Integrating care with equity-deserving communities from the ground-up: High Priority Communities Strategy in Markham, Ontario

BACKGROUND: The High Priority Communities Strategy (HPCS) was a Made in Ontario model funded by Ontario Health between 2020 and 2024 in not only successfully reduced the transmission and severity of COVID-9 pandemic in 7 identified Ontario communities marked by elevated material deprivation, and adapted swiftly to implementing hyperlocal, equity-based population health prevention and wellness model to address intensified care needs of diverse community members.As the Lead Agency for Southeast Markham Ontario, Carefirst Seniors and Community Services Association (Carefirst) has convened a working network of more than 35 co-productive and intersectoral partners that shared the common aims of () providing timely and seamless pandemic response and wrap-around health and social care to families affected by COVID-9; and (2) addressing health inequities that impact peoples quality of life, including mental health and access to preventative care and primary care, by integrating and enabling community assets. The Carefirst journey aligns primarily with the resilient communities and new alliances, one of the nine pillars of Integrated Care.

APPROACH: The Carefirst-led HPCS identified core principles and tactics in integrating better care to create health in the community: (1) Low-rule policy and funding framework that facilitates innovations in meeting people needs and a broader definition of health; (2) Enabling and equitable partnerships for collective impact approaches to complex health needs - High-trust collaborations from the ground-up, hyper-local approaches, shared resources, and working with non-traditional partners; and (3) Building up community assets to re-envision roles of the (health) care systems - i.e. Community Ambassadors, enabling care provision where people liveincluding places of worship. The Carefirst-led HPCS model has also deepened collaboration with multiple Ontario Health Teams (OHTs) to implement various local OHT integration priorities.

RESULTSThe Carefirst-led HPCS has been evaluated continuously and demonstrated promising results. In 2022-23, a team of experienced academic researchers/evaluators conducted multi-methods evaluation of the project and in 2024 the Health Commons Solutions Lab has updated qualitative data summarizing key lessons learned in HPCS across Ontario. Patient and partner testimonials illuminate how HPCS has transformed health care partnerships from transactional to relational, nurturing more equitable, healthier Neighbourhoods of Care.

IMPLICATIONS: The Carefirst-led HPCS model, planned and implemented based on the integrated care concept in partnership with both traditional and non-traditional healthcare and grass-root organizations, has been shown as a practical solution to address social determinants of health and reduce health inequities towards creating health in the near and long terms. The model was enabled by policy, drew on people lived experiences and assets, mobilized cross-sectoral partnership for resource navigation and mutual capacity building, and reached deep within the local populations, in a cost-effective manner.

WORKSHOP OVERVIEW: Audience. This 60-min workshop is appropriate for health planners/leaders, service providers and community representatives.Approach. This interactive workshop aims to generate collective audience wisdom for creating health through integrating care from the ground-up, inspired by the Carefirst-led HPCS:-0 min. Introduction and icebreaker on connection and safety-5 min. Presentation on core lessons learned from the Carefirst-led HPCS-20 min. Co-creation Groupwork: Participants will be divided into small groups and role-play various health partners including residents/patients. Each group will be given a health challenge (e.g. food insecurity and rising prevalence of diabetes) and description of local context, participants will then get into their roles and co-create: Mapping of resident health journey and community assets, generating near and longer-term solutions inspired by HPCS principles and tactics, and identifying enablers and barriers in change management.-0 min. Feedback and Call-to-Action with participants-5 min. Closing: EvaluationOutcomeParticipants will take-home co-created solutions in-session for various health challenges and also key considerations in facilitating change in the community.