East Toronto Health Partners (ETHP) submit full application to become an Ontario Health Team for East Toronto

October 9, 2019

Hon. Christine Elliott
Ontario Deputy Premier and Minister of Health
Hon. Merrilee Fullerton
Ontario Minister of Long-Term Care
College Park, 5th Fl.,
777 Bay St, Toronto
ON M7A 2J3

RE: Ontario Health Team Submission from the East Toronto Health Partners

Dear Ministers Elliott and Fullerton;

In partnership with those who receive care and those who provide care in East Toronto, the East Toronto Health Partners (ETHP) are pleased to submit our full application to become one of Ontario’s first Health Teams. In your call for applications, you invited us to be bold in our thinking, and we have taken this to heart. We also recognize that with the changes envisioned
for health care in Ontario, there are both opportunities and inherent risks. We want you to know that we are fully committed to building a bolder, brighter future for the delivery of health and social care for our local communities, and we look forward to the support of your Ministry to help us transform our systems of care.

Our vision is to work with our community to co-design ‘A System without Discharges’: A seamless continuum of care focused on population health, with programs tailored to our 21 local neighbourhoods and communities. We have grounded our vision in the Quadruple Aim, with goals to improve quality of care and the experience of our patients and caregivers, enhance health and wellness for clinicians and other front-line providers, improve overall population health, and increase the value of investments in health and social care.

About Our Population
Collectively, we serve the approximately 300,000 children, adults and seniors who live in the multiple communities that comprise East Toronto. Our boundaries span from the Don River to the West, to Warden in the East, and from South of Eglinton Ave to Lake Ontario; and include priority neighbourhoods such as Thorncliffe Park and Flemingdon Park. We also serve Ontarians across the Greater Toronto Area and beyond for a total attributed population of 375,000. When our Ontario Health Team reaches maturity, we will have a full population health and integrated care model that supports our entire population; however, in Year 1 we will focus on integrating care for the following three populations:

1. Seniors with chronic care needs and caregivers: East Toronto has a significant population of seniors (53,712) and heavy burden of chronic illnesses including Chronic Obstructive Pulmonary Disease (3,937 people) and Congestive Heart Failure (2,734 people). Seniors with chronic care needs experience high levels of hospital admissions, and long lengths of stay, contributing to hallway medicine pressures. We selected this population because of the risk factors within the East Toronto seniors’ population with chronic care needs, including high rates of caregiver distress (up to 47% in some of our communities). The redesign of care for this population will build on what we’ve heard from patients, families, caregivers, and health care providers about the current challenges they face with fragmented services and poor transitions of care.

2. Youth Mental Health and Wellness: As rates for mental health issues in youth are rising across Toronto and Ontario, some neighbourhoods in our region such as Taylor Massey have three times higher Emergency Department (ED) use for youth mental health than the Toronto average. East Toronto has approximately 7,977 youth living with mental health conditions. Our initial work with youth in East Toronto has identified several opportunities for us to co-design improved access to care and better support youth mental health and well-being.

3. Substance Use and Health: East Toronto providers serve significant numbers of people with issues of substance use. The Canadian Institute for Health Information identified 7,288 people in our attributed population with diagnosed Drug/Alcohol Dependency; often these individuals are disconnected from basic primary care, have significant issues related to the social determinants of health, and have high rates of emergency room use and hospital admission. We have identified opportunities with patients and providers to coordinate harm reduction, treatment, and crisis supports to improve health for this population.

Our work with our priority populations will be grounded in a neighbourhood approach; starting with the five “Neighbourhood Improvement Areas” as defined by the City of Toronto. This neighbourhood-based approach is intended to help us address some of the priority equity considerations facing our population; a high proportion of newcomers and immigrants, patients who are uninsured, individuals and families with lower incomes, and engagement of Indigenous and Francophone populations. Of our total attributed population of 375,000, the 178 family practice physicians who have joined the new East Toronto Family Practice Network (EasT-FPN) care for approximately 200,000 patients. In addition, the priority populations for Year 1 aggregate to roughly 69,000 people.

Through our members and the scope of services we provide, ETHP will provide actively coordinated care for roughly 20% of the total Year 1 population: a total of 13,800 individuals. In addition, the 200,000 residents who access primary care through family physicians who are part of EasT-FPN will have access to integrated care through our SCOPE program, interprofessional care teams, fall/winter community surge investments and other existing programs in East Toronto.

