Downtown East Toronto Ontario Health Team

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Building a Primary Care System “For the Community, By the Community”: Two Providers Share Insights on Health Sector Partnerships for a New Project

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In conversation with partnering primary care providers of Interprofessional Primary Care Team (IPCT) project* – part 1 of 2 (read part two here)

We engaged in a dialogue with two of the key leaders involved in the DET OHT’s IPCT project: Tara Bradford, Executive Director at Inner City Family Health Team (ICFHT), and Maryam Ebrahimpour, Senior Director of Primary Health Care at Regent Park Community Health Centre (RPCHC). These organizations are two of the four primary care providers participating in the project, alongside St. Michael’s Academic Family Health Team and Sherbourne Health. During our conversation, Bradford and Ebrahimpour shared meaningful insights from the early stages of the project’s implementation planning and discussed how the initiative aims to integrate team-based primary care with community services.

In your opinion, what distinguishes the care delivery model in this primary care project from other primary care delivery models?

Tara Bradford: It is important to recognize that we are still in the early stages of the project, so some aspects are what we hope to achieve. I believe the ‘co-design’ approach is a distinctive element that distinguishes the IPCT project from other primary care models. Over the past few years, there have been various efforts to make primary care more integrated with community services, moving away from a silo approach. So this project offers an exciting opportunity to fully embed primary care into people’s care plans and coordinated care networks. The aim is for primary care to be more than just “this is what your doctor says” or “here are your next steps.” Instead, community workers can take that information and do their magic of integrating these services to make them genuinely meaningful and accessible.

Maryam Ebrahimpour: What sets this model apart is the breadth of the partnership. It is a collaborative approach to view the system holistically, at least within the Downtown East Toronto, and explore new ways to approach health and primary care gaps.

We need to shift away from past practices that may have worked historically but created barriers for many communities. During COVID-19, we tested this approach with the Wellness Hub. However, at the time, we focused on responding to daily demands and did not have the opportunity to co-design. Since then, we have learned valuable lessons. Now, we have a chance to slow down and truly co-design a primary care model that incorporates the voices of clients and other community providers.

Could you please share with our audience why we chose to focus on Black and Indigenous communities within our target populations?

Tara Bradford: This project is striving to create meaningful pathways where they may not currently exist, with the responsibility to improve service approaches and delivery. Black-governed and Indigenous-governed primary and community care organizations can likely articulate this better, but from what I understand, trust and cultural knowledge play a huge role. Many Black and Indigenous patients feel they must code-switch to ensure that care providers, who may not share their cultural or community backgrounds, understand, respect, and listen to them. This often places an extra burden on patients, as they must explain their experiences in ways that others will understand.

Additionally, healthcare knowledge has historically been based on research involving predominantly white populations. While health may seem universal, symptoms and conditions can present differently across communities. For example, overdose response training often emphasizes blue skin tone as a symptom – a standard based on one population’s experience of health. This small example highlights how a lack of diversity in healthcare education limits seemingly “neutral” knowledge. These biases permeate the healthcare system, affecting people’s experiences and outcomes.

What key lessons or realizations did you gain while planning to set up this project with various primary care organizations and partners?

Tara Bradford: One of the learnings for me was that there is an unacknowledged or invisible labour that goes into these kind of collaborations and comprehensive designs. The amount of resources, meetings, and time it can take to build something like this is not always considered in the project timelines. When we start consulting across the broader sector, we are working with a lot of interests that both coalesce and compete with each other. It was a surprise to the steering committee how some design elements felt very logical and straightforward and others did not have traction with the larger groups. I think all organizations have a different vantage point in terms of what feels low barrier.

Maryam Ebrahimpour: One of the things I have truly appreciated is the intentional outreach beyond primary care organizations to include other partners essential for the project’s success. We cannot achieve this alone – we need partners to create a primary care system that is built for the community, by the community. There is no one-size-fits-all design.

