Who will you be accountable for at maturity?

The degree of alignment between our originally proposed population and service area and the attributed population as described by the ICES methodology is moderate.   In both our ‘Expression of Interest’ and in this Full Submission, we propose “to serve all 165,000 residents of Guelph, Puslinch and East Wellington and partner with the University of Guelph Student Wellness to better integrate care for students in our community.” This population and service area was selected because of its alignment with our former sub-region boundaries and historical partnerships which are enablers to the trust-based foundation of our OHT work together.  In addition, this population and service area was identified based on utilization patterns in acute care, since approximately 75% of Guelph General Hospital (GGH) patients live in this defined area.

The full data set provided by the Ministry using the ICES methodology describes our attributed population (219,453) as also including Centre Wellington (25,888), Wellington North (12,258), Minto (5710) & Mapleton (4,642). We have not included this population in our efforts to develop the Guelph and Area OHT (G&A OHT) out of recognition and respect of the efforts of our partners in Rural Wellington (RW) to develop their own OHT Expression of Interest (EOI).  Based on historical partnership patterns and the unique rural healthcare partnership, utilization and referral patterns, we support their efforts to explore the feasibility of developing a Rural Wellington OHT. We have reached out to our Rural Wellington partners to advise them of the data that reflects patients in Rural Wellington being part of the same utilization/referral network as Guelph and Area patients and have shared with them our ongoing intentions and openness to work with their community in the capacity that is determined to be appropriate.


As we work towards maturity of the G&A OHT, we anticipate significant opportunities to strengthen existing and develop new partnerships to leverage the population health approach that is already a foundational element and existing competency amongst our partners and within our communities. Specifically, health equity is successfully embedded into our collective work as demonstrated through many successful and impactful community initiatives.  For example, Toward Common Ground is a partnership of social and health service organizations that developed a collective impact-based planning model for all of Guelph & Wellington. The work of this group is supported through contributions of participating agencies and is an example of our collective commitment to work together to collectively address population health and health equity. This group’s strong working relationship with Wellington Dufferin Guelph Public Health (WDGPH) reflects our shared commitment to use data to identify and address the root causes of poor health outcomes and systematically target interventions to optimize health outcomes for all G&A OHT residents.  In assuming responsibility for the health of the Guelph and Area population, we acknowledge the imperative to work in a transformed way with our partners across all sectors of our community to address the health and social needs of our attributed population.  As stated in our EOI, “We are ready to do things differently, ready to innovate, redesign and transform”.

We have full confidence in our community’s capacity to integrate services that result in improved health outcomes for our community. This confidence is drawn from our successes to date, including:

  • our Collaborative Quality Improvement Plan (c-QIP) which resulted in a 37% reduction in COPD readmission rates;
  • the development of a community coalition working together to prevent and reduce the effects of adverse childhood experiences;
  • unanimous support from the City of Guelph Council for the Guelph CHC Consumption and Treatment Service application;
  • integration of CMHAWW crisis workers into Guelph Police Services in a program called IMPACT (Integrated Mobile Police and Crisis Team) which is a benchmark model in the province (See Figure 1); and,
  • the integration of addictions medicine into primary care through the development of Rapid Access Addictions Clinics (RAACs), lead by Stonehenge Therapeutic Community, a local addictions service provider.

These partnerships exemplify our ability to work with all of our traditional health and non-traditional healthcare partners to integrate services and functions in a way that achieves the Quadruple Aim (Improved Patient Experience, Improved Provider Experience, Better Outcomes, Lower Costs). 


We anticipate challenges related to change management amidst expedited timelines, as well as the capacity of our leaders to support this system transformation across all levels of stakeholders (governors, physicians and other clinicians and frontline staff, patients & caregivers, community partners etc.). 

The ‘Full Data Set’ provided by the Ministry includes many patients from Rural Wellington that would be served by the OHT that is being proposed through the emerging Rural Wellington EOI.  This presents a challenge to our ability to fully understand the characteristics and status of our attributed population.

Our population’s demand for Mental Health  Addictions services currently exceeds capacity, and although we will be able to achieve some efficiencies in an OHT model, we may continue to be challenged to meet the need – currently (as per Here 24/7 data reports there are 1,143 people waiting for ongoing Mental Health & Addictions care in 21 different service areas as of October 2019.

The cultures and climates across all organizations vary greatly on key dimensions such as: risk tolerance, relative tightness or looseness, harm reduction, community driven vs. provider driven, etc. In order to support successful integration of teams, the leadership table will undertake a culture assessment and will use that information to inform support strategies for staff. 

Keeping diverse stakeholders engaged and informed on what has happened, what will happen and how they can be involved is key to achieving buy-in and momentum for change. Based on previous projects, we are proposing a structured communication plan at regular communication intervals, tailored to different target audiences.


Perhaps the biggest challenge will be finding the courage to stop doing some of the things we are currently doing in order to create capacity across the system to engage in true transformation. System-level prioritization will be guided by our engagement with patients, families and clinicians.

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