On January 31, 2024 the MWT-OHT held an All Partner Meeting. OHT members from community and hospital-based organizations from across the MWT-OHT attended and learned about 6 leading initiatives within the MWT-OHT.  

Many patients have benefitted from the following collaborations in our OHT. Here is a summary of these Mid-West Toronto OHT programs: 

Open Door Program: Nurturing Health and Wellness 

The Open Door Program works with residents in high-priority neighbourhoods, unattached individuals, recent immigrants and refugees to attach them to primary care and offer health promotion, preventative screening, diabetes, and foot care screening. They have attached over 300 patients to date to primary care. 

In Your Corner Program: Bridging Gaps in Substance Use Support  

The In Your Corner Program is a key program in the MWT-OHT, developed through a codesign process involving Open Lab and individuals with lived experiences with substance use disorders. This program leverages the collective knowledge and navigation skills of multiple MWT-OHT partners to help those facing challenges related to substance use transition to services without relying on acute services. The program has matched approximately 300 patients to over 219 services in our region. The program's success has sparked regional interest, with discussions underway to potentially scale it more broadly.  

CAMH@Home: Empowering Community Transitions  

The CAMH@Home Program, a relatively recent program, emerged to address an internal challenge faced by CAMH in discharging older adults with Schizophrenia to the community. Relationships have been built connecting CAMH with Home and Community Care to successfully transition over 40 people to date. 

Integrated Pathways: Enhancing care for CHF and Lower Limb Preservation 

Ontario Health requested the MWT-OHT to establish two Integrated Clinical Pathways for lower limb preservation and chronic heart failure.  Numerous OHT partners have come together to serve more than 2000 patients with CHF and 115 people with peripheral vascular disease. There are plans underway to introduce a COPD pathway in the coming years. 

ALC: Seamless Transitions from Hospital to Community 

West Neighbourhood House secured funding to facilitate the discharge of ALC patients requiring high-intensity support at home. This initiative has enabled direct pathways and warm handovers from hospitals to community, providing comprehensive care with the collaboration of OHT partners. The program has worked with patients being discharged from UHN and St. Joseph's Hospital and has successfully transitioned over 65 patients to date. The program is exploring expanding partnerships to streamline warm handoffs from hospitals to the community, aiming to improve overall ALC days in the MWT-OHT.  

Connecting Family Physicians and Nurse Practitioners in the MWT-OHT 

The Mid-West Toronto Family Practice Network was established as a non-profit corporation to serve as the representative voice of family practitioners within the MWT-OHT. It advocates for collaborative and coordinated care in the region, representing various primary care models, including Community Health Centers, Family Health Teams and small community practices. To date we have over 300 primary care practitioner members in the MWT-OHT. The Executive has advocated for funding opportunities to expand team based care, formed a family physician and specialist collaborative, and offered educational events, such as the use of AI technology in family practice.