F1-a - The TEAM is in: Adding More Players to Solo Practitioners’ Teams

1. Access to care: improving access to team-based care

  • Date: Friday, September 20, 2019
  • Concurrent Session F
  • Time: 12:00pm-12:45pm

  • Room: TBA
  • Style: Presentation (information provided to audience, with opportunity for audience to ask question)
  • Focus: Practical (e.g. Presentation on how to implement programs and/or practices in the team environment)
  • Target Audience: Leadership (ED, clinical lead, board chair, board member, etc.), Clinical providers, Administrative staff, Representatives of stakeholder/partner organizations

Learning Objectives

Participants will learn methodologies to identify key interdisciplinary members required for team-based care and devise strategies to engage community physicians and recruit physician champions to promote multidisciplinary care and provide continuous feedback. Participants will be able to develop and implement the tools needed to establish team-based programs, build processes, and pathways that are sustainable based on client and provider needs. By the end of the session, participants will be able to define and incorporate key quality improvement indicators and performance metrics into the EMR.  Finally, ongoing feedback and evaluation tools will be shared and demonstrated with the intended audience.


Mental Health and addictions are on the rise within our communities and primary care practitioners (PCP) are faced with an influx of acute episodic care with over 70% of them having no access to team-based care. Our area struggles with supporting a large elderly and migrant population, high Emergency Department visits, elevated poverty rates, and a multitude of issues related to the social determinants of health.     In response to a Ministry initiative with letters of support from community agencies and primary care providers, a proposal was put forward to expand access to team-based services for vulnerable populations. The Windsor Family Health Team in partnership with the Canadian Mental Health Association launched Team Care Centre (TCC) to provide a full continuum of services. TCC supports individuals struggling with mild to moderate mental health and addictions in combination with other chronic conditions that require time-limited intensive case management. Community physicians are instrumental in providing ongoing co-design support for programs and referral processes to close identified gaps.     This innovative model allows non team-based physicians access to a team of interdisciplinary professionals without any negation to the PCP while reducing redundancies in the system. Delivery of care focuses on improving health outcomes, family & caregiver experience, and increased upstream access to Primary Care. TCC’s goal is to be a high-performing team that creates a comprehensive, coordinated, and effective care delivery system centered on the patient’s needs. TCC pathways strengthen the mental health-primary care connections and reduce the overall financial burden to the healthcare system.


  • Brice Wong, MSc., Quality Improvement Decision Support Specialist, Windsor Family Health Team 
  • Jessica Hindi, RN., MN, Practice Facilitator, Windsor Family Health Team 
  • Neelu Sehgal, Director, Team Care Centre, Windsor Family Health Team 
  • Cathy Awad, Nurse Practitioner-PHC, Windsor Family Health Team


  • Mark Ferrari, Executive Director, Windsor Family Health Team    
  • Claudia den Boer, Chief Executive Officer, CMHA Windsor Essex Branch