Primary Care Archives - Page 2 of 2 - Downtown East Toronto Ontario Health Team

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.

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 *********************************

From Crisis Response to Comprehensive Care – Final Part

From Crisis Response to Comprehensive Care – Part One