Problem: Underserved, vulnerable population with complex health care needs and people unattached to primary care services; high impact of social determinants of health including health inequity; lack of access to services, insufficient coordination of care, and inadequate funding mechanisms for health and social care delivery.
Solution highlights: A very participatory evaluation process with broad involvement of all stakeholders, including patient and community members, led to consensus on priorities and gaps in services; prioritization of an innovative, patient-centred, model of health and social care led to development of an integrative Family Health team working from a social determinants of health lens; multiple partnerships support long-term sustainability and educational collaboration; supportive leadership and internal champions created momentum for change and mitigated internal and external barriers to change; active and ongoing engagement of patients, community and health team members in program design and implementation.
Description of practice
The population living in Toronto’s urban city core struggle with poverty, inadequate housing, low levels of education and literacy, social isolation, language barriers, limited access to health care services and unemployment. These social determinants of health negatively impact their quality of life and their health status. People in these neighbourhoods generally lack strong support systems and have difficulty navigating health and social care systems. Additionally, in our local community there was a high prevalence of people with very complex health care issues, unattached to primary care services and who had no opportunity to benefit from comprehensive and coordinated health and social care services. Accessing care was limited by economic barriers and in many cases, services that our patients needed and wanted were not available. Care services were not optimally coordinated and there was overwork and fatigue among our health care workers with less than optimal health workforce quality of life. Our department hosted numerous learners from different professions but their educational programs were not integrated to optimize interprofessional learning.
The St. Michael’s Hospital Academic Family Health Team (SMHAFHT), a large, primary care teaching clinic nestled within the downtown core of Toronto provides services to the inner-city community through 6 clinical sites located conveniently in these neighbourhoods. In identifying the significant impact that social determinants of health have on our community, and in consideration of the research which supports the importance of interprofessional (IP) care and education, our department undertook a visioning and planning process to evolve and ‘re-purpose’ the way we deliver care, how we interact with our patients/community and how we train our learners. Our approach was to first consider what we would want to see as optimal primary care in the future. With this in mind, our team consulted broadly with patients, local community agencies, our health providers and administrative staff as well as our academic partners and funders to identify gaps and top priority areas.
Unique partnerships with academic institutions, community organizations and health agencies not typically involved in funded family medicine models have facilitated this model. Innovative funding mechanisms have enabled provision of services without economic barriers, an expanded menu of services as well as long-term sustainability. Our model of care incorporates patient-, family-, and community-centered values; interprofessional collaboration and education; use of advanced communication technology; and accessible evidence-based coordinated care that is supported by ongoing evaluation and research. As a teaching clinic to approximately 300 learners per year from multiple academic programs, we have embraced interprofessional education to support the attainment of collaborative competency and knowledge about integrated care.
Implementation of practice
What stage is the practice currently in?
Fully implemented and scaled up
Who was/is responsible for the implementation of the practice?
The Community advisory panels that were in place pushed for the change of reforming the model of care to a team-based, comprehensive and people-centred health care model. Patients and local community agencies participating on the community advisory panels are important actors in the design, implementation and continuous improvement of the model of care.
The practice benefited from very highly motivated leadership at all levels that has been fully supportive of adopting comprehensive team-based care and also moving towards an integrative health care model. Facilitation of enhanced service provision and educational programs occurred through collaboration with several academic institutions and organizations.
Important factors in driving the process of change has been the identification of “champions” and institutional facilitators to conceive of, advocate for, and bring the programs to fruition. The credibility of these champions and facilitators was key to the acceptance and growth of the program in each setting.
The practice is well established, long-standing and has been recognized in Canada as a best practice model of primary care. In the past 6 years, the program added two clinical sites which have continued to build upon our integrative, patient-centred model of care. This model has been demonstrated to provide improved access to health and social care services and clinical outcomes for our patients.
The practice has been sustainable through consistent financial and political support, and through ongoing commitment by its academic collaborators, governmental agencies and community partners. It continues to evolve on an iterative basis, based on evaluation results, as well as input/feedback from patients, families and communities, staff, and community funders.
The program has been recognized for our work in designing and delivering innovative interprofessional education. We prioritize mentoring future health professionals in team-based care and model this behaviour in our educational programs and clinical services. Additionally, we undertake a thoughtful process for ongoing development of our teachers, our clinicians and other team members.
The program has achieved very high quality of health care delivery with a comprehensive menu of available services including complementary therapies provided with no economic barriers. We have experienced improved coordination of care, enhanced patient outcomes and satisfaction, improved quality of work life for our team, and patient, family and community empowerment in self-help strategies. Supported by a comprehensive quality improvement program we continue to focus on achieving the ‘quadruple aim’ (improving the patient experience; improving the health of populations; improving the per capita cost of health care; and improving health workforce satisfaction with the quality of their work life).
Please click on the link below for more information about this practice.
- Deborah Kopansky-Giles
- St. Michael’s Hospital, Department of Family Medicine – Academic Family Health Team