care. OntarioMD does this best. Our teams are located throughout Ontario to work directly with primary care clinicians to enhance their EMR use, the use of other digital tools, and integrate them with your workflows. We specialize in digitally optimizing practices and making sure technology is a benefit, not a burden, to your practice. Our services are complimentary (funded by Ontario Health), so contact us at support@ontariomd.com to tell us what you need. We are here to help you!

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Providing equal & equitable healthcare for the community we serve.

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Kiiwetinoong Healing Waters Ontario Health Team (KHWOHT) is a collaborative network of local healthcare providers, Indigenous-led organizations, and community members working together to provide health and social care in Northwestern Ontario for the residents of Dryden, Sioux Lookout, Red Lake, Pikangikum, Ignace, Ear Falls, Vermillion Bay and the surrounding First Nation communities.

Our goal is to provide everyone with better-coordinated, integrated, and equitable care for a more seamless healthcare experience

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Kiiwetinoong Healing Waters Ontario Health Team (KHWOHT)

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Patient centred COPD pathway

COPD service with the patient at the centre and co-designed with people with lived experience.

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Manitoulin Island, Manitoulin District, ON

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Manitoulin Island, Manitoulin District, ON

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Manitoulin Island, Manitoulin District, ON

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Our OHT partners collaborated to develop care to speed patient attachment to Primary Care Teams across Manitoulin.

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Transforming home-based care through predictive monitoring and integrated response

Ontario’s aging population is pushing hospitals, primary care, and home and community care into chronic overload. Our teams at Stay at Home Nursing and CHAH Technology are working to close that gap by building a fully integrated, proactive model of care at home.

CHAH AI Care combines continuous, in-home monitoring with an interdisciplinary response system. Optical sensors and biometric data help detect early signs of decline; our nursing team steps in before issues escalate. This reduces avoidable ED visits, supports safer transitions from hospital, and expands the capacity of OHT partners without relying on new infrastructure.

We’re working with research groups across Ontario to evaluate impact on readmissions, patient safety, and caregiver burden. A short summary of the model is available here: www.chah.ai/whitepaper

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Comprehensive Healthcare at Home (CHAH AI Care)

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Here we a building the Primary Care Attachment Liaison (Supported Intake) role as well as the community IHP team to improve experience and outcomes for small group and solo physicians and their patients.

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Co-designed the Community Wellness Hub Model, an integrated care model for seniors, in partnership with affordable housing providers, home care providers, primary care, social supports and older adults who participate in the model.

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Community member voices identify how properly co-designed care can better meet the needs of those seeking mental health and substance use health care for the West Ottawa HART Hub.

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The Algoma OHT is working on early identification of frailty in primary care. This work is predicated on supporting older adults sooner in their journey and navigating them to the best resources. Anticipated outcomes include improved quality of life, lower cost of care, and a more holistic approach. As part of this work, a screening followed by a comprehensive assessment is completed. Further, capturing residents through health fairs is a key to identify those who are unattached to primary care.

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Doing the hard governance work early so integrated care can move faster later.

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In preparing our IPCT Round 2 and PCAT submissions, our OHT deliberately slowed the system down before asking it to move faster.

Rather than starting with structures or funding models, we invested time in shared governance readiness. We brought primary care, community partners, and system leaders into a disciplined process to surface risks, clarify decision rights, and agree on how conflict and escalation would actually be handled once pressure arrived. This included explicitly naming where system drift occurs, what decisions belong at the system table versus locally, and what guardrails must hold when consensus cannot be reached.

That work paid off. We moved from multiple competing proposals and misaligned expectations to a single, system-backed submission to Ontario Health. More importantly, we now have governance guardrails, escalation pathways, and partner principles in hand ahead of funding, rather than trying to retrofit them after April 1.

Our biggest lesson: integrated care accelerates when governance is treated as operational infrastructure, not as an afterthought. Doing the hard alignment work early reduced friction, protected trust, and allowed partners to stay focused on delivery when it mattered most.

