2024 marked our first year as one of 12 Ontario Health Teams (OHTs) that were selected to accelerate our development and work towards a more integrated health and social care system.
Over the past 12 months, we have been able to advance our Collective Impact and make progress towards a more integrated health care system for all, thanks to the collaborative efforts of our Core and Alliance Members, Patient and Caregiver Health Council, Community Health Ambassadors and Primary Care Advisory Council.
We are grateful to all our OHT partners, the NYGH Foundation and Scotiabank for their generous contributions to our work, as well as the Ontario Ministry of Health and Ontario Health for their leadership and support for OHTs.
Many thanks to our peers, colleagues and everyone that we have worked with this year.
Key highlights from 2024
NYTHP and The Path Forward
Our OHT Acceleration work identified several key priority areas which include:
Improving chronic disease prevention and management (focusing on congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD) and diabetes)
Supporting homecare modernization and enhanced integration of local services
Connecting, integrating and supporting primary care providers within our OHT to improve the delivery and coordination of patient care, especially for patients who do not have a primary care provider
Advancing our OHT’s governance to enable our teams to deliver the Acceleration work.
Through several retreats over the past 12 months, including our Primary Care Advisory Council (PCAC) Retreat in January, our Chronic Disease Prevention and Management Primary and Specialist Care Retreat in April and our Stewardship Council Governance Retreat in July, our OHT partners had the opportunity to come together and plan how we will deliver on the priority areas over the next few years.
To help move the chronic disease work forward, a Chronic Disease Management (CDM) Steering Committee and an Implementation Group were established, and plans are underway to pilot CDM Hubs across North York to allow low-barrier access to an integrated care model that will support those at risk of or who have chronic disease.
We will continue to share updates on these areas of work when available.
Recognizing our community impact
We continue to evolve our Community Health & Information Fairs (CHIFs) and have been offering them at least twice a month, one CHIF in the East (through the North York Family Health Team and Flemingdon Health Centre) and one in the West (through Unison Health & Community Services).
In February, our CHIF planning team, including members from the North York Family Health Team and VHA Home HealthCare, expanded our clinical offerings to include blood pressure and blood glucose checks for community members. The checks are free and available to anyone, regardless of whether they have OHIP or have a primary care provider. Through the North York Family Health Team, we have been able to support anyone who has an abnormal result and is not currently connected to a primary care provider of their own. There has been great interest from the community in our blood pressure and blood glucose checks. Through VHA Home HealthCare, we have been able to bring these checks to other community events organized by local elected officials like Councillor Shelley Carroll and MP Han Dong, and to our OHT partners’ events (Bernard Betel Centre and Better Living Health and Community Services). We even brought the service to a Chinese seniors’ settlement group through Working Women Community Centre at their usual gathering time at Oriole Community Centre and provided 50+ checks.
For the year to date, we have provided through our CHIFs:
423 blood pressure/glucose checks
175 completed cancer screenings
And booked 333 cancer screening appointments
We also had the opportunity to work with IWHC Toronto (formerly known as the Immigration Women’s Health Centre) in April to offer a sexual health clinic for uninsured community members, which included low-barrier cervical cancer screening, birth control counselling and prescriptions and sexually transmitted infections (STI) counselling, testing and treatment.
“It was a light in my heart to have this appointment,” said Mastaneh, a CHIF clinic attendee. “My husband and I have been in Canada for one year, waiting for our work permits and we still do not have access to regular care. We are both over 50 and have been told that we need to have blood pressure checks and cancer screenings on a regular basis. I’m really happy that this service exists, and it gives me confidence for the future.”
This year, our CHIFs and team were officially recognized at various conferences and awards. We presented at the 2024 North American Conference on Integrated Care in Calgary and our CHIFs won this year’s Flemingdon Health Centre Annual Health System Champion Award. We were also one of three finalists for the inaugural Ontario Hospital System Quality and Innovation Award for Improved Population Health. Our Primary Care Advisory Council Co-Chairs, Drs. Maria Muraca and Rebecca Stoller, were recognized with the 2024 Award of Excellence from the Ontario College of Family Physicians for their dedication to developing our CHIFs and community programs to improve primary care access, quality and patient outcomes.
We also want to share that our Community Health & Information Fairs (CHIFs) received a generous grant of $500,000 over a three-year period from Scotiabank. The grant will help our OHT to continue providing low-barrier access to preventative care and connect community members to the care they need at the right place and the right time. We would also like to thank the North York General Foundation team for their support with the grant application and continued partnership.
The fall and winter illness season is a challenging time of year for all of us and for the second year in a row, NYTHP has coordinated fall and winter preparedness across our OHT partners. We brought together over 50 representatives from across primary care, the hospital, community support providers, mental health and addiction services, community health centres, community members, Toronto Public Health and Ontario Health Toronto to share plans and discuss opportunities where we can collaborate.
