Are there specific equity considerations within your population?

While Guelph and Area as a whole can look favourable on some dimensions of the social determinants of health when compared with the broader WWLHIN (i.e. education, income, health status), we know that there is considerable variation at the neighbourhood level with regards to the social determinants of health and health equity.   With this knowledge of our community in mind, we plan to take a population needs-based, equity-oriented planning approach to designing services in our community that matches services to those that need them most. 

Based on the 2016 census Inclusive Definition of Francophones (IDF), the G&A OHT is home to 2,435 French-Speaking residents which is 1.8% of the total population.   According to the Canadian Community Health Survey, Francophones have significantly higher rates of one and two chronic health conditions. In 2018/19 in WW, 99 unique Francophone patients had 142 unique referrals for home and community care services in Waterloo Wellington. 

The actual number of Indigenous residents is estimated at 5 times higher than reported – various reasons for not self-identifying as Indigenous but most common is due to the generational trauma related to the abuses/genocide of the past and the biases/racism that still exist today. The average age of Indigenous residents in our region is 25. According to the 2018 Point in Time Count, 13% of people experiencing homelessness in Guelph identified as Indigenous.

The following targeted initiatives to improve the health on a population level scale and/or to reduce health disparities are currently in progress and will be supported by and incorporated into the Guelph and Area OHT:

The Guelph Family Health Team has approximately 2,800 Health Link Members (HLMs). As of August 2019, 235 have been identified as challenged by one or more SDOH factor (food, money and/or housing). As of March 2018, approximately 43% of Guelph FHT HLMs are socially isolated in that no known family or friends were identified to provide support, as per their care plan. The Guelph CHC’s Health Links approach has been implemented through a “Health Guide’ model which brings together the functions of care coordination, counselling and support for complex populations. With outcomes of this role demonstrating over 40% reductions in hospital utilization post care plan development, partners will seek to build off of this model when integrating home and community care resources for our attributed populations Year 1.

The Indigenous Healing and Wellness program, currently delivered at the Guelph CHC, provides traditional healing opportunities for Indigenous community partners, along with many culturally-grounded programs such as Indigenous feasts, beading, drumming, ribbon skirt making. As Indigenous community partners are identified within our attributed populations, the Indigenous Healing and Wellness Program will be invited as key members of the wrap around care team.  

With a 1.4% vacancy rate in Guelph in 2018 (, housing is a critical need for many in the community, with limited options available to meet this need. In our current state, care providers are spending significant resources assisting their clients to find housing, often having no choice but to place them in market rent housing that is known from the outset to be unsustainable. Health and social service partners are working together to leverage all opportunities to expand housing options for vulnerable populations in the City of Guelph, with the viability of two integrated housing models being actively investigated simultaneously. Partners from several agencies including Guelph CHC and the County of Wellington will be bringing the RentSmart program to Guelph/Wellington as another tool to address housing issues and increase successful tenancies.  The success of these programs, which will provide a continuum of supportive housing options connected to health and well-being support, will be critical to improving the health outcomes of our Year 1 populations.    

G&A OHT partners strongly believe in health equity and recognition in the social determinants of health.  Examples of other health equity based programs that will be leveraged and included as part of the IPCT teams for complex clients include:

  1. Addressing food security and food access issues through the SEED, a community food project which delivers sliding scale food markets, upcycle kitchens (circular food economy), youth urban farm (employing underemployed youth not engaged in school), and emergency food distribution, bringing fruits and vegetables to emergency food providers using efficient/social enterprise models. 
  2. Integrated behavioural health supports bring social work services into primary healthcare appointments to address social and behavioural challenges, supporting clients with same-day appointments, where they are at and enabling primary care providers to work to top of scope.
  3. Health Guides provide care coordination and navigation supports to assist complex Health Links clients in accessing social determinants of health and healthcare services through accompaniment, advocacy and the care planning leadership. 
  4. The Consumption and Treatment Service offers low barrier harm reduction and acute primary health triage care to individuals using substances. 
  5. Primary care outreach is provided in integrated ways at the Welcome in Drop-In Centre, Stonehenge Therapeutic Community, and Wyndham House. 
  6. Integrated interpretation services and navigation supports provided to newcomers with language barriers, with translated wellness programming and counselling to support their stabilization.
  7. Offering 30-40 no cost, accessible, community-led health promotion programs each month, many of which are placed in Guelph’s most vulnerable neighbourhoods in order to build community capacity, reduce social isolation and improve access.

Taken together, our partners have a history of using a health equity lens to develop, evaluate and iterate programs and services to meet the needs of people with the biggest barriers to optimal health and well being. We will leverage this collective experience and expertise as we move forward to implement the G&A OHT.

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