Integrated Primary Care

South Riverdale CHC’s pursuit of integrated health care is as old as the organization itself. However, a process which culminated in its most recent structural reorganization took shape in 2020. This led to the creation of integrated primary care services that support midwifery, clinical and social services.


Our primary care team uses the Rainbow Model. The model is for health care planning, health services integration, and a guide for mathematical modelling of workflow during service integration. It is a part of the essential functions and activities, and administrative support structured around primary care service delivery. The goal is to support accountability and evidence-based decision-making so that access to high quality service is ensured for priority communities. Our day-to-day operation remains rooted in our shared vision, mission and values.


2020 challenged health systems generally, and the primary health care system particularly, in unprecedented ways. It has forced health services to think differently, work more closely together, and adjust their approaches to the delivery of care. At SRCHC, we have leveraged rapid feedback models and the use of evidence to find the best interventions for improving patient outcomes.


As a learning organization, our team meets on a regular basis to plan, reflect and improve our practice. Meeting twice-monthly, the clinical team brings together nurses, physiotherapist, chiropodists, respiratory therapist, midwives, nurse practitioners, social workers, dietitians and physicians to discuss issues around health care. The meetings are used to share best practices and facilitate conversation around emerging health concerns. Working together, we address the needs of those with chronic/acute respiratory health challenges, homebound patients, and those with geriatric care needs. As a team and with our partners across the system, our goal is to ensure the best patient experience.


Our practice of integrated care enables us to effectively and efficiently identify and remove barriers to service. For example, many of our medically complex and socioeconomically vulnerable patients have lost some (if not most) of their important support services due to COVID-19 closures. As the first point of contact with our clinical care team, our registered nurses have taken on greater engagement and more in-depth case management for some of these clients in collaboration with nurse practitioners, physicians and allied health professionals.


The integrated primary health team at the centre, along with our infectious disease specialist, has become an integral part of our effort to maintain safe and accessible service during the pandemic. The team has taken on leadership roles and participates in a variety of relevant committees continuing to inform and support COVID-related efforts.


Additionally, the SRCHC Integrated Primary Care team is working on a post-COVID recovery strategy that builds on the lessons and practices that have worked during the pandemic. Some ideas include looking at revamped clinical spaces, ways to deliver service to where people are at, and consideration of population growth.