Neighborhood-based Local Innovations to Solve Global Problems

Background: In Ontario, Canada, health care is organized and delivered in local communities in the form of Ontario Health Teams (OHTs). The East Toronto Health Partners (ETHP) (OHT) serves a population of approximately 400,000 people across 21 urban neighborhoods in the City of Toronto. ETHP has developed a neighborhood care portfolio of projects designed to improve population health by focusing on addressing health inequities within our highest needs neighborhoods, including expanding access to primary and social care, improving navigation across the health care system and using a population health approach to preventative healthcare, including vaccination campaigns.

Inclusivity to Reduce Inequality: The high needs neighborhoods in East Toronto face numerous health and social challenges that are attributable to greater population density, higher proportion of newcomers and refugees, higher unemployment levels, and higher rates of chronic diseases.  These same neighborhoods were disproportionately impacted by the pandemic with much higher COVID positivity rates, resulting in higher numbers of hospitalizations and deaths and further exacerbation of pre-existing challenges related to the social determinants of health.

Leveraging Partnerships for Health and Development through Innovation 

Through ongoing collaborative relationships among organizations from different stakeholder groups, our innovations include:

1. Delivering integrated primary care and social care through health access hubs within high needs neighborhoods offering both reliable primary care and social prescribing to address health inequalities.
2. Introducing Holistic Intake and Navigation Counsellor roles that act as community connectors within healthcare settings such as acute care and primary care, to increase access to community-based comprehensive primary care and social care.
3. A coordinated response across ETHP to provide seasonal and routine vaccinations to vulnerable populations across East Toronto with enhanced cooperation across multi sectoral partners to achieve a higher level of collective impact.

We are measuring our progress by evaluating process measures such as the number of referrals made across partners and the number of specific provider interactions. We will also review outcome measures such as attachment rates to primary care through the access models and the number of community members who received vaccinations through our collaborative efforts.

 

Distributed Leadership within the Community: This presentation will include an overview of ETHP’s approach to community co-design that includes patient and community leadership at all levels of decision-making. ETHP includes a range of roles for community members from OHT leadership to community health ambassadors working on the ground to provide outreach and support to our high priority, culturally-diverse communities. Distributed leadership amongst service providers, the health care system, and community members through local neighborhood wellness councils is a key aspect to this work. We will highlight how patients and community members are equal partners in driving the design and development of our neighborhood care models and how this deep level of engagement has shaped the purpose and direction of the work.