How will you address diverse population health needs?

How will you work with Indigenous populations?

The actual number of Indigenous residents is estimated at 5 times higher than reported (WWLHIN IHSP 2016-19).  There are 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 years.  It is estimated that 13% percent of those experiencing homelessness in Guelph are Indigenous.

G&A OHT is committed to the principle that healthcare for Indigenous people should be managed by Indigenous-governed organizations. This applies at every step: needs assessment, program planning and delivery, and evaluation. Our work with Indigenous clients must centre their voice, leadership, and governance frameworks. Honouring this commitment is essential to “walking the walk” of reconciliation and allyship.

Engagement with Indigenous communities in Waterloo Wellington has identified the common goal to have a sovereign (Indigenous run & governed) Indigenous Health & Wellness Centre to run in parallel to a Western healthcare system that is culturally safe, respectful of diverse Indigenous cultures and responsive to the needs of Indigenous patients and families who may weave in and out of both systems as they need to. Through a framework of holistic health and wellbeing, Indigenous-led comprehensive primary care provides an array of interconnected, inter-sectoral services. These services include support for building community resilience and healing from ongoing oppression, assimilation policies and the impacts of residential schools. Developed with Indigenous communities and healthcare workers, and drawing on regional Indigenous peoples’ history, Indigenous health focuses on issues of health equity and determinants of health that are specific to Indigenous people and communities. It affirms Indigenous rights to health and to determination in health from Indigenous perspectives. It supports reconciliation, healing, community development and recovery of Indigenous communities’ authority and rights to self-governance and determination. By embodying these principles, we aim to develop trusting relationships with Indigenous people, families and communities to create lasting systemic change.

As we work together to design an integrated network of care, we commit to; recognize the distinct and specific histories, needs, legal rights and constitutionally protected rights of Indigenous peoples; end systems of colonization and oppression that undermine Indigenous rights to determination in health; apply the principles of respect, inclusion, accountability and equity; through this, we embody allyship with Indigenous healthcare providers and the people they serve.

To fulfill this commitment, we will continue to support our governors and staff to complete the online Indigenous Cultural Competency Course to improve understanding of culturally safe practices.  G&A OHT partners will continue to engage our boards and communities in meaningful dialogue about Indigenous-specific health inequities and oppression and we will make space for Indigenous-governed health centres and/or Indigenous health leaders to direct the planning and implementation of Indigenous health services in our region.  We will work with Indigenous partners as we develop action plans for transferring control of services provided to Indigenous clients back to Indigenous people and communities, and commit to funding for Indigenous programs and services that are led, governed, evaluated & are accountable to/by Indigenous peoples.

How will you work with Francophone populations?

The Guelph and Area OHT does not service a designated area. One of our partners, Mango Tree FHT has a mandate to offer services in French through its accountability with the Ministry and has a fulltime Francophone NP.  Additionally, CMHAWW and the Alzheimer’s Society are identified to give services in French through specific LHIN-funded programs in the region of Waterloo Wellington, including Guelph.  CMHAWW is funded for a French-speaking tele-psychiatric service in the WW region. This position is vacant due to recruitment challenges but CMHAWW continues to use the funding for both adaptation and translation services as well as OTN linkages to tele-psychiatry as needed.  To reduce any barriers to accessing and receiving care, CMHAWW utilizes a service called ‘Over The Phone Interpretation’ (OPI), which provides 24/7 access to interpreters in over 50 languages for Here 24/7 staff who are assessing and supporting people of all ages over the phone.

Many G&A OHT partners have already ensured French language capacity and will leverage this as we continue systematic engagement of the Francophone community including patient/client, caregiver, advisor and other stakeholders’ voices. To ensure that the needs of the Francophone population are better captured throughout the continuum of care, work needs to be done around identifying needs, gaps, as well as capacities, and developing strategies and solutions to efficiently meet the needs identified.

The engagement of and collaboration with the local French Language Health Planning Entity (Entity) will continue throughout the process of establishing and operating as an OHT. Beyond engagement, Francophones should also be included in planning and implementation of French language services. The Entity recommends that G&A OHT Working Groups, Committees and Sub-Groups includes Francophone representation, and that different perspectives (patient/client, service providers, advisers, health planners, etc.) be considered as appropriate. The Entity can participate and/or support recruitment for such representation if need be.

In terms of our plans to address Francophone health the G&A OHT’s strategic planning process will include objectives regarding the planning and delivery of French language services to ensure care coordination and system navigation services need are available to Francophones within the region.  We will include the Entity to support


  • We will continue to work with the French Language Planning Entity  to ensure the needs of the French-speaking population are included in our engagement and implementation plan in Year 1
  • We will plan and deliver French Language Services (FLS) as informed in the G&A OHT strategic plan (to be completed in Year 1) in the longer term.
  • We will use existing data and support data collection that assists us to identify and develop plans to address the needs of Francophones in the G&A OHT.
  • We will enable board members, management staff and front line staff to attend training on Active Offer.

Are there any other population groups you intend to work with or support?

Guelph has been active in identifying complex and vulnerable patients for the last 5 years (approx.3,000) including those experiencing vulnerabilities in food, money or housing as well as those who are socially isolated.  The Guelph CHC and the Guelph FHT partnered to support the recent immigration of Syrian refugees, as well as a more recent influx of Eritrean refugees. Leveraging interpretation supports, group medical visits and innovative strategies for urgent care and new client intake processes, these newcomer populations have been successfully attached to team-based primary care supports in the G&A community.

Community Health Van delivers primary nursing care including escorting people to emergency department, wound care, medication dispensing counselling support for those complex mental health needs who have barriers to care.  Over the past 2 years we have had 8,171 visits to the Community Health Van, accounting for 2,743 unique people (most of whom live in Guelph).  95% of people surveyed who access the service felt that the van helps them to live healthier lives. 69% of people who received a referral from the Van report following up on that referral.

In addition to newcomer/refugee populations, comprehensive primary healthcare and barrier-reducing/elimination programs and services are delivered to priority populations including homeless; living on limited incomes; New Canadians with language barriers; those with moderate to severe mental health, addictions and/or disabilities; those without access to primary care; Indigenous community members; vulnerable children and their families and members of the LGBTQ+ community. All OHT partners strive to provide services that are responsive to the diverse cultural needs and preferences of our population.

G&A OHT will be testing many new ideas, while simultaneously scaling existing and evaluated models of care.  For example, Guelph CHC is one of 11 pilot sites across Ontario who are involved in a Social Prescribing project, done in partnership with the Alliance for Healthier Communities. Social prescribing is a structured way of connecting primary care with non-medical supports that address the social determinants of health, with an emphasis on reducing social isolation.  Research shows that 1/4 Ontarians do not have a strong sense of community, that loneliness has an impact on our health, that loneliness is exacerbated for the most vulnerable and that there is an income inequity as Ontarians with the highest income have a stronger sense of belonging than those with low incomes.  Social prescribing in the UK has reduced physician visits by 28% and emergency room visits by 24%.  A recent Ontario Chief Medical Officer of Health report states, “people with a weak sense of community belonging are more likely to be in the top 5% of users of healthcare services, this 5% accounts for more than 50% of total healthcare spending…costs that could be reduced if these individuals were part of connected communities”.  Due to the potential of this model to support integrated care in a sustainable and efficient way, social prescribing will be scaled up in the future, with Guelph CHC supporting local FHTs in social prescribing implementation.

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