Delivering Care to Your Door: Neighbourhood Care Team Brings Health Care Right to Toronto Seniors Housing Tenants
If you were to knock on an apartment door in one of the Toronto Seniors Housing Corporation (TSHC) buildings, you might meet an individual who is dealing with chronic conditions, financial challenges and social isolation.
“We want to live independently, but it can be difficult,” says Kiara Fine, a TSHC tenant and volunteer and former holistic registered nurse. Addressing loneliness and many tenants’ reluctance to leave their homes, she adds, “Some people don’t have the mobility or strength to go outside. When there’s snow on the road, we’re worried about leaving and breaking a hip.”
Add in language barriers, difficulties with digital tools for staying connected and the gap in access to primary care in Ontario, and you can see how over 15,000 TSHC tenants could struggle to maintain good mental and physical health.
Barriers to care
38% of TSHC tenants do not speak English as a first language
81% of TSHC tenants live alone
2.5 million Ontarians do not have access to a primary care physician or team.
Luckily, the North Toronto Neighbourhood Care Team (NCT) is there to help.
Through a collaboration between the North Toronto Ontario Health Team partners, TSHC and TSHC tenants, the NCT is an integrated geriatric outreach care model that brings primary care and social services right to patients’ homes.
In the eight TSHC buildings where the NCT is active, tenants have access to a core support team as a first point of contact. This team includes an Ontario Health at Home care co-ordinator, a social worker for connecting to community and social services and a primary care provider attachment clinic for those who do not have a family doctor or who have difficulty accessing their family doctor.
“Rather than having this organization that does XYZ and the other one that does ABC, we’re bringing the alphabet together,” she says, adding that these improvements have been made without any new dollars for implementation.
All tenants also have access to nursing clinics for services like blood pressure checks, foot care, health education and hearing screening, and they also receive support from a wide variety of care providers who address topics ranging from digital literacy to dental care to social isolation to falls prevention.
“Right now, our health-care system is very siloed,” says Dr. Joceyln Charles, associate professor in the Department of Family and Community Medicine (DFCM), family physician at the Sunnybrook Academic Family Health Team and one of the founders of the NCT. She explains that this program addresses disconnections by bringing existing services together into a holistic model that meets patients where they are at.
“Rather than having this organization that does XYZ and the other one that does ABC, we’re bringing the alphabet together,” she says, adding that these improvements have been made without any new dollars for implementation.
With this new cohesion, TSHC tenants have reported many improvements, including stabilized health conditions, higher quality of life, better access to health and social services, improved relationships and needs addressed earlier.
In a recent tenant experience survey about the model, 77 per cent of tenants reported their experience to be “very good to excellent,” with the remaining tenants saying it was “good.” More than 85 per cent said they now feel more confident managing their health, and 78 per cent said they knew whom to contact for their care as a result of the team’s involvement.
The NCT has also helped to connect 80 previously unattached patients — and counting — to a primary care provider or team!
Tenants prefer receiving care from people they "know and trust," says Einat Danieli, clinical manager at Baycrest Hospital, the operational lead for the NCT. With reliable care providers and better access to services, patient compliance with their care plan improves, says Danieli.
But it’s not just the TSHC tenants who benefit from the NCT.
“My absolute favourite thing to do is home visits,” says Dr. Charles. “Within the first minutes of a visit, I have learned so much about somebody. Not just from what they're saying, but from observing where they live.”
This additional context helps her to make more impactful recommendations, most of which can be met through the services provided by the rest of the NCT.
She describes the fulsome process as “powerful” and “joyful.” “And I really think my remedy to burnout is doing things in a way that will give more joy,” she adds.
This is part of the reason that Dr. Charles is conscious to bring family medicine learners to participating TSHC buildings.
She recalls one instance when she brought a learner who spoke fluent Russian to an NCT site that was populated with multiple Russian-speaking tenants. Due to the language barrier, Dr. Charles had difficulty connecting with these individuals, remembering one woman who was often quick to shut the door when the NCT knocked.
But when the Russian-speaking learner knocked on the door and began speaking Russian, Dr. Charles says, “The patient had this great big smile on her face, and we were there for over an hour.
“She was like a fire hose, sharing everything about her health. When we left, the patient had tears in her eyes, and the learner looked at me and said, ‘This was the best part of my clerkship. Can I come back?’”
Neighbourhood Care Team successes
80+ tenants newly attached to a primary care physician or team
15% reduction in inpatient days
Improved health outcomes and quality of life
No new dollars spent to facilitate the program
Engagement of over 300 tenants in the design and implementation of the model.
Fortunately, more learners and tenants will be able to benefit from the NCT as the model continues to grow.
Looking ahead, Danieli says the program is working its way into more TSHC buildings across North Toronto and North York, and she hopes it will be added to other kinds of retirement
communities as well. The team is also working on a financial model to attract more physicians to help make this growth possible.
Additionally, Dr. Charles says the team is working on gathering better data about the broader impacts of the program on the health-care system, including its effects on emergency department visits, hospital admissions and cancer screenings.
In the meantime, Fine and her fellow TSHC tenants who have access to the NCT are happy to be benefiting from the program’s inclusive model of care.
“They address the whole person, and they give a lot of answers,” she says. “It's really a gift that the NCT comes here.
Number of DFCM faculty at:
Baycrest: 22
Sunnybrook Health Sciences Centre: 92
Originally published in the 2024-2025 Family Medicine Report. Read the full report