Health Neighbourhoods: Applying a Collaborative Health Neighbourhood Approach to Facilitate Access and Attachment to Primary Care
The Health Neighbourhood concept supports provincial priorities towards access and attachment by integrating primary care, community resources, and social services to improve population health and outcomes. As well, it uses population health data to appropriately identify health and social supports required to address community needs. This workshop will present Health Neighbourhoods as a model for primary care planning model using two geographically different OHTs as case examples. It guides the audience through focused table-top discussions that consider key aspects of the health neighbourhood and how they might apply the concepts in their communities. Participants will reflect on similar work happening in their OHT, explore facilitators and barriers to success, assess the readiness of PCNs to engage the planning process, and consider how they might implement the model in their planning process.
Speakers: Liz Garfin, Anne Wojtak, Catherine Yu, Connor Kemp, Jillian Fenik, Kim Morrison, Nalini Pandalangat, Ryan Bhopalsingh
Moving Beyond Pilot Projects to Build an Integrated Healthcare System
This was a presentation by the South Georgian Bay Ontario Health Team (SGB OHT), who has advanced integrated care locally through three pillars of work: digital integrations, data sharing agreements, and collaborative attachment frameworks. In particular, these interventions include the shared use of a one instance of Telus PS Suites that has allowed system partners in SGB OHT to deliver seamless care through real-time provider communications, data sharing agreements that streamline vaccine records between primary care and the local health unit, and a collaborative attachment framework that will provide access to care for unattached individuals.
Speakers: Dr. Harry O'Halleran, Wendy Smith
Stronger Together: Building resilient health and social care systems through collaboration and partnership
Moving Beyond Pilot Projects to Build an Integrated Healthcare System
This was a presentation by the South Georgian Bay Ontario Health Team (SGB OHT), who have advanced integrated care locally through three pillars of work: digital integrations, data sharing agreements, and collaborative attachment frameworks. These interventions include the shared use of Telus PS Suites that has allowed system partners in SGB OHT to deliver seamless care through real-time provider communications, data sharing agreements that streamline vaccine records between primary care and the local health unit, and a collaborative attachment framework that will provide access to care for unattached individuals.
Speakers: Dr. Harry O'Halleran, Wendy Smith
Housing is Healthcare: A report and case review on how collaboration across housing, health and social care are improving outcomes for aging adults
This session provided a peek into the findings of a review by the Toronto Seniors Housing Corporation (TSHC) of several service delivery models and their integrated approaches to aging at home and wellbeing. This was followed by a deeper dive into the North Toronto OHT Neighbourhood Care Team model - its governance structure, partnerships, and frontline strategies that enable collaboration to flourish.
Speakers: Arlene Howells, Einat Danieli
An Innovative Integration for Palliative Care Services in Scarborough
Lightning Talk speakers outlined how this innovative partnership bridges gaps in palliative care with a shared EMR system and a central intake and referral tool.
Speakers: Sari Greenwood, Dr. Ray Berry, Chelsea Braun
Prescribe to Thrive: Advancing Integrated Care through Social Prescribing in Chatham-Kent and Sarnia-Lambton
This Lightning Talk showcased the Prescribe to Thrive initiative, where the Chatham-Kent and Sarnia-Lambton OHTs are embedding social prescribing into local care pathways, linking individuals to community supports that address social determinants of health.
Speakers: Laura MacDougald
Advancing Equity, Diversity, Inclusion and Belonging Across an Integrated Care Delivery System
Lightning Talk speakers discussed how the Brantford Brant Norfolk OHT is advancing diversity, equity, inclusion, and belonging (DEI-B) across its 19 partner organizations, using the DEI-B Maturity Grid to guide organizations in strengthening their equity practices and improving patient and provider experiences.
Speakers: Dr. Ruby Latif, Ben Deignan
Navigating Communities in Crisis: An OHT approach to Community houselessness and the Toxic Drug Crisis in Chatham-Kent
This session highlighted how the Chatham-Kent OHT is tackling the dual housing and opioid crises through a collaborative, system-level response. Leveraging the OHT approach, they have developed initiatives like Pathway2Care, which supports individuals with housing instability, reduces emergency room visits, and integrates peer leadership.
