Neighbourhood Care Teams: Integrating Health Care and Social Services for Seniors in Toronto Community Housing

Toronto Seniors Housing Corporation (TSHC), owned by the City of Toronto, provides housing for 15,000 low-income seniors in 83 seniors-designated buildings across Toronto. The North Toronto Ontario Health Team (including primary care, hospital, community and home-care) partnered with one of the TSHC buildings in North Toronto to develop and implement a Neighbourhood Care Team (NCT)  model to support TSHC’s Integrated Service Model to address tenants' health and social needs, co-designed  with the  tenants. The goal of the NCT is to provide an integrated model of care that is accountable to meeting the needs of people living within a specific neighbourhood so that people experience one system that provides simple access to service, and care that is coordinated with streamlined communication of health care providers.

The NCT objectives include:

• Increasing primary care provider connections
• Increasing mental health & addictions care access and support options
• Increase Digital Health access and literacy to support primary care and specialist access, reduce social isolation and increase wellness
• Reduce avoidable ED and hospital use.

The service design is guided by a co-design process with the tenants as follows:

• Door to door survey to engage tenants in identifying their barriers and the services and supports most meaningful to them
• Eliciting and voting on key education and support initiatives at an influenza vaccination clinic
• Communication back to tenants regarding the results of the survey and how the strategies/activities planned for the building have been prioritized based on their feedback.
• Multi-organization Education Fair focusing on the top issues addressed during the vaccination clinic survey which was well attended
• Regular educational sessions in response to tenant interest, combined with a self-screening component to help link the information to a concrete service/intervention to promote better health.
• Providing translation support to enable access and engagement by tenants from a variety of cultural backgrounds.
• Ongoing commitment to continue and co-design services and elicit tenants’ feedback.

The team has worked to design structures to strengthen coordination and collaboration among the various delivery partners:

• Multi-organizational bi-weekly huddles to discuss residents identified with unmet needs (with consent or anonymized without consent) and identify options for improving their access to health care/social services and respond to their needs in a timely manner
• Designed pathways for ensuring attachment to primary care, access to primary care and specialist support, access to home care services and assistance with social determinants of health
• Established mechanisms to obtain informed consent and enable information sharing between delivery partners.

Multi-modality tenant engagement to tailor services and supports to a TSHC building has led to increased involvement by tenants and a growing interest by tenants in strategies to improve their health and social inclusion. Cross-sector collaboration is an efficient and effective way to establish needs-based integration of health and social care services in this setting. Strong leadership as well as co-developed processes, frequent building meetings and cross-sector huddles were effective ways of sharing innovative ways of meeting needs with limited resources.