Connected Care
People-Centred Care means that everyone receives the right care, at the right time, according to their unique personal needs and circumstances.
North York General is a core partner in the Ontario Health Team (OHT), a key provincial strategy to create more connected care experiences for all Ontarians.
What is North York Toronto Health Partners (NYTHP)?
Formed in 2019, NYTHP is one of Ontario’s first OHTs. OHTs are made up of organizations that coordinate health services for a geographic area, making health care more accessible and improving care experiences. Learn about NYTHP on their website.
In 2023 – 2024 NYTHP made great progress towards a more connected local health system.
- NYTHP brought on 12 ambassadors who use their knowledge of local neighbourhoods to support
NYTHP’s Community Health Information Fairs (CHIFs), where local organizations bring health information and
services to where people live. NYTHP held 12 CHIFs last year including one on Healthy Eating, featuring a
dietician, live demonstrations, information booths, and blood sugar and blood pressure checks. - NYGH’s Edwin S.H. Leong Geriatric Supportive Care Outreach Program — funded by a transformational gift from Dr. Edwin S.H. Leong — provided 24/7 home-based palliative care for 95 patients (September 2022 to August 2023).
- Expanded the Seniors’ Hotline for North York which helps seniors with appointments, counselling, referrals, and wellness checks, including a collaboration with NYGH Social Workers, to connect clients to community services and reduce hospital readmissions.
- North York Community Access to Resources Enabling Support (NYCARES) assisted 67 older
adults with complex needs with wrap-around home and community support services. This saved 3,053
ALC days – days where a hospital bed is used by someone who no longer needs to be in hospital,
but is waiting for community care. - NYTYP’s Primary Care Network of 265 family physicians, nurse practitioners and nurses worked
to coordinate primary care in North York. Last year, 53,000 more patients used online booking for
primary care appointments. - In September 2023, the Ministry of Health selected NYTHP and 11 other OHTs to accelerate
their work to create a connected care experience. The 12 OHTs are focusing on chronic disease
management including heart failure and Chronic Obstructive Pulmonary Disease, access to primary
care and home care, and health care navigation.
Digital Health – Driving Connected Care and Better Health
Digital Health continued to enable us to raise the bar on quality, safety and patient experiences.
SCOPE offers primary care and other providers convenient telephone access to specialists and services such as General Internal Medicine, Medical Imaging, and Surgery, allowing patients to access care close to home.
ED visits prevented with SCOPE
NYGH also continues to advance digital health across Ontario through its co-leadership of Evidence to Practice (E2P), along with the Centre for Effective Practice and the eHealth Centre of Excellence. E2P brings health professionals the information they need, when and where they need it. So far, 19 Ontario hospitals are using E2P to support the management of one or more of heart failure, anxiety and depression or diabetes.
With E2P, we are moving closer to measurement-based care where providers have easy access to a digital tool that guides assessments and care plans for each patient and tracks their progress over time. This translates into better health outcomes and an enhanced patient experience.
— Sandy Marangos, Clinical Director of the Mental Health Program at NYGH
Innovative NYGH Program Enables People to Heal and Age at Home
Patients and providers can all agree, many people prefer to receive care at home instead of in hospital when they can. NYGH’s transitional care and “at home” program is putting digital and other tools to work to enable more patients to heal and age at home, redefining the hospital’s role in community care.
Working closely with community providers, NYGH is supporting seniors to live comfortably and with greater independence across care settings, benefiting patients, caregivers, and the entire health care team.
According to Duska Kennedy, NYGH’s Vice President Strategy, Digital and Chief Digital Officer. “We want people to experience NYGH as a hospital without walls — a trusted place to receive care throughout all life stages that also brings care into their communities and homes.”
North York Congregate Access and Support Team — Improving Outcomes in Long-Term Care
In summer 2023, NYGH and the North York Toronto Health Partners launched the North York Congregate Access and Support Team (NYCAST) to improve outcomes for people living in eight local long-term care homes.
NYCAST’s specialized Nurse Practitioner-Led Outreach Team provides virtual and on-site clinical support for residents and caregivers, including primary care, injury and illness prevention, and palliative care.
In under a year: