Southlake Health’s Distributed Health Network: Building an Integrated Health Ecosystem in Ontario, Canada

Background: Like many systems, Ontario, Canada is facing challenges meeting its goal of integrating health care. In the Northern York Region of the province, unprecedented population growth, persistent siloes between sectors, limited acute capital investment, and a workforce stretched thin across the health system all contribute to the need for change.

 

Approach: In 2024, Southlake Health launched a 10-year strategic plan to evolve the hospital into a Distributed Health Network (DHN); a new way to organize and deliver care across our catchment area by spreading services throughout local municipalities. A redeveloped main acute care site (Newmarket, Ontario) and second acute care site are in the early planning stages. Services that don’t need to be provided in an acute setting will be delivered at Advanced Care Campuses, multifunctional spaces that support high-quality care closer to home (including primary care) and stronger integration with community services.

 

Strong partnerships are being formed with local communities and engagement is being prioritized to ensure that our new system will meet the needs of local communities; especially those who have traditionally been marginalized. The vision has been built on a commitment to Population Health Management, the Quintuple Aim, and establishing a Learning Health System.

 

Focusing on our highest-needs communities first, memorandums of understanding have been signed with 2 of the 6 Towns we serve. Community health needs assessments have included compilation of previously-completed engagement, visioning exercises with local primary care providers, community health fairs, and geo-analytic analyses.

 

 

 

Results: In Georgina (the first Town to sign an MOU), access to Primary Care, access to urgent care, and availability of navigation support were identified as challenges by the community. Since 2024, an Interprofessional primary care team was established, a nurse practitioner led clinic was enhanced, a pediatric urgent care clinic was opened, and a mobile bus service launched. Collectively, these services have increase access to primary care, especially for residents in rural and underserved communities.

 

In 2025, Southlake Health launched Canada’s first Extensivist Clinic and an Integrated Care Centre (command centre) to support improved patient transitions between hospital services and community programs. In 2026, we will launch a Hospital at Home program, enhanced Virtual Care options, and establish a Population Health Registry to strengthen our ability to pro-actively support care coordination.

 

Implications: The term Distributed Health Network is new, but it is built on well-established, evidence-informed principles. Our challenge is bringing it to life. Our 10-year strategy is divided into three ‘sprints’ that allow us to assess progress and course correct as necessary. With one year complete, substantial progress has been made and we're seeing early signs of positive impact. Aligned with the principles of a Learning Health System, it is time to share what we've learned and consider opportunities to improve in the next phase.