Vision for a Neighbourhood Health Home: Integrated Teams as the Foundation

Background: and Context Primary care is often described as the foundation of a strong integrated care system. In Ontario, Canada currently 2.3 million people are without access to an on-going primary care provider. This is being addressed through unprecedented funding to expand new and existing primary care teams over the next four years with the intention of 100% attachment to a primary care provider.

Approach: The Alliance for Healthier Communities (Alliance) has collaborated with members/stakeholders (Community Health Centres, Nurse Practitioner-led Clinics and other community governed primary care organizations) to build a vision for Neighbourhood Primary Care Homes that include a hub and spoke model ensuring that all people in the community can access the services they need and get attached to primary care. This vision incudes a set of six key components including: 1) interprofessional, collaborative primary care; 2) community governance and engagement; 3) a population-based approach; 4) a strong data foundation; 5) focus on equity and determinants of health; and 6) accountability and efficiency.

Several Alliance members (and others) have been successful in funding and are currently implementing Neighbourhood Health Homes and a case example will be described outlining the key enablers and barriers.

Results: The model consists of a Hub (team-based primary health care organization) and Spokes (primary care providers and groups who are not directly part of a team, but who have access to it). In this collaborative Hub-and-Spoke model, primary care providers and interprofessional teams collaborate to meet local needs of the communities they serve.

The Hub (i.e., team-based organization) within this model, provides ongoing primary care as well as social and community-based supports tailored to the needs of people who experience barriers to care. The Hub organization is the lead agency for health promotion and preventive care, as well as social and community supports. The Hub acts as the central coordinating body with the Spokes (i.e., all primary care providers in the community) having access to the services and supports provided by the Hub, ensuring that care is coordinated and seamless. Essentially, the Hub is a one-stop shop where individuals can be screened, supported, and assessed for all their needs, such as primary care interprofessional resources and/or population health programming. Depending on the patient’s health complexity and care needs, they may continue as a patient of the Hub or be transitioned to one of the Spokes. By ensuring patients are attached and connected to the right type of care, this creates a long-term relationship that facilitates stability and continuity of care.

Implications: The neighbourhood health home model is deeply rooted in health equity and ensures that every person will have attachment to primary care and barrier-free access to an interprofessional primary care team.

This model focusses on connecting primary care practices across neighbourhoods to operate as an integrated system without disrupting independent organizations. This model, if deployed across Ontario, will facilitate increased attachment rates and ensure Ontarians are attached to primary health care and have access to the social and community services they require.