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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

Masooma Raza · December 2, 2024 · Leave a Comment

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

Masooma Raza · September 9, 2024 · Leave a Comment

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.

“The real secret sauce – the magic ingredient – was the structure underneath the pathway”: design thinking expert reflects on the lower limb care strategy

Masooma Raza · February 27, 2024 · Leave a Comment

We engaged in a dialogue with Julian Goss, a design strategy consultant with the Downtown East Toronto Ontario Health Team (DET OHT) Lower-Limb Preservation (LLP) project. Goss specializes in incorporating design thinking, process, and practice into healthcare strategies. He played an instrumental role in defining key elements of lower limb care, and helped integrate these elements to develop a client-focused design for the LLP pathway. During this discussion, Goss shared his thoughts on the model’s strengths, feasibility, and scalability.


Looking back, what were some of the initial thoughts and considerations when you and the LLP team were in the process of developing the clinical pathway for lower limb care?

Julian Goss: They were not so much as thoughts, but rather concerns. One of my concerns was, does this pathway reflect feasibility, and what assumptions are we making? After developing a pathway, key stakeholders such as primary care providers, solo providers, chiropodists, or vascular surgeons have a role to play. Once we include them as either means or ends, how do we ensure what we are asking or hoping that they will do is within their capacity – that it is not impossible to do? The other concern was, are we clear on the value of user journey? The values are in a form of five W’s: who is here? What are they doing? Why are they doing it? When in the patient journey or condition is it happening? What level of care needs to happen?

From a design perspective, what insights and outcomes have emerged from the pilot demonstrating the pathway’s scalability?

Julian Goss: The pilot demonstrates the feasibility and scalability of the pathway, which has become an integrative pathway, leading to a big AHA! moment. We realized that ‘screening and prevention’ and ‘escalation of care’ is a continuum. Although they could exist in parallel for different circumstances, they are essentially a continuum. So I have been working under the assumption that once we can tell Ontario Health what we did, how we did it, and the results we have accomplished, we can say that this is now scalable and this is what we need. There is always some kind of resource, like time or money. Hopefully, we have got a very strong value proposition and its impact is cost effective. Preventing someone from losing a lower limb is a lot cheaper than dealing with someone with an ongoing condition of having an amputation.

As a process design expert, could you share your insights on what typically occurs in a complex system like health care that takes away from the clients’ pathway?

Julian Goss: I can give you a couple of design-situated perspectives. First, the solution that we came up with is not just a pathway. The differentiator in this pathway is what we built underneath – the communications structures, connectivity, and conceptual clarity. When you come across a beautiful, simple design, it is tip of the iceberg. The undergirding of a structure that enables it to function is systemic thinking. One of the many problems that healthcare shares with other sectors and organizations is having a complex adaptive system – meaning, it constantly changes and shifts. However, like most organizations, healthcare is working on a good, static organizational framework, which will always lag behind what is really going on.

Secondly, design has a lot to do with subjectivity, particularly product design where you have to work in the head of a consumer – know what they think about, what they need, and how they react. However, in healthcare, there is no guarantee that the nurses and physicians will see the problem on the same scale as we are seeing it. They will look at it with the lens of their capacities and training. A design expert tries to acknowledge that and create a shared mental model of the larger perspectives.

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

Julian Goss: It is really important to share with everyone involved in the project and tell them, we did good work here – thank you! The other thing I am curious about is when we present our story to Ontario Health, I would be really interested in knowing whether they can look at something like this and resonate with this approach; when we tell them we pulled in a design capacity and it helped us arrive at an apparently simple solution. But the real secret sauce – the magic ingredient – was the structure underneath the pathway.

Bridging Gaps in Accessing Mental Health Care: A Conversation

Masooma Raza · October 30, 2023 · Leave a Comment

We invited Dr. Linda Jackson, Senior Clinical Program Director for Community and Primary Care* at Unity Health Toronto, to share her thoughts on some of the work underway in the DET OHT focused on mental health. Dr. Jackson is currently co-chairing the Stepped Care Pilot‘s Oversight Committee. In this discussion, which is a second installment in a two-part series on the Stepped Care Pilot (read part one here), she shares the significance of the stepped care model and how it can support both family physicians and their patients in accessing mental health services.


As a senior leader for Community and Primary Care at Unity Health, what can you tell us about the challenges that the DET OHT’s priority populations (people experiencing homelessness, mental health illnesses, and addictions) have to face to access mental health care?

There is widespread recognition of challenges among the general population in accessing mental health services, specifically counselling and psychotherapy. These challenges include difficulty in navigating organizations offering these services, long wait times, and a lack of funded or affordable services. Our priority populations experience even greater challenges, often not having the resources and supports to navigate a complex mental health system. This issue of navigating to mental health service has been identified by family physicians and nurse practitioners in the Downtown East area who frequently encounter patients presenting with mild to moderate mental health issues, including anxiety and depression, who require and would greatly benefit from accessing counselling and psychotherapy services.

