2024–2025 University of Toronto Family Medicine Report
Editors
Amy Noise, Elaine Smith, Kaitlin Jingco
Design
Trajectory Brands Inc.
Writers Amy Noise, Kaitlin Jingco
Cover illustration
Hawlii Pichette
A special thank you to the Patient and Family Advisory Committee: patient partners Kelly Akerman, Amadou Barry, Sheree Clark, Gerald Crowell, Kareen Farquharson, Eleni Gilligan, Liz Kazimowicz, Cate Mann, Julie King, Michelle Leppington, Trudy Penny, Lolita Prescod, Melanie Simon, Kishany Subramaniam, Tricia Thomas and Atif Zia; patient and family engagement specialist Dana Arafeh; and faculty lead Dr. Melanie Henry.
We wish to acknowledge this land on which the University of Toronto operates. For thousands of years it has been the traditional land of the Huron-Wendat, the Seneca, and the Mississaugas of the Credit. Today, this meeting place is still the home to many Indigenous people from across Turtle Island and we are grateful to have the opportunity to work on this land.
On behalf of the Patient and Family Advisory Committee (PFAC) at the University of Toronto’s Department of Family and Community Medicine (DFCM), welcome to the 2024–2025 Family Medicine Report.
Formed in 2022, the PFAC represents patients and families served by DFCM-affiliated clinics. We strive to share insights from the patient experience with educators and program staff to help improve family doctor education and health care in our communities.
Together with the DFCM, we’ve contributed to a variety of projects, large and small, aimed at improving family medicine education. As patient partners, this has been a truly positive and educational experience. We feel valued and know our voices are being heard.
Each PFAC member brings a unique perspective. Most of us had no awareness of DFCM or the process of medical training before becoming patient partners. Learning the difference between a medical student and a resident doctor, how specialized family medicine is, and how much goes on behind the scenes to make patient care better for everyone has given us a deep appreciation for the difficult work that family doctors do.
We each came to (or stumbled upon!) this role for different reasons: frustration with the current system, negative personal experiences, advocacy for loved ones or feeling that our communities are misrepresented or underserved. Despite our varied motivations, we all share a common goal: a passionate desire to help others and improve our health system.
Throughout our time together, it has been reassuring to know so many dedicated individuals are devoted to providing superior education, improving health care, identifying barriers and leading research to improve patient care for everyone across all our communities. Our small group of patient partners is not just maintaining the status quo — we are empowered to be agents of change.
Thank you for asking to hear about our personal experiences and believing that our collective stories are powerful enough to be catalysts for positive change. It’s simply not enough to dream about big ideas that will make our health system better — it’s about caring enough to strategically remove barriers so that the present conditions can improve.
We also want to thank Dana Arafeh, DFCM’s patient & family engagement specialist, for guiding us through difficult conversations and offering her genuine compassion throughout this entire journey. We are grateful to her and to the whole DFCM team for bringing us together with the shared mission of improving patient care for all.
With our utmost admiration and gratitude for the work that family doctors do,
Gerald Crowell and Michelle Leppington Proud members of the Patient and Family Advisory Committee
PFAC Team at DFCM Conference 2024
PFAC Team at their executive meeting
COMM UNITY
By Amy Noise
A PLACE TO START: COMMUNITY HEALTH INFORMATION FAIRS IN NORTH YORK
Topic chosen by PFAC
Across North York, primary care providers and community organizations have teamed up to offer low-barrier, culturally sensitive health services to residents without OHIP coverage.
Twice a month, Community Health Information Fairs (CHIFs) provide a welcoming space where North York residents can connect with nurses, receive essential screenings like Pap smears and even take part in wellness activities such as cooking classes.
The program, co-designed by North York Toronto Health Partners Ontario Health Team and community partners, brings together community health centres, the North York Family Health Team and community support services to provide care in accessible, non-clinical spaces.
“In North York, a fifth of our population has no dedicated primary care provider,” says Dr. David Eisen, a family doctor and former chief of the Department of Family and Community Medicine at North York General Hospital. “The Community Health Information Fairs are our way of stitching the health system together for those who don’t have a family doctor they can call when they need it.”
Although the CHIFs initially launched as a COVID-19 vaccination clinic, the team quickly realized that many attendees were overdue for cancer screening tests and needed support with mental health, diabetes prevention and even settlement services.
Teresina Stanichevsky, who moved to North York in 2007 and began volunteering with the Flemingdon Health Centre, now leads a team of 11 ambassadors working to ensure that news of each health fair reaches those who need it.
“It is my passion to talk to people, to help people. When you come to Canada, like I did in the seventies from South America, it is hard. You need personal, face-to-face support to figure out how everything works.”
These ambassadors are a vital link, listening and sharing information to ensure the health fairs reflect the needs of each community.
