Improving Outcomes Through Community-Based Care: Advancing ETHP’s Integrated Care Strategy to Achieve 100% Primary Care Attachment Using HSO’s Maturity Assessment

Background: East Toronto Health Partners (ETHP) is a leading Ontario Health Team serving a highly diverse population of over 300,000 residents across East Toronto. The region is characterized by significant variation in social determinants of health, including income, housing stability, food security, and access to culturally appropriate care. These factors contribute to persistent health inequities and uneven access to primary care services. ETHP’s strategic goal is to ensure that every resident is attached to comprehensive, team-based primary care within five years, a foundational step toward building a healthier and more equitable East Toronto community.

 

Integrated care offers a pathway to achieve this goal by shifting the balance of the health system toward proactive, community-based care. Realizing this vision requires more than service redesign; it calls for a shared understanding from all interest holder groups on which structures, policies, and practices must be redesigned, prioritized or strengthened to support effective integration overtime. To support this transformation, ETHP applied Health Standards Organization’s (HSO) Integrated Care Maturity Assessment. This evidence-informed framework will help ETHP identify strengths, risks, and opportunities across 10 design principles of integrated care for all partners to advance integrated care and population health together.

 

Approach: The ETHP strategy is rooted in collaborative governance, equity-based planning, and system-wide transformation. The upcoming application of HSO’s Integrated Care Maturity Assessment will provide shared insights to

Defined population health needs and outcomes

Comprehensive and coordinated continuum of care

Access, flow and transitions

People-centred care teams

System leadership

Shared governance and accountability

Aligned funding and incentives

Interoperable information systems

Performance management

 

Learning culture:The assessment will be conducted through a participatory process involving ETHP’s leadership council, primary care providers, community organizations, and residents. It will include a comprehensive self-assessment and workshops to inform strategic and operational planning and a roadmap for change. The goal is to understand what structural enablers and barriers exist in achieving universal attachment to primary care, and how ETHP can strengthen its integrated care delivery model.

Key areas of focus will include:

Governance and Leadership

Workforce Strategy

Funding and Sustainability

Community Engagement and Equity:

 

Results: (Anticipated) While the assessment is scheduled to take place prior to the conference, ETHP anticipates that the results will identify:

Strengths:

A strong, shared vision for equitable health outcomes across ETHP partners.

Deep-rooted community partnerships and co-design practices that center lived experience.

 

Risks and Gaps: Workforce shortages and retention challenges, particularly in primary care and home care.

Fragmented digital systems that limit real-time data sharing and coordinated care.

The assessment will also help ETHP prioritize strategic actions, such as:

Strengthening governance structures to support integrated decision-making.

Expanding culturally appropriate care models and navigation supports.

Building workforce capacity through targeted recruitment, training, and retention strategies.

 

Implications: The ETHP experience offers practical insights for advancing integrated care and universal primary care attachment. Using HSO’s Integrated Care Maturity Assessment, ETHP demonstrates framework-driven transformation, equity-centered planning, and system-level change. Its scalable strategies grounded in collaborative governance, digital integration, and community co-production offer a roadmap for jurisdictions seeking sustainable, people-centred care.