North York Cares: Health team proving value of innovation

The “silos” in Canadian health systems are a significant barrier to coordinated health care. For instance, a family doctor, home care provider, and several specialists might see the same patient – but they often don’t have a secure and efficient way to talk to each other about the patient’s care.

Without a comprehensive and shared understanding of the problems, it’s hard to build a learning health system, says Michael Green, head of family medicine at Queen’s University and a scientist with the Institute for Clinical Evaluative Sciences.

“In many places that have very strong learning health systems, like the U.K., they have a more integrated organizational structure for health care than we do here,” explains Green. Learning health systems are designed to create partnerships between research, community and clinical operations.

“If people are in a whole bunch of different organizations, you need some way of bringing them together, convincing people of the shared objectives and that there’s value in participating in that kind of work,” he adds.

The hope is that the Ontario Health Team (OHT) model will do just that – bring various primary care, hospital and community providers to the same table. In OHTs, hospitals, family doctors, long-term care providers, home-care organizations and others join forces to apply for ministry funding, creating a financial incentive to coordinate and reallocate money across providers to meet patients’ needs in more efficient ways.

North York Toronto Health Partners was one of the first OHTs, involving North York General Hospital, long-term care, home care and primary health-care providers. After launching in December 2019, the team began implementing innovative ways to design care around the needs of patients. One of its new initiatives is called North York Cares, which aims to help older adults safely transition out of hospital or avoid hospital stays altogether, explains Alan Monavvari, co-chair of the OHT’s primary care working group.

The initiative aims to address a ubiquitous problem in Canadian health care – too often, elderly patients show up at the emergency department after they have missed medications, taken dangerous medication combinations, not eaten properly or spiralled into depression.

Monavvari and his colleagues knew that if patients had routine check-ins from providers, the right kind of caregiving supports at home, and access to community day programs that provide socialization and hot meals, they wouldn’t be showing up at the hospital in the first place. And when they did need to be hospitalized, staff would feel more comfortable discharging them earlier.

That could mean significant cost savings. “A hospital stay is much more expensive than a five-star hotel in Toronto or Shanghai. A hospital bed is about $1,000 a night,” he says. 

To start, the team asked caregivers of elderly and high-needs patients in the community what supports would help their loved one avoid hospital stays. Judy Katz, one of the caregiver advisors who navigated the health system on behalf of her late mother, says she and many other caregivers expressed the same frustration: “You go to a doctor and he asks you a bunch of questions and he sends you on to somebody else … they ask you the same questions again or run the same test again.”

Not only did it seem that no one was talking to each other, patients didn’t know who they should contact – who were they supposed to call with questions about a medication that had been prescribed in the hospital, for instance? 

To address this issue, North York Cares established a single point of a contact for every patient enrolled: a care navigator.

“We have one person who the family can go to,” says Nancy Lin, North York Cares manager. “If there is an issue with PSW care or somebody’s not showing up, if they need Meals on Wheels, if they need updates on referrals to long-term care, the navigator will provide all of that.”

The hope is that Ontario Health Teams will bring primary care, hospital and community providers together.

For a couple who both needed to move from their home to long-term care, the navigator worked to get them a shared room in the same facility and even helped them move their belongings, explains Ivy Wong, senior lead of OHT and System Integration at North York Toronto Health Partners.

Every day, the team meets through a zoom “huddle” to discuss each of the 20+ patients enrolled in the program. The team includes the navigator; PSW supervisors; allied health providers such as social workers and occupational therapists; family doctors and, when needed, hospital specialists. They troubleshoot any issues and make sure needs are addressed. “Did Meals on Wheels enroll Ms. Smith?” a family provider might ask. “The PSW said Mr. Goel has missed his evening medication two times in a row. What can we do to stop this from happening?” the PSW supervisor might say.

North York Cares also has taken an innovative approach to how and where care is provided. Previously, the Local Health Integration Networks (LHINs) would give patients a set number of hours based on their health status category, and patients had little say in how many hours they’d get or when PSWs would arrive. North York Cares eschews a cookie-cutter approach to take into account patients’ needs, using a “concierge approach,” as Wong puts it, in which patients and caregivers choose the services they most need.

Patients with live-in caregivers might need less in-home supports than those with no family in the city, for example. Pre-COVID, some patients didn’t need care in the day because they could attend community programs but expressed that they did, however, want overnight support. Other families and patients weren’t comfortable with having a PSW stay overnight but wanted a check-in or alarms that would alert the care team if a patient’s blood sugar dropped too low, for example. Working directly with families “allows us to be more creative in the solutions we provide,” says Wong.

