A3 OHT Integrated Patient Care Teams: The How, Who and Impetus Along the Way

3. Organizing primary care to advance Ontario Health Teams

  • Date: 2023-10-25
  • Concurrent Session: Concurrent Session A
  • Time: 10:30 - 11:15 am
  • Room:
  • Style: Presentation (information provided to audience, with opportunity for audience to ask question)
  • Focus: Balance between both (e.g. Presentation of a best-practice guideline that combines research evidence, policy issues and practical steps for implementation)
  • Target Audience: Leadership (ED, clinical lead, board chair, board member, etc.), Clinical providers

Learning Objectives:

  • Over the past few years Guelph Wellington OHT has been working on bringing Integrated Patient Care Teams (IPCT's) to life by expanding the Primary Care Team and inviting care team members into primary care rather than referring out.
  • To introduce the vision of an Integrated Patient Care Team to clinic staff and physicians, joint presentations by a primary care lead and Home and Community Care Support Services representative occurred.
  • During these initial touchpoints with providers, a review of the current state and its challenges was presented and followed up with the vision of an IPCT future mature state. This helped providers to understand the multiple aspects of IPCT's and their goal in improving patient care, decrease duplication of assessments and the importance of building a team around the patient.
  • Practicalities such as shared agreements, staff introductions and training occurred.  There were certainly challenges along the way which were overcome in a large part by the flexibility of all those involved to meet each other where they were at.

As a core partner of the GW OHT, Guelph Family Health Team has been participating in IPCT work since 2019. Historically the planning and delivery of care coordination has not been integrated in a seamless, efficient team-based approach to care. In-home service providers have been siloed from each other and from the primary care teams with inefficient communication channels. Complex clients have often had several providers with separate assessments, documentation in multiple records with each provider creating a separate plan of care. This disconnected care has led to a duplication in service delivery, created gaps in care, and resulted in client and caregiver frustration and distress. To date Guelph Family Health Team along with Home and Community Care and Support Services have integrated community care partners into 5 of our clinic sites. These care partners were provided with EMR access, space on site and improved communication channels that have directly improved patient and family care and outcomes. This session will walk participants through the journey (and yes it has been a journey) of what steps were taken to introduce and get buy-in from stakeholders, practical tips for logistical training, challenges faced along the way and how they were overcome, benefits of this model of care to both providers, patients, and the healthcare system at large and shared provider feedback/experience.


  • Victoria Murray Registered Nurse, BScN, Manager, Community Liaison & Privacy Officer Guelph Family Health Team