Speakers: Melissa Sharpe-Harrigan, Jordynne Lindsay, Laura MacDougald
HealthPathways: A One-Stop Digital Platform Empowering Primary Care Providers to Diagnose, Manage and Navigate Care for their Patients
The Streamliners (HealthPathways) team was joined by OHT representatives to deliver an interactive workshop on how evidence-based guidelines can be incorporated into clinical workflows to support primary care providers with decision-making. The HealthPathways workshop functioned as a “living lab” where participants could learn about real-world case studies of HealthPathways implementation in Ontario and beyond, as well as engage in hands-on activities such as developing SMART aims, mapping workflows, and building value proposition canvases to understand how tools such as HealthPathways can support the implementation of care pathways.
Speakers: Mark Girvan, Alastair Roeves, Melissa McCallum, Amber Alpaugh-Bishop, Dr. Reham Abdelhalim, Sarah Jarmain, Dr. Sunita Goel
“Everybody Should Know What to Do Next”: Implementing Frailty Pathways Across Ontario Health Teams
This session featured a case study of how Frailty Pathways have been implemented at Kawartha Lakes Haliburton OHT (as well as BBN OHT, NHH) to support older adults. These pathways are standardized approaches to frailty management, intended to support older adults to age-in-place and prevent unplanned acute-care utilization and early institutionalization (including ALC designation/LTC admissions).
Speakers: Stephanie MacLaren, Rhonda Schwartz, Sabeen Ehsan, Kelly Kay
Evolution of E-nangaabe-jig Health Services – A Journey of Collaboration and Trust
This panel discussion explored the transformative journey of Indigenous health service development in the Sarnia Lambton region, grounded in trust, cultural identity, and Indigenous-led collaboration. This journey demonstrates the power of colonial/Indigenous relationships built on trust and mutual respect, fostering meaningful partnerships, co-creation, and improved health outcomes. This includes the Indigenous Communities Advisory Council’s (ICAC) evolving role within the Sarnia-Lambton OHT and its impact on governance, funding oversight, and cross-community partnerships.
Speakers: Julie Harries, Nadine Neve, Paige Bois, Michaela Nahmabin-Hiltz
Community Health Integrated Care (CHIC): Embedding CP in Mental Health & Addictions Care in Sarnia-Lambton
This panel discussed the innovative model that provides outreach to individuals affected by housing instability, homelessness, mental health issues, and substance use disorders. Born out of a collaboration Bluewater Health, Lambton County EMS, and the Sarnia Lambton OHT, this integrated, community-based approach demonstrates promising outcomes in addressing complex health and social needs, reducing emergency department reliance, and strengthening local support networks.
Speakers: Donna Morreau, Nadine Neve, Stephen Turner
Learning from Home Care Leading Projects: Recommendations for Advancing the Integration of Home Care and Primary Care
At this session, participants learned how OHTs can support integrated home care models, from the perspective of contracts, governance, operational models, and care improvement. In Spring 2022, Seven Ontario Health Teams were invited to put forward proposals for Home Care Leading Practices, as a part of the Ministry of Health’s Home Care Modernization strategy. OHTs proposed models to support improved integration of home care providers and care coordinators within local teams, including several OHTs with primary care-centred models. These programs launched in Winter 2025. The workshop explored several components of the Home Care Leading Practices experience, with reflections on what OHTs have learned and promising opportunities for further development.
Speakers: Emmi Perkins, Jonatan Bobadillo Madlonado, Karen Taillefer, Karin Swift, Margery Konan, Wendy Smith
Success Stories: Health System Transformation Through Authentic Co-Design with Primary Care
This presentation showcased strategies that OHTs can deploy to foster a more engaged and cohesive primary care workforce. Drawing on examples from three different OHTs, presenters shared lessons about authentic co-design, structured primary care networks, and formal primary care leadership education and remuneration. Health system leaders learned about how to better involve family physicians and primary care networks in change initiatives.
Speakers: Kim McIntosh, Marilyn Crabtree, Nicole Nitti
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