Through this outreach, one of the greatest lessons for Regent Park Community Health Centre is recognizing that despite our longstanding priority to expand access to Black health, there is still more work to be done. When the IPCT team began working with early adopter organizations, one of the gifts we received was the opportunity of engaging in honest conversations about building trust and partnering on anti-Black racism, Afro-centric care, and Islamophobia training. Initially, we envisioned this training just for the IPCT, but to achieve IPCT’s broader goal, which is embedding care for unattached clients into the larger system, it is important for Regent Park to extend this training throughout our organization.

Given the increasing challenges in resources and capacity within the primary care sector, how can we support the long-term growth and sustainability of projects like the IPCT?

Maryam Ebrahimpour: One of the challenges is the limitation imposed by short-term and restricted funding. It puts a ceiling on our imagination, potential to innovate, and how far we can advance these initiatives. When funding is time-bound or project-specific, it does a disservice to the communities we serve. We invest time in building something, establishing trust, engaging communities, and encouraging them to utilize services. But when the funding ends, those services are withdrawn, creating a cycle of broken promises and eroded trust.

Sustainability, at its core, requires a commitment to developing an integrated model that connects partnerships, systems, and the community itself. I think a huge undertaking like this requires a long runway. A robust framework for evaluation and research must also be built into the process, ensuring that findings inform dialogue about stable, long-term funding. This is not a one- or two-year endeavor but a project that must span several years to truly succeed.

In conclusion, would you like to add something or share a key takeaway from our conversation?

Maryam Ebrahimpour: At the Regent Park Community Health Centre, we are excited to be going through this journey, learning the lessons, making mistakes, and getting up and doing it again. We hope that this is not a time-limited project, and that we can truly see this vision being incorporated into the larger picture of the other work that we do.

*The IPCT project is a primary care initiative of DET OHT, aiming to enhance access and attachment to interprofessional, team-based primary care for individuals in Downtown East Toronto experiencing significant financial and social barriers. These populations include people experiencing housing insecurity, 2SLGBTQIA+ community, refugees, people with disabilities, and individuals who use drugs. The project places a specific emphasis on addressing the unique needs of Indigenous and Black communities.

At the time of this conversation, the project was in its initial launch phase and the four primary care providers were collaborating closely with their referring community partner organizations to establish a strong foundation for success.

New Primary Care Program to Serve Underserved Populations of Downtown East Toronto

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Overview

DET OHT is committed to connecting its diverse communities to the primary care services. To advance this priority, the DET OHT is launching one of its most significant primary care initiatives to date in Fall 2024. This program will address the service gaps for individuals facing substantial social and economic challenges in accessing team-based, interprofessional primary care. These groups include:

  • Indigenous communities
  • Black communities
  • People experiencing housing insecurity
  • 2SLBTQIA+
  • Refugees
  • People with disabilities
  • People who use drugs
  • Others facing barriers to comprehensive team-based care

About the Program

The program will encompass a two-pronged approach to improve client navigation:

  1. Increasing access to team-based primary care services
  2. Increasing attachment to these services.

It will follow the principles of health equity and population health to reduce disparities in health outcomes across diverse DET community.

The DET OHT is undertaking this program in collaboration with four of its Team Members, representing a diverse mix of partnering primary care organizations (PCOs) including Community Health Centres, Academic Family Health Teams (AFHT), and Family Health Teams (FHT):

  1. Sherbourne Health FHT
  2. Regent Park CHC
  3. St. Michael’s AFHT
  4. Inner City FHT

The care model will embed Nurse Practitioners (NPs) in the four PCOs mentioned above to strengthen clients’ access and attachment to primary care. The NPs will offer low-barrier primary care services outside of the traditional primary care office, including pop-up clinics, weekly drop-in clinics, and walk-in services, to enhance access to and reach of primary care services.

Caseworkers will work alongside the NPs to provide navigation and service coordination support. Moreover, over time, other care providers will join the circle of care; these will include, but are not limited to, community ambassadors, system navigator(s), a chiropodist, a social worker, a mental health practitioner, and a physiotherapist.

The partnering PCOs will collaborate closely with referring community partners, specifically Black- and Indigenous-focused organizations, to proactively identify clients.

