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Our Work

OHTs are focused on increasing the overall population health* of their communities

and have begun by working together to address persistent gaps in the health system for

communities that struggle to access quality care. The OHT – ÉSO has initially focused on

improving care for frail older adults, and adults with mental health and addiction concerns.

Community Health Teams are an in-depth, community-based care and support approach to

stabilize or overturn declining function and ultimately shift the trajectory of frail older adults

away from avoidable higher levels of care and prolong their ability to live at home longer. 

Read about the important work of Community Health Teams.


Leveraging an online appointment booking platform, Counselling Connect (CC) provides individuals virtual, rapid-access to mental health and addiction services from over 20 community organizations.  

Read about the continued impact of Counselling Connect - Counseling en connecte.

* Population health is the concept of gathering data & insights about population health & well-being across multiple care & service settings, with a view to identifying the main health & social needs of the community & adapting services accordingly.   

 (Deloitte Centre for Health Solutions, 2019) 

Improving System Navigation Services for Clients and Families 

The goal of this initiative is to help clients get the care they need more easily, from where they need it, and from whom they need it. We are working to build a comprehensive directory of services within our OHT that includes all the information clients need to determine which programs are right for them. This work is being done in collaboration with regional and provincial stakeholders.  

Improving Preventative Cancer Screening for Newcomers and Racialized Populations 

The Ottawa Health Team - Équipe Santé Ottawa is designing community outreach and screening initiatives to support more newcomers and racialized community members to access breast, cervical, and colorectal cancer screening, including those without regular access to primary care. 

Supporting Transitions from Hospital to Home, Wherever Possible 

Home First aims to support clients in returning home as the desirable outcome after acute hospital care. Under this program, transferring clients from hospital to a Long-Term Care facility is considered only after all other community options are explored. The Home First philosophy effectively and proactively considers these options by involving and engaging the client and family in decision making. The Ottawa Health Team - Équipe Santé Ottawa is working with partners to reinvigorate this approach within our community and support organizations serving older adults to examine how they can adjust their practices to support clients returning to their homes and communities following hospitalization as much as possible. 

Fulfilling the "Quadruple Aim"

The Quadruple Aim is an internationally-recognized framework that helps design and deliver an effective health care system.  

Working within this framework, health systems provide a better experience for clients, families, caregivers and service providers. It encourages us to achieve better individual and population health outcomes, and deliver greater value and efficiency. Over time, our OHT - ÉSO will work to achieve those Quadruple Aim benefits for everyone.  

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