About Our Team and How We Will Work Together
The ETHP are building on a 25-year history of collaboration to improve the health of our local population through collaborations such as Partners for Health and the Solutions Network. In late 2017, the CEOs of five organizations that represent the continuum of healthcare came together to form the foundation for an integrated care network (ETHP). Over the past two years, the ETHP has been working with patients, families, community representatives and a range of partner organizations towards this goal.

In October 2019, the ETHP welcomed our newest Anchor Partner, the East Toronto Family Practice Network (EasT-FPN) which was created to be the representative voice of the over 260 family physicians in East Toronto. EasT-FPN has established an Interim Board of Directors, Interim Executive and a Memorandum of Understanding for engaging with family physicians. Over the next few weeks, EasT-FPN is hosting a series of engagement sessions for family physicians to learn about the work of the ETHP and encourage physicians to participate in the design and development of our Ontario Health Team. To date, 178 family physicians have joined the EasT-FPN, who care for approximately 200,000 patients as part of the ETHP.

The ETHP is governed through an Anchor Partner model, with each member of our anchor organizations representing a different care sector. Our starting point for governance has been a ‘network of networks’ model which has enabled a small group of trusted partners, which represent the full continuum of care, to facilitate change and improve care through a streamlined decision-making process. The current members of the East Toronto Health Partners are:

  • Patients, Families and Caregivers** East Toronto Family Practice Network – EasT-FPN
  • Michael Garron Hospital (Toronto East Health Network)
  • Providence Healthcare (Unity Health Toronto)
  • South Riverdale Community Health Centre (on behalf of East Toronto CHCs)
  • VHA Home HealthCare (liaison to home care providers)
  • WoodGreen Community Services (representing home and community care, community mental health, addictions and developmental services, community support services and housing)

The organizational members above will be formal signatories to the Joint Venture agreement and to the eventual accountability agreement with the Ministry of Health. Our Joint Venture agreement, which will be signed by the Anchor Partners in October 2019, outlines our shared principles, how we will work together, and how our partnership will evolve over time.
In addition, the ETHP network of providers includes two other levels of partnership:

  • Engaged Partners, actively involved in the planning and delivery of specific initiatives; and,
  • Supporting Partners, who remain informed and involved, but may not be active in planning or delivery.

A letter of support from our partners is included in the supplemental information of our application. Together, all of our partners deliver the full range of services needed to support our Year 1 populations.

**Over the last 6 months, the ETHP has hosted a number of community engagement sessions to involve patients, caregivers and providers in helping us co-design the future of care for our priority populations. To help guide our ongoing work, a Patient and Caregiver Engagement Planning Team consisting of advisors from existing Patient and Family Advisory Committees from several East Toronto organizations was established to advise on different approaches to patient, family, caregiver and community engagement for the ETHP. Our Patient and Caregiver Engagement Planning Team is assisting us with next steps in this work, including a process to identify ongoing membership at the Governance level to ensure patient and caregiver involvement in strategy, priority setting and decision making.

We will continue to work with all our communities as we redesign the future of care in East Toronto. To support this work, the ETHP has developed a Community Engagement Framework; a best practice guideline for current and future engagement activities within the OHT planning context. Patients, community members and providers were engaged in a joint working group with representation from the East and Downtown East OHTs to develop this framework.

How We Will Transform Care
The ETHP see significant opportunities to improve care for our population and health system performance as we create an integrated health system. Our shared vision is centred on creating ‘a system without discharges’; one connected system of health care and support for all residents in East Toronto. Our most important improvement opportunities are fully aligned to this shared vision:

1) Create a one-team approach with patients, caregivers and providers: This includes engaging with care recipients to design care transformations that meet their needs, supporting all our staff to work to their full scope, and building stronger networks between providers who deliver similar and complementary services. For our Year 1 focus, we will expand our existing integrated, interprofessional team-based care models and simplify access to community support services. For our youth and adults with mental health needs, our focus will be on building skills, relationships and trust, to support them with their goals.