Integrated Pathway Design

Following the learnings and insights from the planning and pathway design held earlier this year, the DET OHT hosted the second design session in August 2024. The four partnering PCOs, clients, community members, and referring partners were among the attendants.

The multidisciplinary approach brought diverse perspectives to the table when addressing potential barriers in the client navigation pathway. The session was centered on developing strategies tailored to the unique needs of the target population.
The interactive four-hour session provided additional key insights for structuring and planning the integrated primary care pathway.

The pathway design process is iterative and ongoing. There are plans for continued engagement sessions and rapid testing involving clients from referring partners, both before and after the program’s launch.

From Crisis Response to Comprehensive Care – Final Part

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Primary care capacity is an ongoing challenge throughout both the province and the country. The increased need for primary care access amidst the COVID-19 pandemic necessitated the transition of Regent Park Community Health Centre’s COVID-19 vaccine clinic into a primary care clinic called the Wellness Hub.

In collaboration with St. James Town Community Corner, Sherbourne Health, and DET OHT, the Wellness Hub aimed to serve refugees, immigrants, racialized individuals, and LGBTQ+ communities. The clinic focused on preventive screenings and chronic diseases management.

In the final part of this two-part dialogue (read part one), Monika Dalmacio, Director of Clinical Operations at Sherbourne Health, and Maryam Ebrahimpour, Senior Director of Primary Health Care at Regent Park Community Health Centre, share their reflections on some of their most memorable experiences.

Could each of you share a particular memory from the entire journey of Wellness Hub that holds a special significance for you?

Monika Dalmacio: I will share a story about one of our clients.

A refugee from Afghanistan was found homeless at a subway station by our community ambassadors. They noticed his distress. He was alone in Canada, facing language barriers that hindered his access to necessary health and social care services.

Before arriving in Canada, he had experienced intense trauma in Afghanistan. His arrival was not smooth either. He was detained, lost all his medications, and experienced deteriorating mental health.

Within four days of being approached by our community ambassadors, he visited the Wellness Hub. He received comprehensive primary care and a mental health assessment. We initiated his medications, scheduled regular follow-ups, and connected him with our mental health counselor.

We connected him with an employment counsellor and training programs to improve his job market skills. As a result, he found a job with a construction company and eventually moved out of the shelter system. Additionally, he began attending English language classes.

During the Wellness Hub wrap-up celebration, I spoke with our team supporting this client. They informed me that his family members had also arrived in Canada. Although the Wellness Hub has unfortunately closed, this client is now equipped with a job and knowledge of the systems in Canada. Not every story will be as clear a big win as this one. But I love sharing it with others when discussing the Wellness Hub.

Maryam Ebrahimpour: What stands out to me is the power of a unified system working together. As Monika was speaking, I was thinking of the image from the wrap-up celebration in March 2023. All the partners were there, and we took a snapshot of those who came to the celebration. Monika’s story illustrates the importance of seamless transitions between programs and partners, and knowing the right questions to engage those unaware of their needs.

How have the opportunities in primary care, highlighted by the Wellness Hub, strengthened your conviction to focus on them more than ever before?

Maryam Ebrahimpour: While not new information, the capacity of primary care across the province and country offers an opportunity for increased focus. It was a challenge to find long-term primary care providers for clients accessing the Wellness Hub.

So, the importance of working as a unified system has further convinced me to prioritize primary care and Black health.

Any concluding thoughts or comments you would like to add?

Monika Dalmacio: The model has been a great success with community ambassador support and capacity-building opportunities.

One of our staff at the Wellness Hub started as a community ambassador and is now a medical secretary. Similarly, another community ambassador is now a system navigator.

So, I am thankful for these components of the Wellness Hub.

Maryam Ebrahimpour: I would like to extend a special thank you to everybody who was involved – the leadership, the front line staff, and the community ambassadors. The level of dedication from everyone was truly remarkable. Often, they sacrificed their weekends, arrived early, and stayed late. Everyone worked on top of their existing responsibilities and put in extra hours. I cannot thank them enough.