To ensure patients’ medical needs don’t get missed, North York Cares’ primary care doctors and nurse practitioners provide home visits. They either do this in a shared-care model with the patient’s existing family doctor or, according to the patient’s and family doctor’s preference, they take over as the patient’s family doctor, says Lin.

Monavvari says while overnight supports and home visits may seem expensive, “resources in hospital are way more expensive. We don’t need more money. We need to reallocate the money to the right place,” he says.

North York Cares isn’t yet a full solution – it’s a proof-of-concept project. The team is using a research grant and some of its bulk funding to research whether the patients enrolled have better outcomes than those in similar situations who receive conventional care.

Coordinated models can be good for health workers, too. In the fragmented and siloed health system, Wong explains, health workers want to do what’s in the patient’s best interest but they worry, ‘I don’t know if I’m allowed to speak to this other person about the patient’s medical information.’ With NY Cares, providers “feel relieved to work how they always wanted to work,” says Wong.

Noah Ivers, a family physician and scientist at Women’s College Research Institute who researches ways to improve health-care systems, says OHTs are uniquely positioned to advance learning health systems. That’s why, he says, they should all be given dedicated research funding.

“In an ideal scenario, each Ontario health team would be allotted a (research and development) budget so that it could continually improve what it does and then share that with other Ontario health teams,” Ivers says. “I think the return on that investment would be great.”

The comments section is closed.

  • Linda Murphy says:

    I look forward to the report on results and lessons learned from this grant which incorporates many good elements (care continuum and continuity of caregivers, etc.) identified in many white papers and reports over many years. By chance, I recently completed a survey by the OMA of health care priorities which seemed more focused on simply increasing the number of docs in the system vs the coordination and health record/info-sharing that is so badly needed – esp., across the primary, acute and longterm care sectors.
    As a side note – I have been interacting with the health system on behalf of myself, children, siblings, my parents and in-laws and other members of our extended family for 40+ years. Not only do we not have a continuum of care – we still cannot even share health records across the acute and community care sectors efficiently. Recent experience with EPIC MyChart in the TOH system shows some promise, BUT and it is a huge but, we need to improve input options to include primary care physicians. I understand this is/will be a challenge, but hell’s bells it is past time to make this work.
    One of my experiences with my Dad a few years ago (hospitalized for a broken hip, placed in a program to ready him for return to ltc and ready to be discharged without a treatment plan, or heads’ up to family or his facility despite constant communication on my part to get these). I was lucky to know the physiotherapist and to get him to advocate for Dad for a short delay and I sat with a social worker to go through his ‘chart’ (actually 5″ loose-leaf binder) to pull out pertinent info to create a treatment and needs plan for use by his nursing home and our family. This exercise also taught me how poorly key info is captured (let alone highlighted) in charting, as it failed in any way to identify his s-t memory deficit, so that providers interacting with him without me there took his answers at face value.
    All this to say – of course integrated teams and navigators are good elements, but I think that requiring – and funding – the work of being a ‘primary/navigator’ (possibly the GP) for patients and fixing the issue of health records and information flow needs could also go a long way to improving our still-fragmented system.

  • Catherine says:

    There are many great examples about the OHT model, like this one, but consider this: what if the proposed solution to resolve issues in the acute care sector was to build a new hospital alongside every existing one, create a new and improved version of everything that goes on inside, then when the new hospital is running smoothly, knock the old one down. No one would agree that this was an efficient or cost effective strategy toward an improved system, but in many ways this is analogous to what’s happening in home and community care. Also, if OHTs lead, as they should, to a decreased burden on hospitals, will finding be taken away from the acute sector?
    COVID, not policy, has forced more collaboration and integrated care delivery across the continuum than I have ever witnessed. Turns out it was in us all along.

  • Ted Ball says:

    Oh dear, this sounds so promising—an actual integrated delivery system (IDS) in its embryonic stage!

    Too bad the Ontario Health reorganization is NOT ALIGNED TO CREATE INTEGRATED DELIVERY SYSTEMS.

    Rather, the additional 20-25 Regional VPs (in a the 10 at health office) and their functions are aligned to re-enforce silo-management/ silo-performance evaluation, silo-resource allocation and command-and-control, structures — not integration and collaboration‍♂️

  • Tiiu Uusberg says:

    Helping older adults transition at home, if there is no one there to assist. Remember forty percent of home care is provided by volunteer labour.
    Not adding those new hospital beds when new hospital additions were built in the last ten years in Ontario was a cause for concern at the beginning of the pandemic.


Wendy Glauser


Wendy is a freelance health and science journalist and a former staff reporter with Healthy Debate.


Umayangga Yogalingam


Umayangga is a Toronto-based public health professional with several years of experience in youth health and engagement. She is also a freelance artist who dabbles in acrylic painting, ink illustrations, digital art and more.

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