From evolving our COVID-19 response to finalizing our three-year strategic plan, it has been a momentous year of achievements, learnings and collaboration for our Ontario Health Team (OHT).
Thank you to all our partners, our Primary Care Association, our Primary Care Association Council, our Patient and Caregiver Health Council, peers, colleagues, volunteers and everyone we have worked with this past year.
Key highlights of 2022
NYTHP Strategic Plan 2022-2025 launch
We launched NYTHP’s first strategic plan in March 2022. Guided by our shared purpose, Compassionate North York, this three- year strategy will guide our collective efforts to advance an accessible, equitable and sustainable health system for all the people and communities we serve. Our plan was developed with healthcare providers, clinicians, and patient, caregiver and community partners. It has four focus areas:
Help the health system adapt and rebuild after the pandemic
Address urgent community needs and the impact of service disruptions over the past two years
Engage with communities in a meaningful way to ensure healthcare is designed according to people’s needs and priorities
Make healthcare more equitable and accessible
Learn more here.
Evolution of our COVID-19 Response and Recovery
In recognition of the evolving vaccination needs of the North York communities we serve, we tailored our community vaccine program in its second year to focus on high-risk homebound patients, seniors living in Toronto Community Housing and other congregate spaces, and a low-barrier family-friendly weekly vaccine clinic at the North York Toronto Health Team.
Our North York Vaccine Engagement Team (VET) Ambassadors were vital in reaching communities and providing feedback, and they worked closely with us at every stage of developing our programs.
We collaborated with the Baycrest Interprofessional Primary Care Team, North Toronto Ontario Health Team and VHA Home Healthcare to provide COVID and flu vaccinations in 22 Toronto Senior Housing buildings to a total of 2,067 seniors. During the clinics we identified emerging health issues, conducted health checks, collected demographic information, identified barriers and people who were not attached to primary care.
In May we introduced Community Health & Information Fairs (CHIFs) to provide locally tailored health services and information to support a wider range of health and social needs in the wake of the pandemic. CHIFS represent a true collaboration between our partners, bringing together over 21 agencies and organizations under one roof. We held our first CHIF at Flemingdon Health Centre (5 Fairview Mall Dr.) and have since held 10 fairs to date.
The Fairs offer vaccinations, preventative screening and referrals to more than 20 community services ranging from legal aid, family and senior-friendly programs and food security resources.
Digital optimization for patient care in North York
In its second year, the SCOPE (Seamless Care Optimizing the Patient Experience) programme continued to expand its offerings and register more primary care providers (PCPs). The SCOPE program offers a single point of access to a virtual interdisciplinary team for PCPs.
SCOPE PCPs have direct and centralized access to a range of services and providers through a dedicated phone line and can collaborate with the SCOPE interdisciplinary team to identify and improve gaps in patient care. The aim is to support PCPs in getting their patients the right care at the right time and place. They have access to internists, diagnostic imaging, North York General Hospital resources and community services. It is also a well-established program offered at hospitals across the Greater Toronto Area (GTA), including University Health Network (UHN), Women’s College, Unity Health and others.
To date, there are close to 200 PCPs registered to SCOPE and the program has received more than 780 calls since its launch. NYTHP has also continued to support PCP practices through a project to assist adoption of Online Appointment Booking (OAB), which has 52 providers from 12 practices signed up to date.
Learn more about SCOPE here.
North York CARES helped patients transition from hospital to home
North York Community Access to Resources Enabling Support (North York CARES), 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. It also helps improve access for those who need inpatient care by creating more available hospital beds for those who need them.
North York CARES was designed with 60 people across our network, including patient and caregiver representatives.
More than 70 clients have received services through North York CARES to date. Evaluation of the program confirms that providers felt that North York CARES fills a gap in the healthcare system. Caregivers and patients reported that the program was a lifeline for them during an overwhelming time. Learn more here.
Image: Yuli Kaufman with his mother, Debora, who received care at home for more than three months through North York CARES before moving into a long-term care home. She was provided with 24-hour personal support worker care and medical equipment for her home. (Image credit: North York Mirror)
Strategy for unattached patients presented to Ontario Health
Working with several of our partners, including North York Community House, North York General Hospital, Flemingdon Health Centre, Better Living Health and Community Services, Baycrest, North York Family Health Team and Unison Health & Community Support Services Central, we developed a strategy to reach and support unattached patients (those without a primary care provider).
Many Ontarians are not registered with a main primary care provider (PCP), leading to reduced access to preventative care and worse health outcomes over time. NYTHP is approaching this challenge in North York through multiple streams of activity, including by reconciling multiple wait lists, gaining access to team-based care for local PCPs and increasing awareness of care options for patients without a PCP.
The strategy was presented to Ontario Health in October 2022 and we have been acknowledged as an emerging leader in our approach in developing pathways for unattached patients.
Strengthened connection with Primary Care Providers
Our Primary Care Association hosted a primary care engagement event, Connecting Care, in October 2022 to bring together primary care and many of our NYTHP partners. It was an opportunity to connect, learn about the various services available to support providers in the community.
Over 100 family doctors, other clinicians and community partners joined to dialogue as an Ontario Health Team (OHT) about how we can continue to improve are for our community as providers.
