Abstract
Background: Low-income neighbourhoods with diverse health and social care needs are usually ignored by health planners and have poorer health experiences and outcomes. Fifty years ago, a community based primary health care team was formed to challenge this status quo. Flemingdon Health Centre (FHC) was created to provide accessible, comprehensive and coordinated care to a defined geography in Toronto, Canada. Over time, the organization became the go-to service provider for newcomers and refugees. Clients in our care are 54% more complex than the average population yet only 8.8% use the emergency department inappropriately and only 5% are readmitted to the hospital post discharge. FHC is proud of the impact we have in keeping our communities well.
The first 40 years achieved significant growth and integration of clinical and health promotion under one team and one electronic record. FHC embedded health equity into our foundation by using interpretation for appointments, caring for the uninsured and our salaried staffing model. In the last 10 years FHC’s integration agenda has been ambitious. We are celebrating the following achievements:
Health Access Thorncliffe Park – a team based primary care and social service program that integrates care for the neighbourhood
Integrated Mental Health Services – a program that supports communities without primary care to improve their mental health
Thorncliffe Park Community Hub – a 67,000 sq ft space that brings together health, social services, dental, midwifery, legal, diagnostics and laboratory services to provide comprehensive care as a one-stop shop.
East Effort – a network of Community Health Ambassadors (CHAs) that provide education and navigation to communities who need it most. CHAs speak local languages and are the eyes and ears on the ground. They provide over 4,000 support services per year to clients.
Audience: Policy makers, system planners, primary and community care leaders
Approach:
Background: What is the Community Health Centre model and why is it the perfect foundation for integrated care? (15 minutes)
Impact: Testimonials of the recent achievements in integrated care (10 minutes)
Discussion: What features of our models of integration are the same or different than yours? (20 minutes)
Putting it together: What are the ‘non-negotiables’ for community driven integrated care? (15 minutes)
Outcomes: A newcomer youth attended our Girls Hockey Program focusing on physical and mental health: “As someone with a newfound passion for hockey because of this program... it has helped me build such a supportive community.”
A senior who attends our mindfulness art program: “You never fail to impress us. The program understood our needs and provided us with the time of our lives... we are being respected and valued in this room.”
An adult who received support from our CHAs to complete cancer screening: “They talked to me about the specific test I needed and answered my questions. Usually, other doctors’ offices don’t even call you or tell you that you are due, so I appreciated it.”
FHC’s journey highlights the essential role of community-based health care models in advancing health equity and shaping the health care system.