We Are in It Together KW4 Ontario Health Team

In 2019, the Ministry of Health announced the creation of Ontario Health Teams (OHTs) to replace the Local Health Integration Networks (LHINs). The aim of OHTs is to provide a new way of organizing and delivering care that is more connected to patients in their local communities. Under OHTs, health care providers such as hospitals, physicians, other clinicians, long term care homes and home and community care providers, will work as one coordinated team in all settings.

In Kitchener, Waterloo, Wellesley, Wilmot, and Woolwich (KW4), 31 organizations that provide health, wellness and community-based social services, came together in May, 2019 to apply for this new vision of health and care delivery locally. The process included community consultations with health, municipal and social service agencies and a decision was made to prioritize populations that are socially vulnerable, have inequitable access to services and face complex barriers to care. Three initial target groups were chosen including those who are homeless or precariously housed, the elderly experiencing frailty and refugee newcomers to our community. Mental health and addictions and the urban/rural service planning contexts were acknowledged as overarching lenses which require consideration for each priority group.

The KW4 group received approval as an Ontario Health Team in November 2020. Its goal is a health and wellness system for all 400,000 residents that offers seamless, interconnected care and continuity across providers, including hospitals, primary care, long term care and social and community agencies.

The OHT philosophy of organizational and inter-sectoral care collaborations for optimal health outcomes has been successfully tested during the COVID-19 pandemic response where the good, bad and ugly parts of our health care system were exposed. Key lessons were rapidly learned. The pandemic demonstrated that virtual care was able to be quickly implemented and it was possible to successfully scale collaborative models for mobile primary care, virtual monitoring and screening to respond to urgent needs. These changes occurred as a response to the global health crisis and will help pave the way for the evolution of the system redesign that will take place over the next several years. The KW4 OHT currently comprises 39 member organizations which are the OHT. An OHT isn’t an entity in and of itself. It’s the work of the members that are moving health care forward for the betterment of our community with greater value for money, greater patient, family and provider satisfaction and improved health outcomes.

This is an exciting time for health care in our region. Despite exhaustion and burnout suffered with the pandemic response, member organizations are genuinely committed to collaborate together with patients, families and care partners to design and implement our Ontario Health Team and bring connected care to the communities we serve.

As the KW4 OHT moves forward, work is being accomplished through working groups, various councils and committees. This collaboration involves about 400 people tackling equitable access to health care, digital & virtual care, mental health and addictions, data and continuous improvement, and many other important areas.

With many good people involved in this community, the future looks promising. Together we share a commitment to a healthcare system that works better for everyone in our community where everyone thrives, and no one is left behind.

ABOUT THE AUTHOR Joseph Lee MD, CCFP, FCFP, MClSc(FM)

Joe is a family physician who chairs the KW4 OHT steering committee, the Centre for Family Medicine and the e-Health Centre of Excellence. He’s the primary care lead for KW4 and married to Dr. Linda Lee.