With the help of our partners, NYTHP created joint communications materials and resources for the community on how to access COVID-19 and flu vaccines, information about the respiratory syncytial virus (RSV) prevention program, vaccine fact sheet and how to manage symptoms safely at home.
Community materials can be found here and are available in Arabic, English, Farsi, Pashto, Russian, Simplified Chinese, Spanish, Tigrinya and Ukrainian.
In partnership with the North York Family Health Team, we also created a suite of resources and materials to support our health care providers during this season and those can be found on our Primary Care Network website.
Recognizing that there are community members who have challenges in accessing COVID-19 and flu vaccines, VHA Home HealthCare and North York General Hospital Outpatient Pharmacy are helping bring vaccines to where people are. We have provided vaccines to the community via Flemingdon Health Centre, Working Women Community Centre and Unison Health & Community Services. To date, we have provided 84 vaccines to equity-deserving members of our North York community.
Integrated care and support
To better support newcomer patients and their families who come to North York General (NYGH) for care, a settlement worker program was launched in partnership with North York Community House (NYCH). As part of this pilot program, a NYCH settlement worker has been available on-site at NYGH’s General site one day a week and helped newcomer patients and families connect with housing support, completing government applications, refugee/asylum and immigration support, and recreation programs for children and food security concerns. The pilot has been a great success, with 51 clients served and over 100 interactions (including repeat interactions), and plans are underway to make this program permanent at the NYGH General site and expand to the NYGH Reactivation Care Centre in the new year.
October marked the one-year milestone of the North York Congregate Access and Support Team (NYCAST). This innovative program supports eight long-term care (LTC) homes in North York by providing streamlined access to specialist physician teams, including palliative care and internal medicine, as well as a nurse-led outreach team (NLOT). Together, these teams deliver clinical expertise to improve health outcomes for LTC residents, offer additional support for caregivers, and build capacity among staff. This year, NYCAST proudly welcomed Dr. Amit Arya as its Medical Lead.
North York Community Access to Resources Enabling Support (CARES) is a program that helps people with complex needs safely return home instead of staying in hospital for a prolonged amount of time. Through NYTHP, North York CARES began as a pilot program, and it is led by North York General and delivered in partnership with Bayshore Healthcare and VHA Home HealthCare. In 2024, 86 patients were enrolled and cared for by an integrated team.
Advancing primary care in North York
In October, we brought together over 170 primary, specialist and community care colleagues and local elected officials, MP Han Dong and Councillor Lily Cheng, for our third Connecting Care Evening. With the additional generous support of the North York General Foundation and the Ontario Medical Association, this annual event provided the opportunity for us to network, share ideas and learn more about how we can collaborate towards a more integrated health and social care system.
As part of increasing access to digital tools that can help primary care providers in their practice, our OHT ran a successful AI Scribe pilot with 57 North York primary care physicians. The pilot gave physicians the chance to use an AI scribe to help reduce administrative burden and improve the patient care experience. The collaboration between our Primary Care Network, North York General’s Department of Family and Community Medicine, and our OHT staff was crucial in successfully implementing and facilitating this project.
North York Toronto Health Partners, the Department of Family and Community Medicine at the University of Toronto and health system partners were awarded a $1 million Health Care Unburdened Grant to support AI scribe technology and reduce the administrative burden facing primary care clinicians. Funding for this multi-partner initiative to implement AI scribe technology was made possible by the Canadian Medical Association, MD Financial Management Inc. and Scotiabank as part of the Health Care Unburdened Grant.
We also welcomed Edwin Alvarado as our dedicated North York Primary Care Digital Support Consultant. We heard from our primary care physicians that they needed more support implementing digital tools. In this innovative new role, Edwin provides members of our PCN with in-person or remote support for primary care offices across North York, free of charge.
Collective of Toronto OHTs
We proudly marched alongside our fellow Toronto Ontario Health Teams (OHTs) to celebrate Toronto Pride this year. We introduced some local North York neighbourhood representation through our OHT’s marching signs this year, and carried an important message of making Toronto a safe space for all and making sure gender-affirming care is accessible.
Growing our OHT
2024 was a year that we expanded our Backbone team and welcomed new members to our Patient and Caregiver Health Council (PCHC). Our Backbone team provides support and coordination for a collaborative effort across our OHT, and our Patient and Caregiver Health Council provides the important voice of those with lived experience that help us develop our initiatives and programs.
Melissa Lai, Moon-Jan Park, Teresina Stanichevsky and Lisa Rogers joined our PCHC earlier this year and have been actively supporting many of our community-focused initiatives such as our CHIFs and Chronic Disease Prevention and Management work.
We welcomed new and returning members to our Backbone team: Edwin Alvarado, Amanda Cheung, Adora Chui, Janine Davis, Sierra McGee, Christina Gallucci, Sammy Gold, Ella Nugent, Mala Shastri, Neil Stephens and Wayne Yeung. They will be supporting our OHT work across various committees, Acceleration initiatives and primary care advancement.
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