Enhancing primary healthcare delivery in the inner-city community in Toronto, Canada

A very participatory evaluation process with broad involvement of all stakeholders, including patient and community members, led to consensus on priorities and gaps in services; prioritization of an innovative, patient-centred, model of health and social care led to development of an integrative Family Health team working from a social determinants of health lens; multiple partnerships support long-term sustainability and educational collaboration; supportive leadership and internal champions created momentum for change and mitigated internal and external barriers to change; active and ongoing engagement of patients, community and health team members in program design and implementation.

St. Michael’s Hospital, Department of Family & Community Medicine-Family Health Team

The St. Michael’s Hospital Academic Family Health Team (SMHAFHT) is a large, primary care teaching clinic, affiliated with the University of Toronto, and nestled within the downtown core of Toronto. The Family Health Team provides services to the inner-city community of Toronto through 6 clinical sites located conveniently in these neighbourhoods. We serve the poorest communities in Toronto - people who are marginalized, underhoused and with significant health comorbidities who are significantly impacted by many social determinants of health that negatively affect the quality of one’s life, such as poverty, inadequate housing and inequitable access to health and social care services. 

In identifying the significant impact that social determinants of health have on our community, and in consideration of the research which supports the importance of interprofessional (IP) care and education, our department undertook a visioning and planning process to evolve and ‘re-purpose’ the way we deliver care, how ...