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2023 - NYTHP Year in Review

This past year has been a milestone of collaboration, learning and achievements for our Ontario Health Team. 

Thank you to all our partners, our Primary Care Network and Primary Care Advisory Council, our Patient and Caregiver Health Council, peers, colleagues, volunteers and all who collaborated with us this year.


Key highlights from 2023

Supporting accessible and equitable health care access

Our Community Health & Information Fairs (CHIFs) are events NYTHP has co-designed with community partners to improve health and wellness in high-needs neighbourhoods in North York. They were created to support a wide range of health and social needs and provide tailored offerings.

In January we introduced cancer screening as an offering at our CHIFs in the form of cervical cancer screening (Pap tests) on-site with a female primary care provider and the opportunity for people to be referred to breast cancer screening and colorectal cancer screening. We worked together with Flemingdon Health Centre to deliver CHIFs in the East end of North York and partnered with Unison Health and Community Services and North York Harvest Food Bank in the West. These partnerships meant we could offer these services to members of our community that need them the most. To date, we hosted nine CHIFs and provided over 50 Pap tests and made more than 40 referrals for breast and colorectal cancer screenings. Our Primary Care Leads, Drs. Maria Muraca and Rebecca Stoller, presented on our CHIF model at this year’s Association of Family Health Teams of Ontario (AFHTO) conference.

Under the leadership of our Health Equity Committee and Unison Health and Community Services, NYTHP secured funding to support our High Priority Communities strategy. We were able to expand accessible and equitable care programs through our many of our community-based partners, and support system navigation and community education through our team of Community Health Ambassadors.

To support fall and winter surge planning, NYTHP, along with the North York Family Health Team, created an awareness and communications campaign with cold, COVID and flu resources for health care providers and the community. Community Ambassadors have been busy distributing NYTHP information sheets on local pharmacies’ service offerings, in multiple languages, to community members across the geography.


NYTHP welcomed New Zealand delegation to share integrated care best practice

Collaborative Aotearoa, a national network of primary health care and community partners from New Zealand, visited NYTHP as part of an international study tour to learn more about integrated care models and experiences and share best practice.

The delegation and a group from NYTHP shared learnings and insights, as well as a “Taste of North York” lunch from local family-owned restaurants, and visited various NYTHP partner organizations, including the North York Family Health Team, Bernard Betel Centre and North York General Hospital’s Finch Site Reactivation Care Centre. Learn more here.


Working together as Ontario Health Teams

This summer saw the launch of the Toronto Health and Social Services Directory which includes more than 8,000 health, social and community service listings in Toronto.

This initiative is a partnership between NYTHP and seven Ontario Health Teams serving Toronto. The directory is part of all Ontario Health Teams’ mandate to improve local navigation to care services. It is supported by the City of Toronto and the Ontario Health Teams serving Toronto, which are funded by the Government of Ontario. Learn more here.

NYTHP celebrated and marched in Toronto Pride this year as part of Toronto’s group of Ontario Health Teams.


Advancing the modernization of home and long-term care

Launched in 2021, our successful North York Community Access to Resources Enabling Support (North York CARES) program provides care and support for patients who would otherwise be in hospital, so they can safely stay at home while waiting for a bed in a long-term care or another setting. More than 150 patients have received services through North York CARES to date.

This summer Bayshore Healthcare and VHA Home HealthCare were selected as the two home and community care providers to support North York CARES following a competitive procurement process. The innovative procurement process and program model was co-designed from start to finish with hospital and primary care clinicians, home and community care providers, patients and caregivers to ensure the continuity of care and comfort throughout the entire patient/client journey.

At a workshop co-hosted by North York General Hospital in July, we launched the North York Congregate Access and Support Team (NYCAST) to help improve health outcomes and quality of life for people living in congregate settings. As part of its first phase, NYCAST provides eight long-term care homes in North York with access to a group of on-site advance practice nurses, primary care, specialist services (both virtual and on site), and support for seniors and their caregivers where they live.


Strengthening primary care in North York

In response to Ontario Health’s Expression of Interest to expand and enhance interprofessional primary care teams, NYTHP submitted our vision for compassionate team-based primary care for all. Working with our primary care partners, North York Family Health Team, Flemingdon Health Centre, Unison Health and Community Services and Vibrant Healthcare Alliance, we outlined our strategy which includes:

  • enabling access to primary care for all

  • enhancing team-based care to include social determinants for those who need it most and

  • training the next generation to expand and scale innovative practices.

In November, we hosted our second annual primary care engagement event, Connecting Care Evening, with generous support from North York General Foundation and Ontario Medical Association. Turnout this year exceeded our previous event, bringing together over 100 primary, specialist and community care colleagues to learn more about the ways we can work together towards a more integrated health care system. This event helped us connect with new primary care providers in the community, strengthening our Primary Care Network to 258 members.

Our partner, the North York General’s Department of Family and Community Medicine’s (DFCM) leadership in medical education and primary care practice-based research and quality continued to be a great asset to NYTHP. This included teaching a large cohort of medical students from the University of Toronto in addition to over 30 Postgraduate Family Medicine Trainees and initiatives such as UPLEARN, the largest practice-based research network in Canada, led by Dr. Karen Tu, UPLEARN’s Associate Director and member of NYGH DFCM.


Optimizing digital tools for patient care


Since its launch in 2021, the SCOPE (Seamless Care Optimizing the Patient Experience) program continues to provide primary care providers (PCPs) with direct and centralized access to a virtual interdisciplinary team through a dedicated phone line. The aim is to support PCPs to provide patients with the right care at the right time and in the right place. They have access to internists, diagnostics, surgical consults, palliative care, pediatrics, support for seniors, mental health services, and systems navigation through nurse and mental health navigators.


NYTHP has also been making strides with encouraging more PCPs and specialists to use eReferral to increase efficiency and make it easier for patients to receive care.

Online Appointment Booking (OAB)

The Online Appointment Booking (OAB program) has continued to support patients and providers in the community to access care in a more efficient way. 


Expanding our team

2023 was a year of growth for our NYTHP team and partnerships.

We expanded our Patient and Caregiver Health Council and welcomed four new members: Trudie Mulalu, Cheryl Lipman, Shoshana Pellman and Rosemarie Owens-Tunney.

Learn more about them here.

We also welcomed Bernard Betel Centre as a new member to our Stewardship Council.

The end of the year also saw two new Project Managers and a Project Director join our Backbone team to support our High Priority Communities Strategy, primary care expansion and other key initiatives.

Welcoming our new Backbone team members with a festive gathering.


Accelerating the Path Forward

In September, the Ministry of Health announced that NYTHP was selected as one of 12 Ontario Health Teams to accelerate the work towards a more integrated health and social care system.

NYTHP’s selection reflects the successful collaboration we have demonstrated through programs such as NY CARES, our CHIFs, the North York Seniors Hotline, our Primary Care Network, and our dedication to culturally sensitive and safe care to individuals who need them the most.

At this year’s NYTHP Annual Retreat, we focused on planning for acceleration and how we will collectively strengthen the role of primary care through our Primary Care Network, build integrated care pathways to improve outcomes for chronic conditions and enhance system navigation.

We will continue to share updates on our OHT’s acceleration when available. 


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