2) Coordinated Care tailored to Local Neighbourhoods; scaling up our early successes: This includes evaluating and expanding our existing integrated care initiatives and shifting more care from hospital to community. We will co-design tailored solutions for our 21 neighbourhoods to address their distinctive needs, ranging from designated improvement areas to higher income communities. For our Year 1 focus, we are targeting improvements to three Neighbourhood Improvement Areas; Thorncliffe Park, Taylor-Massey and Oakridge. We will also expand our Home 2Day program to support a broader range of patients with cardiac and respiratory conditions, increase our community investments during the flu season, and expand our interprofessional care team models to other neighbourhoods in partnership with our primary care partners.

3) Support the Success of our New Primary Care Network – The ETHP is very excited to welcome our newest Anchor Partner, the East Toronto Family Practice Network (EasT-FPN). Full engagement of primary care at every level of the ETHP is critical to the success of an integrated model of care in East Toronto. Together, the ETHP will develop multiple ways to engage and connect with local family physicians so they can continue to be an integral part of the design and evolution of integrated care. The ETHP are also working on a financial plan as part of our shared commitment to develop and sustain our partnership.

4) Streamline Access and Navigation, enabled by Digital and Virtual Care: This includes providing easier access to information and access to services, reducing the burden of chronic disease, and improving coordination of care to support patients and their caregivers. For our Year 1 focus, we will: finalize our asset maps of services that support our Year 1 populations; create digital navigation tools for local services such as Youth mental health and wellness programs; and, establish patient navigators to support seniors with chronic disease and caregivers with health system navigation, service planning, care plan accountability, and one touchpoint for hospital to community transitions. For individuals who access the Emergency Department related to substance use we will coordinate access to community services based on similar models implemented at peer hospitals.

5) Improve population health and health equity: This includes reducing gaps in care and improving coordination of services for vulnerable, marginalized and under-served populations. For our Year 1 focus, we are targeting improvements for seniors living in Toronto Community Housing buildings, youth with mental health concerns, and adults with substance use issues.
Our overall vision for care redesign is centred on creating integrated, community-based health and social care teams across our 21 neighbourhoods that will support 24/7 access, and link to acute care, specialty care and other regional services as depicted in the graphic below.

Unlike our current siloed health care system, through our neighbourhood-based model of integrated care, people will experience one local system that provides simple access to health services and social supports, navigation and care coordination, inter-professional/ interorganizational teams, and streamlined communication of health and social care providers. This model focuses on simplifying the system for patients and frontline staff, maximizing current system investments and enhancing efficiency and effectiveness. Key enablers of this model of care are:

  • A simplified model for care transitions, with established care pathways that support patients to move easily from hospital to home;
  • Integrated, neighbourhood-based care teams, that align interprofessional teams from home care and community support services with primary care;
  • Care Coordinator/Navigators aligned to neighbourhoods / specific geographies using existing staffing resources from organizations that currently provide these services;
  • Access to regional supports including, but not limited to; acute care, specialty care, 24/7 call centre support services for patients and caregivers, virtual care and remote monitoring; and,
  • Digital communications and integrated information systems to support care teams, patients and caregivers with real-time access to patient health information and care plans that address the full social determinants of health.

Digital Health

The ETHP Digital Health Team has created a vision and a strategy for advancing virtual care, access to health information, information sharing, and quality improvement. Our overarching goals for the ETHP Digital Strategy are:

1. Achieving Digital Connectivity – to allow for the exchange of information and open communication that is fundamental to an integrated system of care

2.Digital-First Customer Service – to prioritize solutions that support health equity, positive experiences and flexible virtual care options

3. Fostering an Intelligent Learning System – to optimize our use of population health and care data, advance predictive capabilities, provide centralized supports and enable innovation

Specific solutions included in our Digital Strategy include expanding the use of the MyChart application across our partners, testing a patient-oriented portal, leveraging existing app-based technology to facilitate 24/7 access to support for patients and caregivers, expanding use of virtual visits, and enabling secure messaging between providers (and eventually patients and caregivers). The ETHP are in the process of developing a data-sharing agreement as well as common policies for privacy, security, cyber-security and data governance.

