Community
Health Teams

Ontario Health Teams are proving that collaborative, patient-focused approaches to care are changing lives for the better. 

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One of the best examples of this is in a recent pilot project by the Ottawa Health Team - Équipe Santé Ottawa (OHT - ÉSO) called the Community Health Teams; a project focused on keeping frail seniors living well in their own homes for as long as they can.  

 

With the Community Health Teams initiative, 25 clients were supported over nine months with improved access to health care and social supports, everything from wound care to tax preparation assistance.  

 

Designed with relationships in mind, this initiative targeted people in early stages of frailty who were 55+ years old, and living with limited financial and social supports. A proactive community-based care and support model, key features included preventative and standardized frailty screening, stepped care planning to ensure the ‘right care at the right time’, care delivered closer to home and smooth transitions to alternate care environments, as needed.   

 

After major abdominal surgery, senior Stephen M. was at a loss and had a hard time keeping track of doctor’s appointments, rehab consultations, and a list of medications prescribed for him, on top of the day-to-day tasks of living alone during his recovery. 

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Megan, a social health facilitator, and Patricia, a clinical health facilitator, worked with Stephen through the Community Health Team model trial to connect him with health appointments and other supports he needed. 

 

“Quite frankly, I don't know where I would have been or where I would be now if I didn't have both Megan and Patricia to help me,” said Stephen. “I wouldn't have been able to navigate all this stuff, especially immediately post-op.” 

 

This type of help, provided by Megan and Patricia, wouldn’t have been available without the newly designed Community Health Teams model by the OHT - ÉSO. 

Within the current system, frailty in seniors is often identified too late in care plans or not identified at all. This often leads to duplicate assessments among various providers, conflicting care plans, poor care transitions without coordination, and avoidable readmissions to hospital.   

 

Nancy U. is one of the estimated 20,000 people in Ottawa aged 65 and over who are frail. She knows how a program like this can immediately improve life. Feeling isolated, Nancy was overwhelmed by the numerous health and quality-of-life decisions she was facing. 

 

“The referral to the Ottawa Health Teams was, quite frankly, a godsend,” says Nancy. “Suddenly I had a nursing contact and a social facilitator and all my issues were addressed in a quick and organized fashion”. 

 

“Both Patricia and Megan have always been compassionate, caring and joyful in assisting me even though I can be very stubborn and have been known to talk too much!” 

 

Initiatives like Community Health Teams, made possible through the collaboration of OHT- ÉSO partners, will improve care for more seniors in the future, allowing them to live and thrive in their homes and communities – where they prefer to be.  

 

Ottawa Health Team – Equipe Sante Ottawa partners will be working together in 2023 to scale up key learnings within the health system to ensure more community members can access integrated health and social supports close to home.