@NHLC2019 #NHLC2019

Smarter Healthcare from the Perspective of Toronto Newcomers

Presenters: Mohan Doss, Julia Chao

Initiative Partners

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Issues for Newcomers and Immigrants

Population SpecificChallenges

• Social determinant related issues - income, employment, access to healthcare, physical environment (housing), social supports etc.

• Settlement related stressors

• Illness Vs Wellness management approach

• Lower attachment among newcomer men to a family doctor or primary care

• Focus on reproductive health, maternal and child health

• Health literacy & cultural dynamics of understanding health

• High % of newcomers from countries with social unrest/war have experienced trauma

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Issues for Newcomers and Immigrants System Specific

Challenges

• Lack of language specific and culturally competent mental and family health services

• Lack of culturally competent trauma informed care

• Lack of coordinated care (social and health)

• Healthcare access points

• Eligibility criteria

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Oakridge Neighbourhood Demographic Data

Oakridge Neighbourhood

Toronto City Average

Immigrant population 68% 58%

Visible minority population

75% 51%

Low income 43% 20%

Unsuitable & inadequate housing

37.5% 19.2%

Unemployment rate 14.7% 8.2%

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Health System Utilization in Oakridge

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Taylor-Massey Neighbourhood Demographic Data

Taylor-Massey Neighbourhood

Toronto City Average

Non-official mother tongue

56% 46%

Immigrant population 72% 58%

Visible minority population

67% 51%

Low income population 33% 20%

Unsuitable & inadequate housing

41% 19.2%

Unemployment 11.5% 8.2%

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Health System Utilization in Taylor-Massey

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Issues for Newcomers and Immigrants

System Specific

May 19, 2019

“This Toronto doctor helps people get more money to improve their health”

Leslie Young, Senior National Online Journalist, Health Global News

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Social Determinants and Health Outcomes

Oakridge & Taylor-Massey Initiatives

Interprofessional Primary Care (IPC) model

Oakridge 2 Primary Care Physicians, 1 Registered Nurse, 3 Social Workers

Focus on four Toronto Community Housing (TCHC) buildings located along Warden Avenue between St. Clair Avenue East and Danforth Avenue.

Taylor-Massey 1 Case Counsellor Specialist - Settlement

Embedded in Crescent Town Health Centre

Taylor-Massey Expansion

2 Case Counsellor Specialists - Settlement

Rotate through 4 clinic locations Comprehensive Health Network (Family Health Group)

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Strategies for Effective Partnerships with Primary Care

Relationship Building

Co-location Plus

Ongoing Engagement

Regular and Ongoing

Communication

Shared EMR

Streamlined Referral Process and Loop Back

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Lessons Learned

YAYs AHAs

Client-centeredness Building consensus for a clear, shared vision that all parties supported takes a lot of time and dialogue

Primary Care engagement Be really appreciative of uncompensated time; support primary care to participate in meetings/rounds

Clarity of Expectations – front-line staff, WoodGreen, clinics, larger community, other providers, funder

Need to be willing to learn and adjust; checking assumptions; a lot of good will and patience is required

Communication – timeliness, transparency, accessibility

Adjusting communication strategy, approach and styles

Resource allocation – matching resources to needs/capacity

Levering internal resources and ability to seek support from pre-existing partnerships

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Lessons Learned

YAYs AHAs

Common data systems Working through privacy and consent issuesis not always simple or easy

Working in the community; safety When faced with space limitations, repurpose available space, borrow space, be flexible; Need to develop team safety protocols

Coordination across various internal and external levels and providers

Internal, external coordination and collaboration are not straightforward processes

Evaluation Taking a Quality Improvement approach andspirit

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Impact

“The biggest advantage of the program is that we address mental health stigma in a community where mental health is viewed as a disease. Clients with severe

depression or other mental health issues come to see us for medical assistance, social support or to find solution to their financial difficulties, and would ignore their mental health challenges but after a few sessions and information about

mental health they are willing to participate in mental health program, or discuss with their family doctor.”

~ Program Staff ~

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Impact

“Excellent service! [CCS] is a great counsellor…I was very depressed after the loss of my mother and I didn't move on with my life when I met with [CCS] after 2

sessions, he figured out my problems and connected me with the right resources. Now I'm back on track, and looking for jobs, attending grieving

counseling that [CCS] connected me with. I would definitely recommend this service to anyone who needs help.”

~ Client/Patient ~

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