2025 - NYTHP Year in Review

This was another significant year for North York Toronto Health Partners Ontario Health Team (NYTHP OHT) and the past 12 months proved how our Collective Impact can drive purposeful collaboration to improve health care access for our communities.

Thank you to all our OHT Core and Alliance partners, Primary Care Network, Primary Care Advisory Council, Patient and Caregiver Health Council, Community Health Ambassadors, peers and colleagues we have collaborated with in 2025.

We are grateful to our OHT partners, the NYGH Foundation, and Scotiabank for their generous support of our work, and to the Ontario Ministry of Health and Ontario Health for their leadership and ongoing commitment to OHTs.

Key highlights from 2025

How NYTHP OHT is supporting primary care access and attachment

The Ministry of Health announced earlier this year that the province would be making a historic investment of $1.8 billion and developing an action plan to connect every person in Ontario to primary care by 2029.

This ambitious plan includes a broad series of initiatives involving primary care leaders and health system partners through Ontario Health Teams and will include connecting people to a primary care team, making primary care more connected and convenient and supporting primary care providers.

OHTs were invited in the spring to submit proposals to expand primary care capacity on a local level. We are proud that two of our OHT’s proposals, led by Flemingdon Health Centre and Get Well Clinic/Get Well Health Team, were approved for funding. Together with their primary and community care partners, these lead organizations will increase attachment to primary care for people in North York, with an initial focus in the M2J, M2N and M3H postal code areas. These areas were identified as having the highest number of people who do not have a primary care provider.

In November, our OHT submitted two more proposals in response to the second call for primary care expansion funding.

Our teams have also been working closely with Health Care Connect and our OHT partner, Better Living Health and Community Services, to help connect those in our catchment on the Health Care Connect waitlist to a primary care provider or primary care team. To date, our OHT, along with our partners, has helped Health Care Connect clear 88% of the people who have been on the waitlist in our area since January 1, 2025.

In May, we launched our nurse practitioner-led North York Community Care Clinic (NYCCC) which provides ongoing health care for community members who do not have access to a family doctor or nurse practitioner on a regular basis.

NYCCC provides primary care on a temporary basis while people are waiting to be connected to a permanent primary care provider. This ensures that people receive the care they need and includes health checks, management of conditions such as diabetes or heart disease, cancer screenings and, prescriptions and vaccinations. In the first five months of NYCCC, 271 people have been connected to primary care.

To date, NYCCC has seen 500+ patients through our partners, Baycrest Hospital and Get Well Clinic.

Building a stronger Primary Care Network

We are proud to share that thanks to the leadership of our Primary Care Advisory Council and its Co-Chairs, Drs. Maria Muraca and Rebecca Stoller, our OHT’s Primary Care Network ‘s membership has increased by 13% to 369+ North York primary care providers.

The Network expanded its membership earlier this year to include allied health professionals, nurse practitioners and medical administrators to ensure the voices of those who play an essential role in primary care provision are included in the work of our OHT.

We hosted more than 130 primary care, specialist and community providers in October for our annual Primary Care Network Connecting Care Evening. We had a record number of 17 exhibitors this year and attendees had the chance to share their insights and feedback on topics such as primary care access and attachment, chronic disease management, improving access to mental health and addiction services and how digital tools can improve primary care practice. We are grateful to North York General Foundation, the Ontario Medical Association and Layla Care for their generous support and thanks to our attendees for helping us collect nearly 100lbs of food donations for North York Harvest Food Bank.

The PCN continues to support primary care providers in delivering care within their practices and reducing administrative burden. Through the Health Care Unburdened Grant (HCUG), the PCN has sustained a funded AI scribe program in partnership with the Department of Family and Community Medicine, the University of Toronto, and several OHTs. Funding for this initiative was made possible by the Canadian Medical Association, MD Financial Management Inc. and Scotiabank. In addition, 146 primary care providers are now participating in online appointment booking—both initiatives designed to ease administrative workload and enhance practice efficiency.