Members of the CHIF team
“Our ambassadors are out there, talking to community members and finding out what they are struggling with. For many it is mental health, food insecurity and system navigation,” says Dr. Maria Muraca, a family doctor, co-chair of the Primary Care Network of North York Toronto Health Partners Ontario Health Team and past medical director of the North York Family Health Team. “Many aren’t able to access a family doctor or aren’t comfortable in clinical settings but will come back again and again to discuss preventive health measures and update their cancer screening tests with our nurse, or chat with our ambassadors.”
Since 2022, the team has hosted more than 25 health fairs and reached over 1,000 local residents — 86 per cent of whom are women. Most attendees lack a primary care provider (35 per cent) or prefer to see a female care provider.
“It was a light in my heart to have this appointment!” says Mastenah, a local resident and clinic attendee. “My husband and I have been in Canada for one year, waiting for our work permits, and still do not have access to regular care. We are both over 50 and have been told we need to have blood pressure checks and cancer screenings regularly. I am happy that this service exists, and it gives me confidence for the future.”
As interest grows, the team is expanding its services to provide more chronic disease screening and management. For example, visitors screened for diabetes and hypertension can now receive follow-up care from a nurse practitioner with the family health team.
For Teresina, it is these personal touches that make the program successful.
“Technology is amazing, but it doesn’t reach people when they really need it. Yes, we can look online or scan a QR code, but when there is so much information you don’t know where to start, it is too overwhelming.
“The fairs give people a place to start, but we don’t say, ‘Come to the health fair.’ We say, ‘Come and see me, I will be there,’ and that’s what brings them.”
Number of DFCM faculty at North York General Hospital: 199
A partnership between 360ºkids and Health for All is providing unhoused teens with essential medical care and the skills needed for a more secure future.
Living throughout York Region, on friends’ couches and in cars, in church basements and in the abandoned house down the street, are teenagers with no place to call home. We don’t see them because they look like any other young person, but they’re unhoused all the same.
360ºkids works to surround these young people with care, giving them the opportunity to feel nurtured and loved. For those facing an immediate housing crisis, the organization offers transitional and longer-term housing, along with medical care through the Health for All Family Health Team, an academic teaching unit in Markham.
“Many of the young people come to us with significant histories of trauma and a complete lack of trust in systems that have let them down over and over again,” says Jessica Ward, senior manager of housing programs at 360ºkids. “We have a lot of youth who have been neglected or abused, so getting them medical care is critical, but can also be extremely triggering.”
The SHINE program (Supportive Housing for Independence through Nurture and Empowerment) operates two youth homes where individuals aged 14 to 19 who have experienced, or are at risk of, homelessness can spend up to a year learning life skills for independent living and working through the issues contributing to their homelessness.
“For youth that stay with us, the SHINE program is all about empowering them to stand on their own two feet, make decisions soundly and seek out help and support whenever they need it,” says Jacqueline Esdale, SHINE program manager.
“Building trusting relationships takes a lot, so for them to have the opportunity to build a trusting relationship with a doctor is huge.”
Many SHINE residents arrive with overlapping crises and without a go-to support person. Every teen must see a health professional within three days of arriving in tempo-
rary housing. Dr. Jessica Wong, a family doctor at Health for All and lecturer in the University of Toronto Department of Family and Community Medicine, oversees the program.
“Many of these youth are uncomfortable when they first come in. We try and change that,” says Wong.
“It’s not only about addressing immediate health needs like mental health support, gender-affirming care or help managing other issues, but beginning to build a healthy relationship with family medicine and the health system as a whole.”
Since its inception in early 2024, the partnership has made a dramatic impact. Many of the youth at SHINE have built trusting relationships with their family doctors.
“Some of my 360ºkids patients will just come in once or twice, but others come back quite regularly as they get more and more comfortable,” says Dr. Simon Hendy, who recently completed his family medicine residency training at Health for All.
“As residents we are not only practising family medicine, but actively expanding our knowledge in areas like mental health and addictions. We bring the latest knowledge from our off-service rotations into our daily practice, which can be hugely helpful.”
While SHINE housing is time-limited, the program equips youth with vital skills and confidence for the road ahead. For those who stay in the Markham area, the patient-doctor relationship can continue.
Together, the partnership offers much more than a temporary solution — it provides a foundation and empowers young people to navigate the world beyond the care system.
Number of DFCM faculty at Markham Stouffville Hospital - Oak Valley: 93
POSTAL CODE-BASED CARE: TAILORED HEALTH AND SOCIAL SERVICES FOR THORNCLIFFE PARK
By Kaitlin Jingco
Topic chosen by PFAC
When Rahma and her family moved to Canada from Saudi Arabia eight years ago, she did not have a family doctor to care for her or her children — a common problem as Canadian newcomers are half as likely to have access to a family physician than established immigrants.
