Integrating Primary Care and Home Care: Dependency-Informed Strategies to Improve Attachment in East Toronto

Background:

East Toronto Health Partners (ETHP), part of the first cohort of Ontario Health Teams, is responsible for delivering integrated care to a diverse urban population. For ETHP, home care recipients represent one of the most medically complex and socially marginalized groups in the system.

Approach:

We analyzed 2020 population-level data from the Ontario Community Health Profiles Partnership (OCHPP). OCHPP provides high-quality, area-specific health data and maps through an open-access platform, developed by experts in primary care and public health. The dataset included stratification by long-term home care status and primary care attachment, enabling comparison of home care recipients with the overall ETHP population.

Results:

Over half of home care recipients were aged 80+, compared with only 3% of the overall population. They were disproportionately concentrated in marginalized neighbourhoods: about 40% lived in the most unstable areas (vs. 22% overall) and 20% in the most dependent areas (vs. around 10% overall). Their illness burden was extreme: 60% were living with 10+ chronic conditions, compared with just 12% of the overall population. This level of co-morbid disease translates into very high system use. Three-quarters visited the emergency department within the prior two years, 60% were hospitalized, and one-third readmitted within 30 days.
Unattached home care patients were slightly older (59% vs. 54% aged 80+) and more often newcomers (17% vs. 13%). They had 33% higher non-urgent emergency department (ED) use and a 26% higher hospital readmission rate within 30 days. Among home care patients, those living in the highest-dependency neighbourhoods were substantially more likely to be unattached (30.0%) compared with their attached peers (19.5%). In the overall ETHP population, dependency had little effect on attachment (9.8% unattached vs. 9.5% attached).

Implication:

Lack of primary care attachment places home care patients at a clear disadvantage, reflected in higher non-urgent ED use and higher hospital readmission rates, despite a similar illness burden compared to their attached peers. In the data, neighbourhood dependency (areas with large proportions of children and older adults and fewer working-age adults to coordinate care) emerges as a critical barrier to attachment. Home care patients in high-dependency neighbourhoods face a double burden: personal vulnerability (multi-morbidity, mobility and cognitive impairment) and limited community supports. Standard attachment methods, which assume patient or family self-navigation, fail in this context. These findings reinforce the need for proactive, community-based care models that bring primary care to where people live, supporting independence and reducing avoidable hospital use.

The ETHP Leading Project, an integrated care initiative focused on redesigning home care services in high-vulnerability neighbourhoods, is using these findings to guide dependency-informed strategies, including:

● Seamless enrolment pathways where entry into the home care system automatically creates a direct route to primary care attachment.
● Embedding primary care into home care delivery via on-site primary care within residential settings, so frail patients are attached at the point of care rather than left to navigate on their own.
● Measuring success not only by attachment rates, but also by continuity of care and reductions in avoidable hospital use.