The Province’s policy shift to the Ontario Health Team model has provided a substantial opportunity for East Toronto to spread and scale the work we have already started, as well as creating new platforms for change and innovation across all our provider partners. In our application we have identified specific actions the provincial government can take to help us accelerate our efforts (including addressing policy barriers, providing resources and funding support in specific areas, and supporting provincial digital solutions), which we would be pleased to discuss further. We are excited to submit our full application and are confident that we are ready to be one of the province’s first Ontario Health Teams.


Anne Babcock
President and CEO, WoodGreen Community Services
On behalf of the East Toronto Health Partners

Dr. Rueben Devlin, Special Advisor and Chair of the Premier’s Council on Improving Healthcare and Ending Hallway Medicine
Helen Angus, Deputy Minister, Ministry of Health
Marie-Lison Fougère, Deputy Minister, Long-Term Care
East Toronto Health Partners

The Full Application for ETHP to become an OHT can be read here.

Board appoints co-CEOs to lead SRCHC during transition

SRCHC’s two directors Jason Altenberg, Director of Programs and Services, and Shannon Wiens, Director of Organizational Health Systems were jointly appointed as interim Co-Chief Executive Officers effective September 6.

Lynne Raskin retired from her position as Chief Executive Officer at South Riverdale Community Health Centre effective September 5, 2019.

Ms. Raskin’s leadership established a resilient organization, well positioned to continue advancing SRCHC’s vision of empowered, healthy and thriving communities where everyone belongs. In the interim, the Leadership Team will continue the organization’s good work and rely on internal management resources to maintain the vision, mission and values of the organization.

The Board of Directors has a plan in place around the search for a new CEO to lead the organization with a view to ensuring a smooth transition during this change of leadership. The Board has engaged the services of a reputable executive search firm in the process to appoint a suitable and qualified successor who will meet the needs of the organization. This process could take four to six months.

News Release: Films for people with chronic disease to ‘Choose Health’ in East Toronto, September 19, 2019


September 19, 2019

Films for people with chronic disease to ‘Choose Health’ in East Toronto

TORONTO (September 19, 2019) – Last night, South Riverdale Community Health Centre (SRCHC) and the Toronto International Film Festival (TIFF) launched a community film screening program to bring short films into communities across Toronto. As part of a community building experience to address social isolation, the two partner organizations leveraged their strengths to train people living with chronic health conditions to facilitate post-screening discussions. This community film screening program is an expansion of work previously done with arts and cultural institutions within SRCHC’s city-wide service, Choose Health. Choose Health is a Government of Ontario, Ministry of Health mandated service offering 14 peer-facilitated programs that help people learn how to take care of themselves while living with long-term health conditions such as diabetes, heart diseases, cancer and other chronic health conditions.

People watching a movie in a group setting.
Participants enrapt with the film “Roy Thomson”at the inaugural peer facilitated community film screening program of South Riverdale CHC and TIFF.

“We are excited to begin this partnership with TIFF and bring celebrated Canadian short films and guided conversations to our clients who will benefit from social interaction, community engagement, and wellness opportunities like these. We have found that a social activity like visiting the museum or watching a film together that is led by someone with similar lived-experience and relatable health conditions improves access and connections for our clients,” said Jason Altenberg, interim co-CEO and Director of Programs, SRCHC.

By partnering with arts and cultural institutions across Toronto and co-creating peer-led programs with people who live with chronic conditions, SRCHC and Choose Health are inviting clients to engage in their health and well-being through social interaction and belonging.

“TIFF’s Mental Health Outreach program is one of several community initiatives dedicated to increasing access to film. Year-round, we partner with hospitals and community health programs across the Greater Toronto Area to co-create film experiences that reflect the needs, interests, and experiences of each group. Watching and discussing film in a supportive group setting can be a transformative experience, promoting well being by creating space for self-expression, social connection, and skills development. We are thrilled to partner with SRCHC and Choose Health to empower a passionate group of film lovers to bring these films and experiences to their communities,” said Elysse Leonard, Senior Coordinator of Youth & Community Initiatives, TIFF.

This partnership with TIFF is built upon the success of the community health centre’s partnership with the Art Gallery of Ontario that began in January 2016. In both partnerships, SRCHC and Choose Health have brought in expertise, an understanding of the importance of the social determinants of health and people who live with chronic health conditions trained to deliver the services. TIFF, much like the AGO, provided an empowering training program that encouraged peer facilitators to approach film through the lens of their individual strengths, interests, and experiences, as well as those of their audience, and also allowed time for co-design with trained peer facilitators.