“We’d go to the walk-in clinic,” she says, recalling what she would do when one of her children got sick. But with the lack of continuity and limited time with the physician, she says, “Sometimes, it wasn’t very helpful.”
All of that changed when Rahma and her family moved to Thorncliffe Park and automatically gained access to Health Access Thorncliffe Park (HATP).
Co-led by the Flemingdon Health Centre and The Neighbourhood Organization (TNO), HATP provides health and social services to anyone with an M4H postal code.
Launched in 2016 with a focus on comprehensive primary care, HATP has about 30 staff members today and offers a range of additional services, including social work, nutrition support and connections to resources important to the neighbourhood’s population demographics.
“At HATP we are committed to the geography; we are committed to the population,” says Dr. Catherine Yu, medical director of HATP, family and community physician and assistant professor with the Department of Family and Community Medicine (DFCM) at the University of Toronto.
"If you are living in the M4H postal code, whether you're insured or not, whether you speak the same language or not, no matter how complex you are, you are eligible for our services. That is a distinction that I'm proud of and one that I think the entire health-care system in Ontario should have — much like schools.”
This model of automatically rostering patients to a family physician based on where they live, similar to the way kids are automatically eligible to attend a nearby school, is a model for which Dr. Jane Philpott, chair of Ontario's Primary Care Action Team and DFCM associate professor, has been advocating.
By adopting this model, everyone in the M4H area can rest easily, knowing they have access to care. Additionally, they can be assured that this care is specific to their needs, as the HATP team has tailored their services to the residents.
Home to over 20,000 Torontonians, Thorncliffe Park is one of the most densely populated and multicultural communities in Canada. One of the country’s earliest highrise neighbourhoods, it has been a hub for new immigrants and refugees for generations and is a designated Neighbourhood Improvement Area by the City of Toronto based on its socio-economic needs.
“The neighbourhood is very vibrant but missing some social infrastructure,” says May Massijeh, TNO hub development and partnerships manager. “It’s a place where, if you are a newcomer with no established connections, it will take you time to set those up.”
With this context, HATP has relationships with services including income, legal, settlement, employment and language supports, to which the health-care team refers patients regularly. Many of these services can be accessed in the Thorncliffe Park Community Hub (TPCH), the new home of HATP since early 2025.
“A person who is receiving health services at HATP can also be connected with social, legal and additional health services at the TPCH based on their needs. We can actually walk someone down the hall to get the support they need,” says Massijeh. “We are operating within a holistic access model of care. It makes it easier for us to support our patients because we feel more like a single team in a shared space.”
The team-based environment and the emphasis on looking at the patient as a whole are some of the reasons why Dr. Yu brings upcoming physicians to HATP.
"It's very, very important for learners to be in this space because the health and social care model that we provide is a critical evolution of how family practice, in my mind, should be delivered,” she says.
“I remember as a medical student thinking, ‘My goodness, this is such rewarding work, but difficult when you're looking after complex populations.’ Here, I hope our medical students can see that it's difficult, but it's doable with a supportive team. Here, I hope they feel rewarded and a sense of purpose and belonging in the profession we chose as family practitioners.”
As Dr. Yu hopes learners will see the value of HATP and this geography-based model of care, she also hopes that the team will be able to continue growing its capacity to support more Thorncliffe Park patients—patients like Rahma.
When reflecting on how HATP has improved her family’s life, the M4H resident praises the team’s knowledge, reliability and compassion.
“My physician is so smart. She’s so helpful. And if she’s busy, the nurse will call you and give advice,” she says. Thinking about HATP as a whole, she adds, “It’s amazing.”
Members of the HATP primary care team, including Dr. Catherine Yu (right)
Photo: May Massijeh
Emergency departments are a critical health access point for many Indigenous people but are often not viewed as safe spaces by community members. In the University Health Network emergency department, Indigenous patient navigators are helping to overcome some of the barriers Indigenous people face when seeking urgent care.
“You tell me when you are coming, you tell me what you need, and I'll be that person to support your health-care journey.”
Naaniibwid genoozid zhingwaak kwe, whose given name is Victoria Manitowabi, is one of the Indigenous patient navigators in the University Health Network (UHN) emergency department. An Anishinaabe Kwe from Wiikwemkoong Unceded Territory on Manitoulin Island, she had a long history of working in health care as a personal support worker for Elders and an auntie helper at the Toronto Birth Centre before becoming a navigator.
“I am here as a shkaabewis (helper). The community members coming in have their own voices. They can self-refer to our program, or emergency department staff can inform them about our services. My role is to support community in navigating the health system, help with communication with the health-care team, and creating a safe space where they can feel supported and a little bit safer.”