From Crisis Response to Comprehensive Care – Part One

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Primary care capacity is an ongoing challenge throughout both the province and the country. The increased need for primary care access amidst the COVID-19 pandemic necessitated the transition of Regent Park Community Health Centre’s COVID-19 vaccine clinic into a primary care clinic called the Wellness Hub.

In collaboration with St. James Town Community Corner, Sherbourne Health, and DET OHT, the Wellness Hub aimed to serve refugees, immigrants, racialized individuals, and LGBTQ+ communities. The clinic focused on preventive screenings and chronic diseases management.

In part one of this two-part dialogue (read part two), Monika Dalmacio, Director of Clinical Operations at Sherbourne Health, and Maryam Ebrahimpour, Senior Director of Primary Health Care at Regent Park Community Health Centre, delve into the clinic’s journey of transition.

What were your initial observations while managing the COVID-19 vaccine clinic before it evolved into the Wellness Hub?

Maryam Ebrahimpour: There was certainly a heightened need for COVID-19 vaccination across the Downtown East neighborhoods. We brainstormed ways to make access as barrier-free as possible. As subsequent waves occurred and boosters became available, we recognized the importance of community education. This led to the evolution of the vaccine clinic into a vaccine engagement initiative. A group of dedicated community volunteers received training on vaccine education before going out into their communities. They would go to skating events, university job fairs, and even playgrounds. Sometimes they escorted individuals directly to vaccine administrators for a warm handover. While other times they encouraged them to ask further questions.

What were some of the care needs that led the transition of COVID-19 vaccine clinic into an enhanced primary care clinic?

Monika Dalmacio: Throughout the COVID-19 pandemic, many clinics had to redirect their resources toward vaccination and testing. This led to a reduction in preventive screening and disease management. Consequently, individuals postponed screening or regular check-ups for chronic illnesses like diabetes and hypertension. Some likely went undiagnosed during this period, facing challenges due to the lack of in-person support. As things began to reopen, catching up became a daunting task for primary care providers. However, the Wellness Hub provided crucial support across the system, with a specific focus on unattached individuals, racialized communities, and those living in poverty. Unlike a walk-in clinic, the Wellness Hub offered comprehensive care services. This included preventive screening, chronic disease management, access to a system navigator, and health education from a registered nurse.

Maryam Ebrahimpour: Many people had additional needs beyond COVID-19 vaccination. This was particularly true for those who could not return to their home countries due to closed borders or faced uncertainty regarding their immigration status. So, when they required care beyond vaccination, they turned to the vaccine clinic. We have anecdotal accounts of numerous newcomers, refugees, and non-status folks who were unattached or whose primary care providers were not available.

What challenges did the Wellness Hub face in providing services to the Downtown East Toronto population?

Maryam Ebrahimpour: One of our challenges was expanding our services into spaces that were not initially designed for clinical purposes. During the pandemic, it made sense to provide vaccines in the lobby. However, as our services transitioned to offering primary care, requiring private spaces for sensitive conversations, lobby spaces were no longer suitable. We had to balance staying in a location familiar and well known to our clients while ensuring there were spaces that allowed for private conversations.

Monika Dalmacio: Ensuring ongoing care for those in need became challenging due to the time limitations imposed by the funding, as it risked leaving them without a primary care provider once the funding ceased. The primary care system is at capacity. That makes it difficult to find a permanent primary care home for the Wellness Hub clients. Our team has been determined and persistent in building connections with physicians in our community to facilitate the transition for individuals from the Wellness Hub. At Regent Park and Sherbourne Health, we have endeavoured to keep our doors open for primary care. However, our primary care providers also have their limitations in terms of capacity. Even across the system, we recognize the difficulty people face in finding family doctors or nurse practitioners, as highlighted in the news.

