Integrating the Social Determinants in Health Care Delivery: A Social Medicine Care Model

Background: Based at Canada’s largest academic health sciences network, the University Health Network (UHN), the Gattuso Centre for Social Medicine is a data and partnership-driven program integrating health and social care delivery for UHN’s most medically and socially complex patients. The Centre for Social Medicine recognizes that health and poverty are inextricably linked. To address long-standing health disparities, the Centre co-designs models of care with partners across sectors and patients with lived experience towards sustainable solutions. These care models focus on “super-utilizers” — patients with repeated emergency department (ED) and inpatient visits — with comprehensive and wrap-around health and social supports to better address structural factors such as homelessness, food insecurity and poverty. 

Audience: This workshop invites health and social care professionals, policymakers, and leaders interested in multi-sector partnerships to improve population health. Ideal participants are those looking to co-design interdisciplinary, integrated care models that align with local needs and strengthen multi-stakeholder cooperation for sustainable impact.

Approach: The link between health and social outcomes demonstrates the importance of co-designing the program with people with lived experience, incorporating local knowledge from community partners and forging relationships with all levels of government to improve population health. The workshop will explore the creation of the Social Medicine Initiatives developed collaboratively with the Lived Experience Advisory Council and implemented through cross-sectoral partnerships:

Social Medicine Housing Initiative (Dunn House) an innovative model of permanent supportive housing that integrates community supports and mobile, low-barrier access to care including primary care, psychiatry, and harm reduction with affordable housing. 

Social Medicine Care Model that addresses complex medical and health needs through supports from Nurse Practitioners and Community Health Worker teams.  

Stabilization & Connection Centre to provide preferential care to patients experiencing alcohol and/or opioid intoxication.

Participants will engage in a 20-minute interactive session, where they will discuss action plans for implementing partnership-driven integrated care models in their communities.  

Outcomes: Participants will leave equipped with strategies for fostering inter-agency partnerships and strengthening collaboration to meet local health needs. Participants will learn the fundamentals of engaging with individuals with lived experience, service providers, and other stakeholders throughout the design, implementation, and evaluation stages. The program will cover identifying best practices for delivering integrated care, improving population health, and recognizing high-priority populations. Additionally, participants will learn strategies for generating partnerships with government and philanthropic donors, enhancing their capacity to support community health initiatives effectively.

Patient stories will highlight the impact of the Centre for Social Medicine, underscoring its role in connecting patients with essential resources, reducing avoidable ED visits, and fostering sustainable housing solutions. This workshop offers attendees a framework for community-driven integrated care to strengthen partnerships that can improve health outcomes for vulnerable groups.