According to data from Our Health Counts Toronto, more than one in four Indigenous adults reported being treated unfairly by health-care professionals due to their Indigenous identity, with 71 per cent stating that experiences of racism prevented, stopped or delayed them from returning to health services.
“You tell me when you are coming, you tell me what you need, and I'll be that person to support you on your health-care journey.”
With up to 37 per cent of Indigenous people in the city lacking a regular primary care provider, emergency departments are a critical health access point. But community members often avoid seeking care because of previous negative experiences, the experiences of others and the ongoing impact of colonialism and systemic racism in Canadian health systems.
The Indigenous Patient Navigator program, part of UHN’s broader Indigenous Health Program, seeks to create healthier spaces for Indigenous patients in the emergency department by embracing the Medicine Wheel model of care.
It is supported by Drs. Jennifer Hulme and Marcella Jones, emergency physicians, health equity co-leads for the UHN emergency department, and assistant professors in the University of Toronto Department of Family and Community Medicine.
“While training in family medicine, I was drawn to working in the emergency department because our door is always open; we’re here for any person at any time,” says Dr. Jones. “But for that to be a reality for everyone, it needs to be a safe space, particularly for those from systemically marginalized communities.”
The program has three core components: supporting Indigenous community members in the emergency department, building relationships with the Indigenous community outside the hospital, and education for hospital staff.
Launched in May 2023, this combination of emergency department support, community engagement and education
is already making a difference for community programs like Sagatay, which offers transitional housing in a safe, supportive and culture-based learning environment.
“I want to thank you for doing the work you do. It has already made enough of a difference that word is spreading. Sagatay community members are becoming aware that they have people to advocate for them and receive them with kindness at the hospitals, and as a result, most do not avoid the hospital as they used to. This is a new experience for our guys; residents and staff are extremely grateful to have you [Indigenous patient navigators] there,” says Jane Roy, Sagatay program manager.
For Dr. Hulme, the difference is symbolic as well as practical.
“Too often, health equity interventions are one way. Why is this working well? Because we have the emergency department working hand-in-hand with the patient navigators, the Indigenous Health Program at UHN and community partners to address more than just Indigenous patients’ physical health, but also their emotional, mental and spiritual health through access to traditional medicines and ceremony.”
Looking ahead, the team hopes to expand the program to allow for more navigators, more of the time.
LACE UP AND LEARN: THE POWER OF COMMUNITY WALKING PROGRAMS
By Amy Noise
Topic chosen by PFAC
“The education sessions are useful, but it’s the conversations that happen on the walk that have the most impact,” says Dr. Kolker, an assistant professor in the Department of Family and Community Medicine at U of T.
“As a clinician, it gives you the time to get to go so much deeper, to understand how their diabetes fits into the fabric of their lives, what other support they might need and how to help them through what can be a very challenging diagnosis. Plus, you have the peer support component.”
Dr. Nikola Despotovic and Dr. Alex Mouratidis helped lead the pilot as second-year family medicine residents. For them, the program was mutually beneficial.
“It can be frustrating to have just a few minutes with a newly diagnosed patient to try and get across all this important information and then not see them again for a few months,” says Dr. Mouratidis.
Dr. Despotovic adds, “But with this program, instead of saying the same thing to three patients, you’re bringing a group of patients together so we can use the time to go beyond surface information, build support networks and go on a walk.”
These connections are particularly valued by Andy Liu, a Mississauga resident and regular Walk with a Future Doc participant.
“My wife and I joined the program to help with her recovery after she had two strokes and brain surgery,” he explains.
“She has a family doctor, but it is different on a walk. There are more opportunities to ask questions and learn more about all sorts of conditions. Plus, being new to the area, it’s a great way to talk and make friends. You can’t be staring at your phone the whole time when you are walking.”
Although it began with a small pilot group, Dr. Kolker and the team saw improvements in blood sugar level management in nearly all participants over a 12-week period.
These programs demonstrate the power of blending education, exercise and social connection to foster stronger relationships between patients and clinicians and take care beyond the clinic, one step at a time.
Number of DFCM faculty at Sinai Health System: 185
Members of
RELATION SHIPS
FROM CRISIS TO CONTINUITY:
NEW CLINIC TO CONNECT
UNATTACHED PATIENTS TO PRIMARY CARE
By Amy Noise
Dr. Clara Sawires with a patient
A new partnership in northwest Toronto is transforming health-care access, aiming to link thousands of unattached local residents with a family doctor through hospital and community referrals.
For patients without a family doctor, the emergency department might be their only option when a health crisis hits. But, when that crisis has passed, they are on their own again—until the next emergency.
This is a familiar story across Ontario, where 2.5 million people live without a family doctor to manage chronic health issues and prevent new ones.
