When in need of any kind of social supports, the first place vulnerable people often turn is to their family doctor. In an over-burdened medical system, primary care providers have acknowledged a real need for better access to community supports from community service agencies like WoodGreen, who are best equipped to handle non-medical care.
To address this growing need in alignment with the TC LHIN primary care strategy, WoodGreen’s Community Care Unit (CCU) has built new relationships with 3 primary care clinics to bring community supports directly to doctor’s offices. Driven by an integrated model of care, we meet clients where they are to deliver wraparound care and provide access to a basket of community services, bridging the gap between primary care and the community. The needs of each community WoodGreen works with have been carefully evaluated by staff, and a unique, tailored approach has been implemented at each site.
The Crescent Town partnership also differs from the other two communities: because there is a large population of newcomers in the area, and access to culturally competent support with specific language skills was lacking. A staff member from WoodGreen’s Newcomer Services Unit is embedded in the Crescent Town Health Centre to work with members of the health team to support clients as they settle into their new city.
Working with our partners in primary care has enabled people in need to easily and conveniently connect with WoodGreen to access critical community supports. This new collaboration also helped primary care physicians and nurses learn more about community services, and together we’re able to better serve our communities. WoodGreen plans to scale this integrated model to offer more seamless, unified access to services across the city.
“Being truly client centred means meeting clients where they are to deliver wraparound care.”
At the Albany Medical Clinic, primary care physicians had previously identified that many patients they see are seniors who are in need of resources beyond medical care. A WoodGreen social worker is now onsite at Albany, forming an allied team with physicians and nurses and connecting seniors with a variety of WoodGreen services including Meals on Wheels, PSW support and much more.
In the Oak Ridge Neighbourhood, the main needs of the community are different. Primary care physicians identified a need for more mental health and addictions support. Working closely with a family doctor who has been in the community for over 20 years, a nurse and other community resources, WoodGreen now provides 3 social workers to provide low barrier access to care. Offering service within these communities, rather than asking clients to travel far distances to receive support helps to address issues of access and equity.
from April 1, 2017
to March 31, 2018