Why Team-Based Primary Care
Primary care is where we typically turn first when sick, vulnerable, or in need of someone to listen and guide us – it’s there we find comfort and continuity of care, while feeling seen, heard, and valued.
What are Primary Care Teams?
Primary care recognized as the foundation of Ontario’s publicly funded health care system – it is often and should be the first and ongoing point of contact for persons seeking health care within Ontario.
Interprofessional primary care teams are led by family physicians or nurse practitioners, working in a coordinated fashion with multiple other dedicated healthcare professionals to provide care for the whole you. While each team might look a little different, they all share a common goal: timely, comprehensive, high-quality care through strong interprofessional collaboration.
Building a Future-Focused System
We believe in a primary care system that is comprehensive, connected, and centered on people’s needs.
Team-based primary care is the foundation of a strong and sustainable healthcare system. By working collaboratively, physicians, nurse practitioners, nurses, social workers, dietitians, pharmacists, mental health professionals, and many other important team members create the conditions for people to stay healthier, avoid hospital visits, and receive truly comprehensive care.
We’re committed to building a primary care system that is:
Grounded in Evidence and Experience
- Care is informed by the best available research and data.
- Clinical decisions are guided by healthcare professionals expertise and interprofessional collaboration.
- Patient preferences and lived experience shape care planning, delivery, and ongoing improvement.
When the best available evidence is combined with clinical expertise, interprofessional collaboration, and patient lived experience, we see high quality care that improves outcomes, strengthens system performance, and remains sensitive to changing needs of the population.
Person-Centred
- Care that addresses physical, mental, emotional, social, and cultural well-being, and is aligned with the patient’s values and preferences.
- Support for self-care and community resources.
- Anticipates changing needs over time to maintain health and prevent unnecessary hospital visits.
Evidence consistently shows that team-based, person-centred primary care improves the patient experience, strengthens relationships, and supports better self-management, especially for people with chronic or mental health needs.
Accessible and Continuous
- Timely and reliable care, available when it’s needed—including on short notice.
- Community-based services that are close to home.
- Healthcare professionals who know the person, their history, and what matters to them; their care is managed as an ongoing journey, rather than episodically.
Strong, locally accessible primary care increases preventive care uptake and reduces avoidable emergency department use. When patients can see their primary care team close to home, the system functions better for everyone.
Seamlessly Integrated
- Comprehensive, integrated medical records that capture a patient’s full primary care experience, and move with the patient across the rest of the health system.
- Coordinated referrals to specialists, hospitals, and community supports with appropriate communication back to the primary care team.
- Communication and follow-up tracked to prevent gaps in care.
Underscoring primary care’s role as the organizing hub of the health system, when primary care is intentionally embedded in integrated models, access and continuity improve.
Recognizes Primary Care as Home
- Functions as a home base for all care decisions.
- Builds trust and lasting relationships with patients.
- Strengthens the health system, improves outcomes, and reduces costs.
Jurisdictions with strong primary care see fewer avoidable hospitalizations, lower total system costs, and better population outcomes.
Investing in Primary Care
Despite the well-established value of team-based primary care, Canada’s progress toward high-performing primary care systems has been gradual. We need clear policy direction, stronger governance, performance measurement, and strategic investments to fully realize the benefits of integrated care.
Primary care teams face persistent funding, operational, and implementation barriers that must be addressed to strengthen access and greater attachment. Learn about how AFHTO and its teams are advocating for system change, today.