In northwest Toronto, where over 50,000 residents are unattached or ‘uncertainly attached,’ Humber River Health and the Schulich Family Medicine Teaching Unit (Schulich FMTU) have created a simple, elegant solution.
Any local patient who arrives at the hospital without a family doctor can be referred to the on-site primary care clinic in a few clicks, like referrals for cardiology or radiology.
Humber River Hospital Schulich Family Medicine Teaching Unit opening
“Northwest Toronto has been described as a primary care desert. It has one of the highest rates of patients unattached to primary care in the entire Toronto Central Local Health Integration Network,” says Dr. Priya Sood, a family doctor and the inaugural postgraduate program director of the family medicine residency program at Humber. “We’ve intentionally taken a socially accountable approach when building our FMTU. Focusing on local, unattached patients is a big part of that.”
For patients who have spent years trying to find a family doctor, having a regular, compassionate care provider is a huge relief.
Daniella has lived with iron deficiency anemia for the past 12 years, with complications including fainting, heavy periods and seizures that have required emergency care.
“At one point, I was in a really bad place. I was visiting the emergency department every few months and had three blood transfusions there, which wouldn’t have happened if my anemia was well managed,” says Daniella.
Now a patient at the Schulich FMTU, after being referred during one of these visits to Humber’s emergency department, Daniella and her mother, Berta, couldn’t be happier to have a family doctor helping manage Daniella’s anemia.
“One month after finding out about the clinic, we went in together and came out smiling so much—we couldn’t believe it,” says Berta.
Since then, Daniella hasn’t needed to use the emergency department for her anemia.
“They caught me up on everything I needed in such a short amount of time. The resident doctors are so kind and capable, their motivation and passion shine through. We feel very lucky,” says Daniella.
Daniella (left) and her mother, Berta (right)
DELIVERING CARE TO YOUR DOOR: NEIGHBOURHOOD CARE TEAM BRINGS HEALTH CARE RIGHT TO TORONTO SENIORS HOUSING TENANTS
By Kaitlin Jingco Topic chosen by PFAC
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.
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?’”
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
Barriers to care
38%of TSHC tenants do not speak English as a first language
81%of TSHC tenants live alone
2.5millionOntarians do not have access to a primary care physician or team.
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.
“Health is a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity.”
Constitution of the World Health Organization, July 1946
“What is health? For me, it’s having the capacity to think and having the capacity to do things on my own or with the help of others,” says Janet Rodriguez, a disability justice advocate who lives with visible and invisible disabilities.
“It’s everything from being able to go to a party, go grocery shopping or clean my house. Even though I’m in pain, if I can manage it and have satisfaction in the things I do, that is health.”
As a patient of St. Michael’s Academic Family Health Team and a lived experience expert advisor to its Social Determinants of Health Committee, Rodriguez is deeply involved in disability justice work. For her, if health goes beyond how well our body parts function to include our mental wellness, emotional stability and ability to engage in social relationships and community life, it’s clear that health care should do the same.
Proponents of the social prescribing — or social interventions — movement agree.
“Social prescribing is about expanding our understanding of what family medicine is and what health is,” says Dr. Gary Bloch, a family physician who has long championed the integration of social determinants of health into frontline primary care.
“Family medicine is a relationship-based specialty, so we develop a deep understanding of the complexities of our patients' lives. This holistic view of health — where social, mental and physical aspects are interconnected — helps us understand and support what health really means to our patients," says the Department of Family and Community Medicine faculty member.
Social prescribing as a term was coined in the United Kingdom in the 1990s, alluding to efforts by health professionals to refer patients to non-clinical services. While free museum visits and national park passes have attracted public attention, the core of social prescribing focuses on connecting patients to community programs and resources such as social benefits or disability supports.
“This is work that family physicians have been doing for decades,” says Dr. Dominik Nowak, a family doctor at Women’s College Hospital, DFCM faculty member and president of the Ontario Medical Association.
“We do it because it is part of being a ‘good doctor’ and we know our patients need the support, but it often seems like something that is outside the system. When you name it, you can make it systemic and start to put supports around it.”
On the east side of downtown Toronto, Dr. Bloch and the St. Michael's Academic Family Health Team are starting to make these systemic changes with programs including the SEED (Support, Equity, Empowerment and Dignity) for seniors initiative.
Launched in 2023, SEED focuses on isolated older adults in the St. Jamestown, Regent Park, Moss Park and St. Lawrence neighbourhoods, which have a high proportion of seniors living alone and in poverty.
The program relies on community health workers, who build partnerships and map out community resources, and link workers, who develop relationships with individual clients to understand their needs and connect them with appropriate services.
“As a link worker, my job is to get to know my clients, understand their goals and co-design a plan with them,” says Sandesh Basnet, a link worker with the SEED program.