“I’m passionate about film because it can entertain, enlighten and change hearts and minds. It’s a window into society. It communicates feelings and thoughts, ideas and culture, in an inclusive and powerful way. As a TIFF Peer Ambassador, I look forward to introducing film to clients so that they can engage in activities and meaningful discussion about what they see,” said Carolyn B., SRCHC Peer Ambassador.

Hosted at SRCHC’s Danforth and Greenwood location, the program featured short films that explore themes of “storytelling” as a vehicle for family reminiscence (Roy Thomson, directed by Sofia Bohdanowicz), navigating one’s cultural identity (Show & Tell, directed by Reem Morsi), and combating colonial views of history (Flood, directed by Amanda Strong).  The 14 people who attended the screening were past participants from one of seven community based peer programs offered through Choose Health.

The idea of referring patients to supports offered in the community to improve their health and well-being has been described as social prescribing and has gained broad support in the UK’s National Health Services. In Ontario, the Alliance for Healthier Communities’ social prescribing pilot has brought similar attention to the power of community supports in helping a patient live a healthier life. SRCHC’s partnership with arts and cultural institutions, such as TIFF and the AGO, are about leveraging community supports to engage people in their health and well-being. The peer-facilitated model and access to co-designed programs provided by these cultural institutions is a unique service offered by SRCHC and its partners like TIFF and the AGO.

SRCHC and TIFF will host two more film screenings in the coming months. To learn more, please visit: www.selfmanagementtc.ca

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About SRCHC:  South Riverdale Community Health Centre is a non-profit, multi-service organizaton that provides primary healthcare, social and community outreach services with an emphasis on health promotion and disease prevention primarily to people of East Toronto. Our mission is to improve the lives of people that face barriers to physical, mental, spiritual and social well-being. We do so by meaningfully engaging our clients and communities, ensuring equitable access to primary health care, and delivering quality care through a range of evidence informed programs, services and approaches. We value health equity and inclusion and respect in our work and in the delivery of our services.


About Choose Health: Choose Health is one of South Riverdale Community Health Centre’s city wide services. Our service mandate is to enhance patient self-management and provider health literacy using evidence-based training and programs. Choose Health works in partnership with 33 arts, health, and social service sector organizations that are located in neighbourhood improvement areas and engages 1300 people annually in Toronto.


About TIFF: TIFF is a not-for-profit cultural organization with a mission to transform the way people see the world through film. TIFF is dedicated to presenting the best of international and Canadian cinema and creating transformational experiences for film lovers and creators of all ages and backgrounds. As Canada’s premiere home of cinema, TIFF offers screenings, lectures, discussions, festivals, workshops, events, professional development and opportunities to meet, hear and learn from filmmakers from Canada and around the world.

SRCHC Launches New Community Food Centre in East York

Woman and man chefs in a kitchen
Special guest chefs prepare a meal in new kitchen at Harmony CFC.

In early 2019, South Riverdale’s 2 Gower Street location became a partner site of Community Food Centres Canada (CFCC), a national organization that’s driving the development of community food centres across the country. Prior to this, SRCHC was and remains a Good Food Organization with CFCC with the goal of improving food security for people in our communities and creating an accessible and healthy food system. Our location at 2 Gower Street also hosts the Harmony Hall Centre for Seniors program.

In addition to our community food security programs, where space is provided for community to come together to make and eat healthy meals, we are now going to grow, cook, share, and advocate for healthy and accessible food for all as we expand our food programming.

With funding from CFCC, we have renovated the kitchen facilities at the 2 Gower Street location. This welcoming space for Harmony Hall and community members enables them to come together, and learn to cook and garden. Their health, and the general health of the community, is improved through healthier food choices. In addition to an enlarged, renovated kitchen, the hall was given energy efficient lighting, an updated ceiling, and new windows. We also redesigned and rebuilt the upstairs storage and washroom areas to make these spaces more accessible and energy- and water-efficient.

Along with other community food centres across Canada, South Riverdale CHC is increasing access to healthy food, empowering people to acquire food skills, and creating opportunities for people to become engaged in their community.

