The NWT OHT strives to deliver coordinated care through identifying and understanding the needs of our community. To accomplish this goal, our OHT has a number of key priorities, please see below.
Mental Health, Substance Use & Wellness
Mental Health and Substance Use (MHSU) is a clinical priority for the North Western Toronto Ontario Health Team. The MHSU work aims to expand access to integrated supports for mental health and substance use recovery.
The high incidence of mental health and addiction in the NWT region underscores our OHT’s commitment to implementing the right support and services for our community. We have 3 new projects COMING SOON in Spring of 2025. Stay tuned for updates!
Looking for mental health and substance use resources? Visit the Substance Use Community Resource page under Resources for Patients, Clients, and Caregivers for more information.
Community Capacity Building
Provider Capacity Building
MHSU Pathways
Intensive Care & Support
The Intensive Care & Support Priority Area focuses on projects that will aim to improve self-management and access to the support clients need throughout the span of their chronic conditions.
Chronic Obstructive Pulmonary Disorder (COPD)
The North Western Toronto Ontario Health Team’s COPD Working Group has created a COPD Pathway in partnership with Ontario Health atHome, Toronto Community Paramedicine, Black Creek CHC, Lumacare, West Park Healthcare Centre, Runnymede Health Care Centre and Humber River Health. The pathway was designed to provide access to clinical and social services for patients and clients with COPD.
Lower Limb Preservation (LLP)
The NWT OHT is creating Lower Limb Preservation pathway to help patients access wound care in a timely manner and improve patient and provider experience. The focus is to help put off wound progression, promote recovery, and decrease acute care utilization by bringing the support of Own Health’s vascular surgeons to the patients. The LLP pathway can reduce avoidable amputation rates, optimize scarce healthcare resources, and provide person-centered life- and limb-saving care to the HRH community close to home.
Hospice @Home
The Hospice @ Home program is designed to help individuals, families, and caregivers understand and cope with the emotional, psychological, social, spiritual, and practical challenges when experiencing life-limiting illness and loss. The program is in partnership with Dorothy Ley Hospice (DLH) and Etobicoke Services for Seniors (ESS).
Senior Friendly Care
Promoting aging in place with coordinated, person-centred care.
Essential Care Partners
Caregivers play a critical role in providing unpaid emotional, physical, and cognitive support to their family member, partner, or friend. Essential Care Partner (ECP) programs and practices are a way for care settings to identify, include, and support caregivers as part of the care team.
The NWT OHT is working on an ECP program in collaboration with The Ontario Caregiver Organization (OCO) and Humber River Health. For more information about the ECP Program and OHTs please click here: https://ontariocaregiver.ca/ontario-health-teams/essential-care-partner/
Looking for additional resources for caregivers? Visit the Caregiver Resource page under Resources for Patients, Clients, and Caregivers for more information.
Post-Fall Pathway
The GTA Rehab Network is working with Toronto Community Paramedic Services and the North Western Toronto Ontario Health Team (NWT OHT) to start a new program to help prevent falls in the NWT OHT area. The initiative aims to reduce functional decline and prevent future falls for NWH OHT residents aged 55 and over who have called 911 for a fall, or who reported a fall to paramedics, but who were not transported to the hospital. The NWT OHT area was chosen for the initial pilot in part because it has one of the highest number of seniors in the province.
Visit https://gtarehabnetwork.ca/community-paramedic-post-fall-rehab-pathway/ for more information on the pathway.
HEART@Home
HEART@home (also known as Hospita2Home) is a new program that provides you with the care you need at home after you are discharged from Humber River Health. The program was created by the North Western Toronto Ontario Health Team and other community partners – Humber River Health, Lumacare, SE Health, LOFT, Circle of Care, and Reconnect Community Health Services. The goal of the program is to make your first weeks at home as easy for you as possible.
Check out the document for more information: 005261_HEARTatHome.pdf.
LTC+ Hub
LTC+ is a virtual care program developed in partnership with long-term care homes in Toronto, acute care hospitals and community services. Each LTC home that is part of LTC+ is partnered with an Ontario Health Toronto (OHT) Hospital Hub. Visit LTC+ Partners – LTC+ Program for more information on the program.
Supporting Newcomers
Addressing unique health and access barriers for immigrant and refugee communities.
Newcomer Navigation
In October 2024, we launched the Healthcare Navigation Working Group to address the navigation needs of newcomers. A needs assessment is in progress to identify navigation needs for newcomers.
Newcomer Care Advocacy – Coming Soon
COMING SOON
Newcomer Care Pathways – Coming Soon
COMING SOON
Leading Practices
Driving continuous improvement through supporting the adoption of evidence-based best practices.
Best Practice Spotlight Organization (BPSO)
The BPSO OHT program is a partnership with the Registered Nurses Association of Ontario (RNAO) to implement 4 Best Practice Guidelines (BPGs) that support with health system transformation in Ontario over 4 years. We are pleased to share we received our official BPSO OHT designation from the RNAO in June 2024.
For more information on the BPGs, please visit the BPSO page under Resources for Providers.
Health Equity Community of Practice (CoP)
The Health Equity Committee launched a Community of Practice (CoP) to provide a platform for sharing knowledge and resources across our partner organizations.
Health Equity Training
In October 2024, the Health Equity Training Working Group was created to guide the development of an OHT-wide health equity training program to enhance knowledge and skills.
Care Closer to Home
Breaking down barriers to access by strengthening our capacity to deliver a full spectrum of services to the communities that need it most.
The HUB@2115 is a collaborative community space that brings together health and social care services all under one roof. Located within the Jane and Finch community, the HUB@2115 is a “one stop shop” model of care to increase access services and reduce barriers to care. The HUB aims to:
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Strengthen collaboration with health and social care organizations in the community
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Increase service coordination
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Improve access to essential health and social care services in one, convenient location
Visit the HUB@2115 page under Find Services to learn more!
North Western Toronto Primary Care Network
In 2024, Ontario Health announced their support of collaboration and engagement with primary care in the province through the formation of Primary Care Networks, or PCNs.
PCNs are distinct structures comprised of:
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Primary Care Physicians
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Nurse Practitioners
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Interprofessional Healthcare Clinicians
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Patient Family Caregiver representatives