“One person might want to be able to go swimming or do a cooking class or become more tech savvy. But not everyone is ready for that right away. Some of our clients don’t
leave their apartments, so we work on building their confidence about going outside, even if it is just down to the lobby or across the street for a coffee.”
In the program’s first months, from January to September 2024, SEED’s two link workers saw about 80 clients in the community. But with almost 50,000 patients associated with the family health team, the need far outstrips supply.
“When you get older, every day can be a struggle. You look at your calendar and it is all medical appointments and not a lot else. And that’s the reality,” says Barbara Center, a St. Jamestown resident and SEED community advisory committee member.
“Those of us who aren't living on the edge or are managing OK, we have a responsibility to those who need help and services. I live alone. I've been lonely. I've been depressed. I came to this program because I felt I had experiences to share.”
While not all clinics will have the benefit of link workers on staff, Dr. Bloch and the team hope to build a network of programs, resources and educational curricula to nurture a health workforce that understands, values and can implement social interventions.
A significant inaugural step is the first Canadian social prescribing resource for primary care providers, launched in October 2023 in collaboration with the Centre for Effective Practice, Alliance for Healthier Communities, Canadian Institute for Social Prescribing and St. Michael’s Academic Family Health Team.
The resource, which has been accessed over 4,000 times, is intended for family physicians and others wanting to practise social prescribing in a more formalized way. It is complemented by a new, interactive, web-based training module.
“People look at doctors and see that our power isn’t just around medications, it’s about relationships and how we connect people to broader health,” says Dr. Nowak, co-clinical lead for the resource.
“Social prescribing has been around a long time, but its importance has flown under the radar. These projects are part of a movement helping change that.” Number of
When facing a life-limiting illness, most Canadians say they’d like to spend their final days at home. Unfortunately, only about 15 per cent of Canadians have the palliative care resources to do this.
Programs led by faculty at the Department of Family and Community Medicine (DFCM) at the University of Toronto aim to close this gap.
Neuropalliative Program — Credit Valley Family Health Team
With a wide range of possible neurological disorders — from ALS to multiple sclerosis to dementia to stroke — and with numerous specialists often required for care, the journey to and following a diagnosis can be quite complicated. Navigating support and care in the community is often challenging for these patients and their families.
What psychological and social services are available to the patient and their family in their community? When should palliative care be the focus? Is palliative home care an option? Whose responsibility is it to arrange all of this? Who will see a patient when they can no longer visit a clinic?
With the Credit Valley Family Health Team’s pilot Neuropalliative Program, a family physician can answer these questions while providing care and helping patients and their families navigate this difficult time, including by supporting care at home.
“As a family physician, you really have this opportunity to be an anchor in your community and support community integration at all stages of disease for patients with advanced neurologic conditions,” says Dr. Nina Yashpal, family physician with the Neuropalliative Program and assistant professor with the DFCM. “You can be a constant throughout the journey and really provide comprehensive and compassionate care to a population of patients and their caregivers who often feel invisible and isolated at home.”
When patients are diagnosed with an advanced neurological illness, they are often referred to the Neuropalliative Program by neurologists, geriatricians, internists or palliative care physicians at the hospital. From there, one of the four family physicians, including DFCM faculty members Drs. Ali Damji, James Pencharz and Melissa Graham, will join their care. This involves collaborating with the patient’s family physician or serving as their family physician if they don’t have one, all while offering a palliative approach. The program also provides home visits, especially towards the end of the patient's journey when their abilities are deteriorating and they are unable to leave their home.
Although the pilot program has only been running for two years, it has been operating unofficially for longer, providing many home visits to patients, allowing them to remain where they are most comfortable while receiving the care they need. It has also been ensuring caregivers are supported, preventing burnout and helping to manage the emotional challenges of caring for a loved one with advanced neurologic disease.
Hudson Regional Cancer Centre.
Photo courtesy of Royal Victoria Regional Health Centre.
“It is so rewarding being able to help patients stay home and collaborate and coordinate with others to improve care,” says Dr. Yashpal. She hopes that other communities and future family physicians will see the value of this work and will help to expand it moving forward.
Dr. Carleigh Clarke, a DFCM family medicine resident at Credit Valley who has been working with the Neuropalliative Program, shares this sentiment.
“This experience deepened my appreciation for the importance of patient-centred, home-based care and the impact it can have on improving quality of life,” says the resident. She adds that working with the program has helped her develop skills in having difficult, compassionate conversations and has highlighted the value that family physicians provide.
“I am excited to build on what I have learned and continue making a meaningful impact on patients and families.”