Harm Reduction Program in East Toronto Enhanced by the Addition of Supervised Consumption Services

Harm Reduction Program
Woman hands supplies to a man in the office.

keepSIX, SRCHC’s supervised consumption service (SCS) at our 955 Queen St. E. location, has been open for a year and a half. In July, 2018, SRCHC also began operating the Moss Park Overdose Prevention Site (OPS) at a stand-alone location on Sherbourne St., just south of Queen. SRCHC operates two of the six consumption services in east Toronto. These services have had over 13,000 visits and have reversed 270 overdoses (the vast majority at Moss Park).  As if this life saving work were not enough, the dedicated teams (overdose response workers, nurses, and community health workers/health promoters) at each location provide counseling and crisis support, health care, referrals, their lived experience and expertise on safer use techniques and a vital space for safety and community. The team shares responsibility for maintaining the flow and safety of these services, including responding to overdoses.

What’s A Typical Day at keepSIX? Here’s a Glimpse:


keepSIX opens at 9:30 and the first service users arrive shortly after. Staff have already been getting things set up for the day: preparing syringes of naloxone, checking the oxygen monitoring equipment and making coffee.


The first visit of the day is Bob.* (Editor’s note: where is the asterisk’s reference?) Bob was also the first person to use at keepSIX and comes every morning. Although he has his own place, he comes to the SCS because he doesn’t feel judged for his drug use here and knows that he’ll be taken care of if something goes wrong. Bob is a service user rep on the community liaison committee, made up of a range of community members, which meets every two months or as- necessary. He reports that the last meeting was good, there are no major community concerns and everyone seems really positive, eager to help and supportive.


One of our health promoters is at Moss Park OPS to provide an Indigenous sharing circle to support service users. Both keepSIX and Moss Park see a large proportion (between 30-55%) of Indigenous clients. Having access to these kinds of cultural practices in harm reduction spaces is vital.


By noon, keepSIX has had 20 people use the service. Visits to the SCS have doubled in recent months, as have overdoses.


An SCS staff-person notices that the person at booth two has slouched over and breaths appear infrequent. Other team members are called to help with the assessment. Everyone agrees that we should monitor the person’s oxygen levels with the pulse oximeter. Levels are low so the oxygen tank is brought over. The harm reduction worker holds the oxygen mask in place while the health promoter keeps track of vital signs. Providing oxygen is almost always the first step in providing overdose care and, in this case, is enough to support respirations until the service user is able to be roused 20 minutes later. The service user heads into the chill space for a snack and to chat with the harm reduction worker who will continue to assess for any signs of distress.

Late afternoon/evening

Toward the end of the day, Bernadette, SRCHC’s Hep C treatment nurse, stops by to offer rapid hepatitis C testing to service users. A service user comes in, ready to try detox. The nurse starts making phone calls and is able to find a treatment spot after several tries. We give the service user a taxi chit to ensure transportation. Meanwhile, the health promoter is providing some informal counselling to someone who recently learned they have HIV and tells them about community resources they can access.


By the end of the day, there have been 40 visitors. A day in this service can be stressful and hard, but it is just as often a positive and happy space where people find community, safety and a brief break from the war on drug users.

*Name changed to protect privacy.

MATCH Midwives provide equitable, quality midwifery care

A woman holding a baby.
A friend of the family holds this baby who was delivered by MATCH midwives.

The Midwifery and Toronto Community Health (MATCH) Program provides access to high quality, perinatal, reproductive and sexual health care for all people, regardless of OHIP status, at South Riverdale Community Health Centre.

Launched during the fall of .2018, MATCH prioritizes care for people who sometimes face barriers in accessing midwifery care that meets their needs. MATCH serves vulnerable communities such as new immigrants to Canada, visible minorities or people of colour, Ontario residents who don’t have OHIP insurance, people who are using drugs, people with low income, queer and trans folks, young or single parents, and people who are homeless or under-housed.

MATCH is a team of four registered midwives who join multidisciplinary primary care teams at South Riverdale Community Health Centre and Regent Park Community Health Centre; these teams include doctors, nurses, nurse practitioners, social workers, physiotherapists and others. MATCH midwives also provide care and services at Michael Garron Hospital, The Toronto Birth Centre or at the client’s home.