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What we’re doing:
At our OHT, we are working on a variety of different communication and engagement strategies to support the Primary Care Network (PCN). Our PCN is composed of Family Physicians, Nurse Practitioners, Registered Midwives, Pharmacists, Community Paramedicine and Indigenous Health Providers. The Couchiching Ontario Health Team is proud to have dedicated clinicians in key roles to drive projects forward and ensure informed decision-making at the executive level.

This is leading to:
This work is helping to create a connected health care system by supporting and organizing primary care providers and helping to improve the patient and provider experiences and health outcomes, making care more accessible and equitable for all.

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In 2021, the Eastern York Region North Durham (EYRND) OHT launched the Seniors Home Support (SHS) program to provide longitudinal, interprofessional, home-based primary care to frail, home-bound older adults. This is an integrated care initiative with providers from four different partner organizations, working as one clinical team. Our partner organizations include Oak Valley Health, Markham Family Health Team, Ontario Health atHome, and York Region Community Paramedicine Services.

The SHS program serves the most vulnerable and medically complex older adults in the communities of Markham and Stouffville. By delivering a hybrid of primary care with geriatric and palliative focus, alongside community providers, patients receive goal-congruent care ranging from routine preventative care to urgent care. The SHS program is improving access to primary care for homebound older adults and has shown high levels of patient/caregiver and provider satisfaction, and reduced hospital utilization.

With interest and investment, this program can be adapted and spread in other communities.

https://www.eyrnd.ca/seniors-home-support

Contact: Jenniffer Joseph (jejoseph@oakvalleyhealth.ca)

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What we’re doing:
At our OHT, we are working on screening for risk of COPD.  Through several concerted efforts, we are ensuing those with risk factors of COPD are being identified and offered spirometry for diagnosis.  These efforts include the following:  screening PCP rosters for risk factors of COPD; use of the Canadian Lung Health Test (CLHT) at the local Adult Diabetes Education Centre (ADEC) to screen for risk factors; using the CLHT at Community Paramedicine Wellness Clinics to screen for risk factors for COPD.

This is leading to:
This work is helping with early identification of COPD to connect those with undiagnosed COPD to specialized care with the goal of improved patient outcomes.

Partners:
PCP’s

County of Simcoe Community Paramedicine Program

Orillia Soldiers’ Memorial Hospital ADEC

Pro Resp

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Angela Munday, Population Health & Evaluation Lead, COHT

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What we’re doing:
At our OHT, we are working on improving the social health of our community.  In partnership with 211/Community Connections, we are bringing Social Prescribing to our community.  Through development of an easy-to-use asset map, providers and the public will be able to access dedicated support for connection to what matters to them.  Research shows that improving social health has a direct impact on physical health

This is leading to:
Improved mental and physical health for our community.

Partners:
211/Community Connections

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Angela Munday, Population Health & Evaluation Lead, COHT

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Brampton Civic Hospital, Bovaird Drive East, Brampton, ON

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Brampton Civic Hospital, Bovaird Drive East, Brampton, ON

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Brampton Civic Hospital, Bovaird Drive East, Brampton, ON

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What we’re doing:
At our OHT, we are working on achieving 100% primary care attachment by 2029, including all patients currently on the Health Care Connect (HCC) waitlist in our assigned Forward Sorting Areas, by working with Round 1 Interprofessional Primary Care Team leads. Given that the Central West region is home to more than 140,000 unattached patients, we are creating a coordinated central intake system that supports and aligns provider and patient needs, built on a foundation of collaboration and equity. Our neighbourhood network model focuses on identifying patients, clearly communicates how patients can become attached, and centralizes and coordinates matching based on principles of equity, supporting patients that are in the greatest need. This affirms the OHT’s continued commitment to the one front door but no wrong door approach.

This is leading to:
This work is improving patient attachment and provider coordination, with the OHT adopting a framework built around six foundational pillars to guide attachment (with implementation underway) which ensures that both system design and service delivery are equitable, coordinated, and population responsive. The six pillars are: interprofessional collaboration; enhanced navigation; increased primary care support; integration; equity, diversity and inclusion; and improved access to care.