Oncology Symptom Management Clinic (OSMC) — Hudson Regional Cancer Program
When a patient living in Simcoe County or the District of Muskoka is diagnosed with cancer, they are often sent to the Hudson Regional Cancer Program (HRCP) at the Royal Victoria Regional Health Centre (RVH) in Barrie. While the HRCP offers great care, toward the end of a palliative cancer journey, when immunity is low and comfort is the top priority, it can be hard to access depending on a patient’s location.
“At the OSMC, we'll bring a palliative approach to cancer care to you,” says Dr. Jacky Lai, family and community physician, palliative care physician and DFCM assistant professor. “We'll bring our team. We'll bring our medications, hospital bed and supports. We'll manage your pain and your symptoms at home."
Before the launch of the OSMC in 2019, Dr. Lai says a patient’s cancer journey was often disjointed. When treatment stopped working, the transition to palliative care would be unclear.
If a patient's family physician did not feel comfortable providing a palliative approach to care — or if the patient lacked a family physician altogether — the patient would
end up in the hospital emergency room seeking pain relief. It was only at this point that they would be connected with palliative care services.
With the OSMC, which runs through the HRCP, oncologists know exactly to whom to turn to navigate the next steps.
Following a referral to the program, patients can expect to connect with the team in a timely manner. From there, palliative and home care are arranged.
And while Dr. Lai and the 12 other family and palliative care physicians on the team — many of whom are DFCM faculty — are very accessible to the OSMC patients, Dr. Lai takes pride in knowing that only about 30 per cent of patients are seen in the clinic.
“The mic drop part is that most patients who are referred to our program aren’t actually seen by us,” he says. “About 60 to 70 per cent of the individuals actually get connected back to their local communities, back to their family physician or back to their local palliative care team.”
Dr. Lai says this is so meaningful to him because when the program was being developed, the patient and family advisory council was clear that they wanted to receive their palliative care as close to home as possible.
This success is part of the reason why the OSMC received the Quality Award from the Cancer Quality Council of Ontario in 2021 and why referrals grew from 30 to about 1,000 annually in just a few short years.
Looking ahead, Dr. Lai and the OSMC team hope to expand the team’s capacity so they can support more patients with cancer. One day, they’d like to expand to services to palliative patients experiencing other illnesses.
Number of DFCM faculty at:
Credit Valley Hospital: 136
Royal Victoria Regional Health Centre: 69
A “BRAVE SPACE” FOR FEMALE FAMILY DOCTORS WORLDWIDE TO GROW LEADERSHIP SKILLS
By Amy Noise
A new global initiative is helping female family doctors to grow their leadership skills, paving the way for stronger, more inclusive health-care systems worldwide.
DFCM faculty Dr. Suzanne Shoush cofounded the Call Auntie Clinic, which provides primary care grounded in Indigenous ways of knowing and being.
Dr. Roshni Jhan
Topic chosen by PFAC
AThe AWE-FM course was honoured with a prestigious Helen P. Batty Award for Excellence in Innovation in Program Development and Design at the 2024 Temerty Medicine Annual Education Achievement Celebration.
lmost half of all doctors in OECD (Organisation for Economic Co-operation and Development) countries are female. This shift, growing over the past two decades, marks a dramatic change in the physician workforce, but one that is highly variable depending on the country and medical specialism.
“In countries such as Latvia and Estonia, almost three-quarters of doctors are female, compared to approximately one-quarter in Japan and Korea,” says Dr. Meseret Zerihun, a family doctor, assistant professor at Addis Ababa University, Ethiopia, and former program director of Ethiopia’s first family medicine residency program—a role she stepped into soon after graduating.
“In all contexts, female doctors tend to work more in general medicine and medical specialties like family medicine and pediatrics, and less in surgical fields.”
In Canada, 45 per cent of all physicians are women, with a 50-50 split in family medicine and younger physicians more likely to be female.
While women make up an increasing percentage of the health workforce, the World Health Organization estimates that women hold only 25 per cent of leadership roles.
“We know that women are leading in family medicine work—in clinical spaces but also academic, teaching and leadership spaces. We also know that globally they may be underrep-
GROWING ACADEMIC, COMMUNITYCENTRED FAMILY MEDICINE IN SCARBOROUGH
By Amy Noise
Scarborough is a vibrant and diverse community. With its rich cultural mosaic, natural beauty spots, thriving local businesses and strong sense of community, it is a dynamic hub of growth and opportunity.
Its appealing qualities draw newcomers from across the globe, but as the population grows, access to primary care is lagging.
“There are 100,000 people in Scarborough without a family doctor or nurse practitioner,” says Dr. Avnish Mehta, family physician and corporate chief of family medicine at Scarborough Health Network (SHN). "In an area where many residents have complex health needs and face multiple barriers to care, we have many patients without primary care. This leads to high numbers of emergency department visits for minor and chronic issues."