MATCH midwives are experts in sexual and reproductive health and are committed to providing respectful midwifery care to all people, particularly people living in complex situations. Guiding the sexual and reproductive health care that midwives at MATCH provide is a philosophy that patients/clients should have freedom of access and freedom of choice to decide if, when and how often they want to have children.

Since MATCH started accepting clients with due dates in February, 2019, the midwives have cared and are caring for 32 clients. Most receive pregnancy care and/or postpartum care but others are seen for pregnancy counseling and case management around abortion care. One client needed only to access the multidisciplinary team for immunizations. So far, MATCH midwives have attended seven births, one at the Toronto Birth Centre and six at Michael Garron Hospital. They are expecting to deliver nine more babies before the end of summer, 2019.

Chronic Disease and Homelessness


Based on a 2011 study conducted by St. Michael’s Hospital, 85% of people experiencing homelessness have at least one chronic health condition and more than 50% also experience mental health challenges. We often speak of “hard to reach” communities yet, for many, it is the traditional programs and services that are not reachable. As a result, many high-risk individuals go undiagnosed and untreated. A critical component of our cross-organization strategy lies in grounding our work where, how and when it is most relevant for those who are most at-risk for a range of chronic diseases

This past year, the Diabetes Education Community Network of East Toronto (DECNET), offered diabetes programs and services at more than six community locations where people who are precariously housed/homeless congregate, many of whom are also impacted by mental health concerns and/or substance use. Locations included Heyworth House, Mustard Seed, 416 Community Centre for Women, Nellie’s Shelter for Women, Warden Woods Community Centre (Out of the Cold program) and Oakridge Community Recreation Centre. The 21 community workshops and talks reached more than 128 individuals from these at-risk communities.

DECNET health care providers and peers with lived experience go where people are living to facilitate engagement and to reduce barriers. Along with the Canadian Diabetes Risk Questionnaire (CANRISK), screening and diabetes education, access to nutritious food is a vital component of this work. For example, at Nellie’s Shelter a six-week series was held with Cantonese and Mandarin interpretation for 45 women accessing the HerShare program. During these diabetes prevention workshops, offered by our outreach worker and diabetes prevention peer leader, 45 CANRISK assessments were completed. Keeping services relevant to reflect current life circumstances and complexities, all of our outreach is provided on a drop-in basis using a harm reduction approach; this gives individuals the option to participate when, how and if they feel ready. Through our participation in the Homeless Connect Toronto event in October, 2018, an additional 123 individuals experiencing homelessness received some connection and information about our diabetes services.

Within the SRCHC clinical team, similar outreach initiatives took place. Regular drop-in foot care during Outreach Clinic hours, annual flu clinics in local shelters and ongoing primary care in partnership with the Red Door Family Shelter are a few examples of how this work happens. In terms of new initiatives, in the fall of 2018, Michael Garron Hospital received funding to reduce the burden of “winter surge” on emergency department visits. In addition to increasing the hospital’s capacity, funds were given to partner community agencies so that hospital use was avoided. SRCHC was provided funding so that nurse practitioners could work in east Toronto shelters and drop-ins and, over six weeks, was able to provide urgent episodic care to the New Hope Shelter and the Mustard Seed.

Innovation and knowledge transfer are also important aspects of SRCHC strategic planning across teams as we continue to support and enhance the health of equity-seeking groups. Engaging in research advancements is one strategy. In early 2019, team members participated in the Homelessness and Diabetes research project led by researchers at St. Michael’s Hospital. Discussions are ongoing around how to better understand our program approaches in order to influence, in meaningful and respectful ways, the health outcomes for this community.


Group of people celebrate with a cake
Community members, Board and staff celebrate accreditation of SRCHC for the next four years

STRATEGIC DIRECTION: Strengthen Organizational Capacity

Accreditation provides an external review of an organization’s operations in relation to accepted standards of good practice and risk management. SRCHC worked with the Canadian Centre for Accreditation (CCA) to conduct a detailed review of our governance practices, operational management, and program and service delivery. We worked for over a year preparing documents, conducting a staff survey and organizing interview teams (Board, staff, clients and volunteers) and preparing for the site visit on February 12-14, 2019.