An attendee said: “Although being a new graduate from residency is a daunting endeavor, the Connecting Care primary care event helped to inform me about a number of useful community resources, and identify ways to better optimize my practice. I left feeling more confident about my ability to provide my patients with the best possible care. It was also a wonderful opportunity to put faces to names and build meaningful personal and professional connections to colleagues across the health disciplines. I look forward to attending the next event!”.
Organizational strides
The NYTHP Core Group became the Stewardship Council as we continued to develop our decision making and governance processes.
We also welcomed new members to our Stewardship Council:
The University of Toronto Department of Family and Community Medicine
The Canadian Mental Health Association (CMHA) Toronto
North York Community House
Flemingdon Health Centre (FHC)
Our current NYTHP Stewardship Council members:
Penelope Marrett, Addiction Services Central Ontario
Todd Bruce, Advent Health Care
Kari Quinn-Humphrey, Alzheimer Society of Toronto
Scott Ovenden, Baycrest Centre
Deb Galet, Baycrest Centre
Karen Fisher, Bayshore Healthcare
Sonya Murray, Better Living Health and Community Services
Michael Anhorn, Canadian Mental Health Association, CMHA, Toronto
Helen Leung, Carefirst Seniors and Community Services Association
Dara Zarnett, Circle of Care
Paul Bruce, Cota
Jen Quinlan, Flemingdon Health Centre
Tini Le, Home and Community Support Services Central
Bonnie Hunter, North York Community House
Neil Shah, North York Family Health Team
David Eisen, North York General Hospital and University of Toronto Department of Family and Community Medicine
Janine Hopkins, North York General Hospital
Maria Muraca, NYTHP Primary Care Advisory Council
Rebecca Stoller, NYTHP Primary Care Advisory Council
Kim Utley, Saint Elizabeth Health
Courtney Bean, VHA Home Healthcare
Ivan Ip, Yee Hong Centre for Geriatric Care
With the help of our partners, we completed our Collective Impact Agreement (CIA). The CIA is an updated governance structure which sets out how the NYTHP makes decisions, operates, and advances our mandate, shared purpose and strategic priorities.
We also launched our Operations Committee to facilitate nimble operational decisions.
Our Backbone support – the team who together facilitate coordination across all our active areas – expanded to 17 members from seven organizations. The cross-functional team now includes NYTHP coordinators, managers, leads, and students. Backbone supported the development and implementation of the NYTHP annual operating plan which includes all NYTHP work streams, projects, reports and community engagement. (Image above: Members of NYTHP Backbone)
NYTHP 2022 Annual Retreat focused on embracing complexity and catalyzing change
Our Annual Retreat in December 2022 gave us the opportunity to celebrate our Ontario Health Team (OHT) achievements with partners, peers, colleagues and volunteers and look ahead to 2023.
Our keynote speaker, Mark Cabaj, an expert in social innovation and collective impact, encouraged us to think about how our OHT fits in the phases of community change eco-cycle. We were prompted to think about how we can continue to drive change in unprecedented and challenging times.
We also welcomed two panels to foster discussions around population health and embedding equity in healthcare design and improvement.
Our population health panel was facilitated by Drs. Adora Chui and Katie Dainty from NYTHP and included:
The embedding equity panel was facilitated by Liz Weaver from The Tamarack Institute and included:
The experiences of Teresina and Sonia, our community ambassadors with established connections to many people across North York, set the scene for discussions around how we can bring about meaningful change and co-create solutions that can make a difference.
Teresina pointed out the need for cultural sensitivity and “even with new technology, there still needs to be real people that are accessible and there for the community”.
Prof. Dougall highlighted the importance of “connecting on a shared population health purpose and finding out who is doing what to come together and develop a partnership”.
Nation emphasized that it is critical to “invest in people and environments to encourage people to have a say and play a role in designing services which means time needs to be spent addressing gaps in understanding how decision making and systems actually work.”
Sonia provided an excellent example of how to bring about change by asking questions and empowering people. She shared her experience of convincing fathers to join her child’s school council when she noticed that it was only mothers that joined. By encouraging fathers at the school to “just try”, the council went from having zero fathers to 8 fathers involved.
Amy said that it is imperative that we look at everything with an equity lens and that it is not just one department responsible for driving it. Ryan added that we are not lacking in good intent but we need to make sure we are taking discussions and turning them into tangible actions.
Yolande focused on the need to have a sense of ownership from the people involved in order to be successful and the importance of being transparent about what we can do together before moving to the engagement phase.
Our Retreat concluded with breakout sessions for attendees to come up with one purposeful action for NYTHP to take forward.
Mikaela Taylor, a University of Toronto student who is project support at NYTHP, said: “The Retreat had the perfect mix of data and theory-based information and first-hand insights. It was so valuable to hear from people who were doing the work in the community. The contributions of the community ambassadors solidified the importance of centering the voices of the population that we hope to serve, rather than having others speak for them. I left the Retreat feeling re-energized and eager to contribute to new initiatives.”.
“This year’s NYTHP Retreat was an opportunity for us to reflect on all the incredible achievements of our Ontario Health Team from over the past year. It was also a chance for us to build on these successes and continue our work in improving the health of our North York communities during unprecedented times.
“I was inspired, amazed and humbled by the experiences that our speakers, panelists and attendees shared with us. We look forward to taking what we have learned and embedding it into our work ,” said Ivy Wong, Director of North York Toronto Health Partners.
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