The Grey-Bruce OHT, along with its community partners, is dedicated to enhancing healthcare delivery through a range of innovative projects aimed at improving patient outcomes and system efficiencies. The Grey-Bruce OHT has identified four priority populations to focus on for collaborative system improvement. These populations include: Frail Seniors, Mental Health and Addictions, Unattached Patients, and Palliative Care.

Through the “Primary Care Action Plan” and the Primary Care Act, Ontario has committed to attaching 100% of people in Ontario to a Family Doctor or Nurse Practitioner.

In alignment with this commitment, and the work of Jane Philpott and her Primary Care Action Team, the Grey Bruce OHT is working with local providers, municipalities, community members and health and social service organizations to understand our primary care landscape, develop a plan to support increased local capacity for access and attachment to primary care, and facilitate the attachment of patients registered to the Health Care Connect Program and access to services as they wait.

Grey Bruce Ontario Health Team (GBOHT) and Grey Bruce Primary Care Network (GBPCN) have partnered with Best Care, an evidence-based, integrated chronic disease management program with a strong track record of supporting patients living with COPD and Heart Failure. Best Care has demonstrated proven outcomes in reducing hospitalizations, emergency department visits, and urgent primary care visits through proactive, team-based care. Their collaborative model emphasizes patient education, early intervention, and ongoing support, leading to better health outcomes and system efficiencies. With this new partnership, all medical clinics in Grey Bruce will be able to offer this integrated chronic disease management program to their patients.

ConnectMyHealth is a secure, web-based digital health solution that provides patients in Ontario Health West Region with a single access point to view their health records from participating hospitals. Operated by the HITS eHealth Office at Hamilton Health Sciences and funded by Ontario Health, ConnectMyHealth consolidates hospital records into one unified view. This project aims to increase awareness of ConnectMyHealth among residents in Grey Bruce, highlight the benefits and features of ConnectMyHealth to increase sign-ups, educate users on how to set up and use ConnectMyHealth effectively, and foster partnerships with local health providers and community organizations to support the initiative.

This project aims to support frail seniors and unattached patients in Grey Bruce, enabling them to age in place with proper care and navigation services. The target audience is older adults living at home in Grey-Bruce. This initiative is supported by the EAIP Project Team, regional geriatric groups, and several working groups and councils dedicated to improving care for seniors.

The Grey-Bruce Community Helpline project focuses on improving access to care and navigation services for Grey-Bruce residents. The initiative integrates data and digital tools to ensure equitable care through population health management. The target audience is the general population of Grey Bruce, with support from the navigation communities of practice, community connections, and multiple working groups and councils within the Grey-Bruce OHT.

This initiative focuses on implementing measurement-based care for mental health and addictions patients in Grey-Bruce. The target audience includes primary care providers and community and hospital mental health and addictions service providers. The project is supported by the Grey Bruce MH&A Measurement-Based Care Project Team, Greenspace Community of Practice, and various Grey-Bruce OHT councils and implementation teams.

This initiative aims to enhance coordinated care by extending the use of secure messaging systems. The focus is on data and digital integration to improve care through population health management and equity approaches. The target audience includes the palliative care team, primary care providers, community paramedicine, community nursing, geriatric services, and other support systems. This project is supported by the Grey Bruce Hypercare Care Project Team and various community councils and practice groups.

IEAPC aims to improve palliative care access for Indigenous people and individuals experiencing homelessness or vulnerable housing in Grey Bruce. The project focuses on integrated care through population health management and equity approaches, emphasizing system navigation. This initiative is supported by the IEAPC Project Team, Healthcare Excellence Canada, and various community and physician councils within the Grey-Bruce OHT.

This project addresses the needs of frail seniors and aims to prevent falls through an interdisciplinary approach involving primary care, allied health, home and community care support services, and emergency services. This initiative is supported by the Interdisciplinary Falls Intervention Project Team, community of practice, and stakeholder groups, along with the Grey-Bruce OHT community and physician councils.

Facilitating adoption, implementation, and utilization of provincially funded OAB licenses for primary care providers and health service providers in Grey Bruce. Provincial funding is intended to support the transformation of how care is delivered, assisting OHTs and the broader primary health sector to build digital health maturity.

Utilizing Remote Care Monitoring Technology, this project embeds a Palliative Care Nurse Navigator in the family health team to increase primary care’s capacity to deliver a palliative approach to care. Currently this project has launched at three sites in Grey Bruce: Owen Sound Family Health Team, Brockton Family Health Team, and Hanover Family Health Team.

SCOPE is a well-established, patient centered navigation tool to help Patients get the right Care, in the right place, at the right time. SCOPE is a platform for primary care engagement, driven and led by and for Primary Care Providers (PCPs) and aims to reduce PCP administrative burden.

The Grey Bruce OHT is proud to be the first to pilot the FREEDcan initiative—a promising early awareness and intervention model that helps young people get the eating disorder care they need, faster.

FREEDcan (First Episode Rapid Early Intervention for Eating Disorders – Canada) is a national initiative focused on identifying and supporting youth with early-stage eating disorders in community and primary care settings. Launched in 2020, FREEDcan was co-adapted for use in Canada with three goals in mind:

• Listening to people with lived/living experience

• Expanding access to care

• Providing flexible, stepped-care options

The model emphasizes early screening and rapid connection to services, helping young people get support before symptoms become more severe. In Grey-Bruce, we are beginning to build awareness of FREEDcan by sharing information and supporting training opportunities for providers and the community.