In your opinion, what distinguishes the Stepped Care Pilot from other delivery models?

The stepped care model has leveraged an existing program called SCOPE to support family doctors and nurse practitioners to refer patients with mental health issues to a trained mental health navigator, who works with these patients to better understand the issues affecting their mental health and their readiness and interest for counselling and psychotherapy. Together, the mental health navigator and patient develop an understanding of the most pressing issues and the options available in the community. The navigator then ensures a warm handover by connecting to appropriate resources and staying engaged with the patient until they are linked to the resource or decide that they are not ready to pursue counselling at this time. For some patients, the opportunity to meet with the mental health navigator for initial exploratory sessions has been the intervention that was needed and they did not wish to link for further counselling.

What do you hope the stepped care model can accomplish for the mental health and addictions community of the downtown core?

The model has assisted primary care providers to link their patients to community based mental health services. It has likely prevented some patients from presenting to emergency departments for this type of navigation. The model has identified where gaps exist in accessing mental health services, which can be a focus for further planning within the DET OHT. Assisting the primary care providers in navigating resources allows greater access to other patients at a time when there are many pressures on primary care. This is particularly important for providers who do not have access to mental health services in their clinics.

Given the rise in mental health crisis, particularly after the COVID-19 pandemic, how can we support the long-term growth and sustainability of programs like Stepped Care Pilot?

The evaluation of this program confirms that patients and providers have benefitted from being connected to the stepped care model as well as the importance of collaborating across organizations to integrate care delivery. Addressing the gaps in the availability of affordable and fully funded mental health services, particularly with a trauma informed approach, should be a focus of the DET OHT to support the sustainability of this program.

*Update – Oct 22, 2024: Dr. Linda Jackson retired from her role as Senior Clinical Program Director for Community and Primary Care at Unity Health Toronto in June 2024.

New Stepped Care Pilot Aims to Bridge Gaps in Mental Health Services – Part One

Masooma Raza · October 30, 2023 · 1 Comment

The Barriers to Mental Health Care

This is the first of a two-part series (read part two here) on the DET OHT Stepped Care Pilot and focuses on the challenges in doctors’ referrals and accessing individualized counselling and psychotherapy support.

Amid workforce shortage, accessing mental health support and services come with multiple challenges, including lack of one-on-one counselling and psychotherapy services tailored to individual needs, lengthy wait times, and timely referrals. According to the 2023 Ontario Association of Social Workers Survey of 1,265 adults, 10 per cent said that they tried but were unable to access mental health support. Their reasons for inaccessibility included long wait lists (60 per cent), high costs (38 per cent) and not having a referral from a family doctor (33 per cent).

Sara Al-Qasir, a mental health navigator with the Stepped Care Pilot and St. Michael’s Hospital Seamless Care Optimizing the Patient Experience (SCOPE) program, sheds light on the challenges.

Some local organizations are currently holding group counselling sessions. While that is a good option, many clients are looking for timely individualized counselling for their recovery.”

In her interactions with clients/patients, Sara has noticed that patients were not only managing challenges with depression and anxiety, they experienced additional stressors from financial barriers, transportation needs, cultural and language differences, and mental health stigmatization.

Clients/patients is not the only group facing accessibility challenges. Initial interviews conducted by the stepped care project team to understand family physicians’ needs revealed family doctors also face accessibility challenges when seeking counselling or psychotherapy services for their patients with anxiety and depression.

The considerable administrative tasks associated with seeking appropriate referrals often cause family physicians to handle them themselves, diminishing the quality of interaction between a family doctor and a patient.

By introducing a mental health navigator in the referral pathway, the stepped care model relieves some of the commonly occurring and significant challenges for both patients and family doctors, while also making effective use of the health system’s resources.

Sara mentioned the mental health navigator’s role having a four-pronged approach;

  • Case management: Ensuring patients feel supported, developing care plans, following up every 2-3 weeks, and relaying information back to family doctors
  • Brief-talk therapy: Ensuring clients can cope with distressing situations and routine challenges by talking to a trained professional while they wait for specialized care
  • Customized care: Providing accessible list of resources tailored to the patient’s needs and circumstances
  • Warm transfer: Assisting with a three-way call to support patients with completing intakes over the phone, allowing them to build confidence and trust newly found resources

Each step focuses on improving the quality of patients’ lives and adding value to the patient-doctor relationship.

32 family physicians, all members of the DET Family Practice Network and registered with the St. Michael’s Hospital SCOPE program, have enrolled in the pilot.

Participating physicians have collectively referred 243 clients to the mental health navigator, allowing the navigator to provide over 544 counselling sessions between April 2022 and October 2023.

While the project team continues to evaluate the impact of the pilot on patient experiences and outcomes, it is clear in the initial phase of the implementation that the pilot has allowed synergies between family physicians and the mental health navigator.

The project team aims to use their findings to inform the long-term growth and sustainability of the Stepped Care Pilot and similar programs. This will ensure that the positive outcomes not only benefit the local community, but also contribute to the broader mental health landscape.

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