******************************** To be continued *********************************

Downtown East Toronto family doctors find this new mental health care model helpful during lengthy wait times

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This news story concludes a two-part series on the Stepped Care Pilot (read part one). We had a conversation with two family physicians, Dr. John Goodhew and Dr. Curtis Handford. We wanted to learn about their perspectives on how the Stepped Care model makes it easier for patients to access mental health support and services. Handford is the Medical Director of the Primary and Community Care Program at Unity Health’s St. Michael’s Hospital site. He also leads the Downtown East Toronto Family Physician Network. Goodhew is a primary care physician specializing in care and treatment of people living with and at risk of HIV and the larger LGBTQ+ community. Both Handford and Goodhew were involved in the design and implementation of the Stepped Care Program.

Dr. John Goodhew can now spend more time assessing his clients seeking mental health support. Instead of grappling with the administrative hurdles of finding the right service, he now contacts a mental health navigator. This navigator, part of both the Stepped Care Program and St. Michael’s Hospital Seamless Care Optimizing the Patient Experience (SCOPE) Program, assists in guiding his clients to the appropriate support they need.

Goodhew’s clients have also found it helpful to have a navigator manage their case while waiting for formal counselling. Wait times are unavoidable. However, when a mental health professional reaches out to support clients and reassure them that things are moving forward, it makes waiting easier.

“It’s like waiting for an MRI or anything else. You know it’s going to be a long wait,” says Goodhew. “The mental health navigator checks in with people and lets them know they haven’t been forgotten, and that it is going to happen.”

With a trained navigator providing brief therapy during the waiting period, Goodhew notes his clients are more confident. They believe the service they receive eventually will be the best match for their condition.

After years of practice, he recognizes that no single physician can be familiar with all available services. In a system functioning in silos, accessing services becomes increasingly difficult. Each organization often has its own specific eligibility criteria.

“When you have a patient sitting next to you and they are looking for counselling services, you have a couple of programs that you would frequently refer,” he says. “But you are not always confident it is a good fit.”

Dr. Curtis Handford echoes this sentiment when discussing the available support and services.

“There is a shortage of mental health resources that are publicly available or at least of reasonable cost. In addition, there is a very difficult course to navigate in order to access what is available,” says Handford.

There are even greater struggles in matching tailored mental health supports for equity-deserving clients. When physicians have to juggle clients, paperwork, and specialist referrals, they often have little time left. This leaves them unable to adequately address the unique needs of Black, Indigenous and racialized people, those with disabilities, and LGBTQ+ communities.

Unlike other care models, Handford says the Stepped Care Model offers personalized navigation to each client. He points out that while some clients are adept at self-advocacy and navigating, many others face challenges and fall through the cracks. Therefore, in managing the details of each case, the navigator invests time in understanding the care goals of every client.

Given the long wait times and increasing shortage of health human resources, it has become crucial to use the existing resources effectively and triage clients based on the level of urgency. Waiting without any kind of intervention makes urgent clients even more vulnerable.

In Goodhew’s experience with the program, one of his highly urgent clients was able to receive brief intervention during the waiting period. He says the results were tremendous. Only six counselling sessions made a significant difference to his client’s mental health. Although the client still awaits a longer set of therapy, he has now found himself in a better place.

Goodhew believes this could not have been possible without navigation accuracy, and it goes both ways. Clients should be going to an organization that can meet their needs and organizations should be receiving clients that are appropriate to them.

“When you have that accuracy and connection between the right patient – who is triaged – and the right organization, it is a win all around the table.”

Efficient capacity utilization can make such triage possible, especially for the most vulnerable individuals.

When the navigator undertakes the task of determining urgency levels and finding referrals, it encourages more providers to collaborate, thereby making room for new clients. Given the limited new resources and capacity in the healthcare system, the navigator is a catalyst in strengthening existing working relationships and system connections within the DET OHT.

Handford and Goodhew say the value of the Stepped Care Model is to bring clients to the right place at the right time ‘the first time’. Although breaking down silos and building effective care pathways remain a long journey, more family physicians and mental health organizations can make lasting progress by actively participating in the program.

If you would like to learn more about how your organization can participate in the SCOPE and DET OHT Stepped Care program, please contact [email protected].