While the needs for family medicine are great, so are the rewards for those who practise it.
Dr. Mehta and the team at SHN are working with the Scarborough Academy of Medicine to add over 80 MD and resident learners and 20 new family medicine teachers.
“We know that learners who train in a community are more likely to stay and practise locally,” says Mehta, who is also the medical lead for the Scarborough Centre for Healthy Communities. “But to do that, we rely on inspiring family medicine teachers who can show learners the joys of family medicine and the joys of Scarborough.”
Topic chosen by PFAC
Platinum Medical Clinic, Scarborough Village
t How long have you been teaching? Eight years; two as co-undergraduate program director
t Why do you teach? I love it. My students teach me so much and it keeps my skills up to date.
t Why Scarborough? It’s home. I can’t imagine living or working anywhere else.
Platinum Medical Clinic, Scarborough Village
t How long have you been teaching? 18 years
t Why do you teach? I started because I felt I had something to give back. I continue because it’s incredibly rewarding watching a nervous new learner bloom into a confident clinician.
t Why Scarborough? I’m a Scarborough girl through and through, working, living and raising my family here. The question is, Why not Scarborough? It is a very deserving community.
Silver Star Medical Centre, North Scarborough
t How long have you been teaching? Less than a year
t Why do you teach? So many people have helped me on my journey in medicine that I wanted to give back and share my passion for learning.
t Why Scarborough? I grew up here and have always felt a deep sense of community connection. I was drawn back because of the needs and challenges in this community.
East GTA FHT and FHO, West Scarborough
t How long have you been teaching? 30 years
t Why do you teach? I had amazing teachers that inspired me, and I wanted to return some of that. You learn so much from your students; it stops you from getting stale.
t Why Scarborough? I was completing an academic fellowship with DFCM in 1992/93 and was told by Dr. Walter Rosser, DFCM Chair at the time, about the exciting new resident teaching program which had just started in Scarborough. I came here in 1993 and have been teaching residents ever since.
Scarborough Health Network, Centenary
t How long have you been teaching? Eight years
t Why do you teach? I enjoy teaching MD students on their first venture into the real world of medicine and sharing my passion with people keen to learn.
t Why Scarborough? I speak a few languages, and I get to use them often in such a multicultural area.
Dr. Karthika Sithamparanathan
Dr. Rosemarie Lall
Dr. Derek Ng
Dr. Randy Lee
Dr. Mark Shew
OurCare
OurCare is a national conversation about the future of primary care, led by Dr. Tara Kiran, vice-chair, quality and innovation at the Department of Family and Community Medicine (DFCM).
Over 16 months, between September 2022 and December 2023, OurCare engaged with nearly 10,000 people to learn about their experiences with primary care and their values, ideas and hopes for the future and improvement of that care.
The conversation placed special emphasis on engaging people who have the greatest care needs, face the greatest barriers to accessing care and are most likely to be excluded from policymaking decisions about primary care.
From the national survey, priorities panels and community roundtables, the OurCare team heard what people believe high-quality primary care should look like. These expectations were distilled into a set of six elements that represent their aspirations for a more sustainable, accessible and equitable system.
Next Steps
The Office of Health System Partnerships (OHSP) at the DFCM is a primary care solutions workshop that aims to leverage DFCM’s breadth of expertise to catalyze practical, data-driven thought leadership in order to strengthen primary care. As part of this work, the OHSP will provide a series of policy briefs outlining concrete action plans and solutions to advance primary care in Ontario to achieve the people-centered goals of the OurCare Standard. The target audience will include policy decision makers such as ministers and deputy ministers of health, regional health authorities and advocacy organizations.
OurCare The Standard
1.
2.
Everyone has a relationship with a primary care clinician who works with other health professionals in a publicly funded team.
3.
Everyone receives ongoing care from their primary care team and can access them in a timely way.
4.
Everyone’s primary care team is connected to community and social services that together support their physical, mental and social well-being.
Everyone can access their health record online and share it with their clinicians.
5.
6.
Everyone receives culturally safe care that meets their needs from clinicians that represent the diversity of the communities they serve.
Everyone receives care from a primary care system that is accountable to the communities it serves.
Vision Mission
Outstanding primary care for all, powered by world-leading research, education, and innovation.
We deliver the world's best education for family doctors and propel knowledge, systems and teams to help people and communities thrive.
As the largest department of family and community medicine in the world, we have a duty to take on the biggest challenges facing the health-care system. To answer them, we need a new plan, new energy, and NEWSCHOOL
THINKING
WHY
Ultimately, our aim in everything we do is to work towards family and community health.
WHAT
We assess and prioritize our actions, concentrate our energy, and focus our strategic intention using three lenses: community, relationships, leadership.
HOW
The core tools of our work are education, research, and high-quality clinical care.