The final report from CCA appreciated the work undertaken by SRCHC and highlighted the welcome they received here. In their verbal wrap-up, the accreditation team praised the organization as a centre of excellence that lives its mission, vision and values. In particular, the team highlighted the work the organization has done to support clients and improve health outcomes. The final report comments on “The level of client engagement and how it led to innovative co-designed programming that valued and leveraged the client and staff lived experience for the benefit of the community.”

The team also highlighted the organization’s commitment to quality programs, continuous improvement and research. They stressed that “SRCHC has a strong tradition of not only generating research evidence but of also using evidence-informed and evidence-based research throughout its programs and services.”

The CCA congratulated the agency on achieving 79 of 79 standards and has accredited South Riverdale Community Centre for a four-year term. SRCHC thanks the CCA review team and everyone who supported this external review that allows us to tell our community’s story with clarity and confidence.

Building an Ontario Health Team for East Toronto

Ontario Health Team for East Toronto
Ontario Health Team for East Toronto

South Riverdale Community Health Centre has been part of a network of health care providers and organizations for several years. Formed in 2018, the East Toronto Health Partnership (ETHP) agreed to work together to form an Ontario Health Team for East Toronto. In early 2019, the Ontario government announced it was consolidating its local and provincial health networks.

The ETHP group’s partner organizations include Providence Healthcare (Unity Health Toronto), VHA Home HealthCare, WoodGreen Community Services, Michael Garron Hospital, and South Riverdale Community Health Centre as well as primary care partners. On May 15, the ETHP submitted an expression of interest in forming an Ontario Health Team for East Toronto.

The ETHP provides a comprehensive basket of health and social services, tailored to meet changing local needs. Its services range from primary to acute care, food security to supportive housing, home-based to community services, birth to end-of-life care, and settlement to employment. Our partnership is built on a legacy of trust in East Toronto, with a multi-decade track record of delivering “made in East Toronto” solutions together with our partners for more than 20 years.

At the centre of our model are the people we serve who have been involved in the planning and design phases of this process, engaged as active members of the ETHP. As our partnership model evolves and expands, we continue to follow a rigorous and inclusive process of engagement involving East Toronto community members.

In the months ahead, SRCHC is pleased to work with all of our partners to shape and design health care, and to deliver integrated services to those living in our community, and to any Ontarian who wishes to receive care in East Toronto.

Healthy Community Grant for Crescent Town Newcomer Mothers Health Living

Healthy Breakfast
Healthy Food


Settling in a new country is a big challenge for many new immigrants. They may need to find a shelter for themselves and their family, get a job, learn a new language, enroll their children in school, find a family doctor and more. Looking for healthy, affordable food gets less priority some of the time. Also, figuring out what to put in a child’s lunch box is a worrisome concern for mothers who are newcomers.

The Crescent Town Newcomer Mothers Healthy Living program of The Neighbhourhood Office was a recipient of an SRCHC Healthy Community Grant for 2018. The program’s objective was to create awareness of healthy living and eating among newcomer mothers, to empower them to keep their families healthy, and to thereby keep their communities healthy.

During eight two-hour sessions, the program addressed and delivered learning about:

  • Canada’s food guide and participating in food preparation.
  • nutrition facts, including nutrient loss during food preparation.
  • how to prepare simple and healthy lunches for school-aged children.

The interactive sessions were conducted by a dietitian for more than 15 families (with a few children also taking part). Feedback from program participants was very positive:

“It was a great opportunity for mothers to talk and share their own experiences and challenges for maintaining healthy food habits. We learned easy preparation of delicious and nutritious food.”

“The sessions were very informative and taught me a lot about the food we eat every day. I found out what carbohydrates and proteins do to my body and that it’s very important to eat a well-balanced meal to maintain a healthy weight and lower the risks of various diseases and complications.”

“The program was important to me because I learned what type of food should be provided during my child’s lunch period at school as well as I learned more about my nutrition.”

“The best part of the workshop was the hands-on practice by the presenter, organizer and participants of preparing healthy lunches. The recipes were easy and delicious, not too expensive but reasonable, hassle-free and full of variety.”

Yasmin Ashraf, Settlement Counselor, said the project helped to empower the newcomer mothers, and this will have a positive impact on the lifestyle of newcomer families in the Crescent Town community.