Showcasing our positive community impact

2025 was a year of exciting new partnerships and opportunities to bring health care services to the people in our community that need them the most.

In March, we celebrated the generous grant of $500,000 over a three-year period from Scotiabank with a Community Health & Information Fair (CHIF) at Better Living Health and Community Services. The grant will help our OHT maintain low-barrier access to preventive care and better connect community members with the care they need, when and where they need it. Click here to read about this CHIF.

Through the North York General Foundation, we partnered with RioCan REIT to offer CHIFs at Yonge Sheppard Centre and RioCan Empress. RioCan REIT provided our Community Health Ambassadors the opportunity to conduct regular outreach at these locations during the summer months to identify what health services would be of most interest to the local community. Through this outreach opportunity, we heard from the community that hearing tests and blood pressure/blood glucose checks are most needed.

Thanks to our partnership with the Canadian Hearing Services, we were able to offer free hearing tests to 20 people onsite at Yonge Sheppard Centre on October 23 and book many more for at-home visits with their team. In November, we offered community members the chance to have blood pressure/blood glucose checks, flu vaccines and the opportunity to be connected to a primary care provider through a CHIF at RioCan Empress.

Our CHIFs and our team of 12 Community Health Ambassadors have helped nearly 600 people across 15 events to date, provided 98 cancer screening appointments and completed 184 blood pressure/blood glucose tests.

Our CHIFs and other innovative ways we are driving a more integrated care system and supporting our primary care providers were recognized at several conferences this year, including the International Conference on Integrated Care. Click here to learn more.

A person-centered approach to chronic disease prevention and management

What started off as a pilot program of pop-up chronic disease management clinics, the Chronic Disease Management (CDM) Community Hub is now a regular clinic running two days a week at Flemingdon Health Centre’s Fairview site. The Hub focuses on people living with, or at higher risk of, congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD) in North York.

In 2025, the CDM Hub team recorded more than 130 patient encounters, while working with partners to align referral pathways across the local health system. Today, people can be referred through a primary care eReferral, as well as through direct links with cardiology and respiratory teams and other community partners.

Providers who are looking for more information about the Hub can click here and community members who would like to learn more can visit our website.

At the Hub, patients and families meet with a multidisciplinary team that includes a nurse practitioner, registered nurse and care navigator. Together, they provide:

• coaching on medications, diet, activity and breathing techniques

• support to recognize early warning signs and prevent exacerbations

• help navigating community programs, home and community care, and social supports.

  
  

As we move into next year, the CDM Hub offers a simple way to add extra support for patients with CHF and COPD, without adding extra steps for clinics and providers.

Integrating care and support for newcomers

The North York General and North York Community House (NYCH) settlement worker program started as a pilot and is now a permanent offering. North York General teams across all sites can now refer directly to the NYCH settlement worker. The NYCH settlement worker can connect clients with services including citizenship classes, school registrations, legal and immigration aid, language classes, and government benefit applications. They can also connect clients with healthcare resources, such as primary care providers and healthcare insurance. These services are available to all NYG sites from Monday to Friday from 9 a.m. to 5 p.m. by phone, email, or in-person. 499 clients have been served to date, with 1,135 interactions (including repeat interactions). 

Ontario Health Teams at Toronto Pride

This year at Toronto Pride, we were honoured to march again alongside our fellow Toronto Ontario Health Teams (OHTs). Our North York neighbourhood pride signs were a great addition and shared a message close to our hearts: creating a safe, welcoming Toronto for everyone and supporting access to gender-affirming care.

OHT updates

This summer, we welcomed Jane Colonna as the new Director of NYTHP OHT. Jane brings a wealth of experience in providing strategic and operational leadership in the health and public sectors. She is dedicated to improving access to coordinated and more integrated care across the health care continuum. Her leadership and expertise is welcome as we move the important work of primary care access and attachment and our other OHT priorities forward. In December, Kamini Harrypersad joined our OHT and will be providing administrative support to Jane and Backbone.