Each year, staff at Health Quality Ontario read the Quality Improvement Plans (QIPs) submitted by Ontario hospitals, primary care organizations, long-term care homes, and local health integration networks (which administer home care).
We identified some stand-out examples from the 2017/18 QIPs showcasing what some organizations have done to address health equity in the populations they serve, and reached out to the people involved to find out more about their experiences.
Toronto Central Local Health Integration Network (LHIN) was one of those organizations. In their QIP, they included a brief description of their Urban Heath Team and Inner City Access Program. We asked them to tell us more.
Sally McMackin, Director, Community Programs, Mid-East Sub Region and Sheila Neuburger, Manager, Client Services, Toronto Central LHIN responded with the following post:
The Toronto area has the most diverse cultural, socio-economic and linguistic population in Ontario. The people we serve include individuals who are highly vulnerable and marginalized, including those who have care needs related to homelessness, mental health and addictions.
Toronto Central LHIN is taking a population health approach to planning at the local level and is committed to health equity. This means that the LHIN is using data, informed by community consultation to understand the greatest gaps in health, and to target efforts and investment. The LHIN recognizes that many populations require the combined effort of health and social sectors to develop joined prevention initiatives, early intervention and targeted interventions in order to significantly improve their health outcomes.
The LHIN’s Urban Health Team
The Toronto Central LHIN has an urban health program, which was started more than twenty years ago to address the care needs of clients with predominantly severe and persistent mental health challenges. At its inception, there were limited or, in some areas, no home care resources designed to meet the needs of this population.
The program’s design addresses the challenges people with persistent and severe mental health illness can experience. For example, many people can struggle to manage their activities of daily living.
Further it was acknowledged that home care providers, at the time, had limited opportunities to develop the skill sets required to best serve this population and a dedicated program would create the critical mass to develop and maintain the required clinical competencies. Thus the urban health program was launched to meet this unique population’s home care needs.
The program is currently supporting approximately 800 people with mental illness to live in the community, with 66% of these clients receiving support for activities of daily living.
Inner City Access Program
As the program evolved, it became evident a sub-population of marginally housed people with severe and persistent mental health challenges and/or addiction issues required an innovative approach to support them post-hospitalization and to prevent future re-admission to hospital.
The Inner City Access Program (ICAP) was designed to meet this need. Through ICAP, we provide nursing and personal support to clients residing at a number of homeless shelters and residential housing settings.
The LHIN delivers care in collaboration with a number of partner sites, including shelters, drop-in centres, and out-of-the-cold programs.
Approximately 60 clients per week are seen in the out-of-the-cold programs and approximately 100 clients are seen in shelters through the ICAP program.
People access this program by self-identifying and by referral. A goal of the program is to make access as low a barrier as possible for the individual. Working in collaboration with partners, this program uses a unique home care delivery model to meet people where they are and where they need care.
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Quorum’s Indicators & Change Ideas page. Find more information about QIP indicators and related change ideas.