A Neighbourhood Based approach to early and comprehensive intervention in chronic disease management

Background: The risks for developing chronic conditions are often rooted in a person’s lifestyle as well as their cultural, social, and physical environment. Many people live with multiple conditions that are commonly treated as individual conditions without consideration of the person’s health and social context. To meaningfully improve health outcomes, care must extend beyond traditional healthcare settings to ensure a comprehensive, holistic, and integrated, team-based approach to chronic disease management within the community.

 

Approach: The North Toronto Neighbourhood Care Team (NT NCT) is an integrated outreach model that unites organizations across sectors to work collaboratively with clients in the community specifically supporting low-income seniors living in Toronto Seniors Housing Corporation (TSHC) buildings. Through a co-design process with community members and system partners, we developed “user stories” from both tenant and stakeholder perspectives to guide the design and implementation of a proactive, on-site chronic disease management clinic within the buildings where tenants live. These clinics bring together diverse health and community providers to support early identification and holistic management of chronic conditions while addressing associated risk factors and social determinants of health.

 

Results: The team proactively screened 193 tenants, 48% of whom presented with three or more comorbidities. Through community-based chronic disease management clinics, the team addressed key risk factors and supported improved health management, including tenants not yet engaged with formal healthcare services. This proactive, localized approach helped improve risk identification, health literacy and co-management to reduce unnecessary complications, prevent deconditioning and optimize health outcomes.

 

Implications: This model highlights the critical importance of early identification through proactive screening and team-based person-centred intervention in chronic disease management. It demonstrates how integration, attention to local context, and the development of trusted relationships can meaningfully improve health outcomes. The presentation will share key factors contributing to the model’s success, along with the care planning tools and assessment approaches developed to sustain and scale its impact.