Integrated Model of Primary Care Delivery for Unattached Low-Income Seniors in Community Housing

City of Toronto owned Toronto Seniors Housing Corporation (TCHC) provides housing for 15,000 low-income seniors in 83 seniors-designated buildings across Toronto. The North Toronto Ontario Health Team (including primary care, hospital, community, home-care) partnered with Toronto Senior Housing to develop and implement a Neighbourhood Care Team (NCT) integrated model to address tenants' health and social needs, co-designed with the  tenants. Central to the model is a multi-modal tenant engagement strategy to tailor health and social services to tenants’ needs. This engagement identified inconsistent access to family physicians. One NCT objective is to increase primary care provider connections. Identifying unattached or poorly attached tenants included door to door surveys to engage tenants regarding their barriers and the services and supports most meaningful to them, multi-organization immunization clinics with wellness checks and assistance with accessing dental and foot care, and biweekly NCT huddles. Our team worked with each tenant with inadequate or no access to primary care in order to: 1.Strengthen attachments through video connections with the tenant’s family physician 2.Provide assistance with transportation to appointments 3.Connect tenants to local family physicians accepting patients 4.Identify family physicians speaking the tenant’s language and facilitate attachment 5.Provide on-site primary care for more vulnerable tenants with complex needs. On-site primary care included monthly primary care clinics by a regular family physician and a monthly nursing clinic for blood pressure checks, foot care, assistance accessing care for all tenants. The clinics were in an equipped clinical space in the building and home visits were provided for homebound patients, including those requiring palliative care. The unattached clinic has been very well attended and highly valued by the tenants. Tenant needs that required wider interprofessional and housing team members included: 1.Medication access and compliance 2.Cognitive impairment and/or low health literacy 3.Adequate nutrition 4.Hoarding/pest infestations Barriers to providing care and achieving health outcomes included: 1.Social resources: Poor or no family connections 2.Communication: Language, access and/or ability to use phone, ability to receive messages, few use email 3.Ability to follow a simple plan – eg. Go to pharmacy, go to lab, notify team if problems 4.Ability to navigate government programs for assistance 5.Transportation and navigation to get to appointments 6.Finances Opportunities to improve access to primary care for more vulnerable tenants include: Engaging local pharmacists to call team when a tenant is not picking up their medications Engagement of tenants’ family physicians to reach out to our team for assistance connecting to their patients, supporting their care Multi sectoral interprofessional team helped to understand and address care needs holistically Working with hospitals to identify unattached TCH building patients prior to discharge and confirming attachment if family physician identified. A collaborative multi-sector integrated team (primary care, community and home care, and housing) used a range of communication strategies and co-designed the approach with tenants to provide on-site primary care to assist more vulnerable tenants at risk for hospitalization and poor health outcomes.