#OneEastToronto shares the faces of East Toronto Health Partners (ETHP), a group of more than 50 community, primary care, home care, hospital and social services organizations in East Toronto working together to improve the way local residents access and receive care. Meet Tamar Meyer, senior project manager at WoodGreen Community Services supporting the substance use and health workstream of ETHP.
“I’ve lived in East Toronto for 15 years and love this part of the city. I have a background in sociology and have spent the past decade supporting the design, development, implementation and evaluation of system-level mental health and substance use projects.
In my current role, one of my main responsibilities is supporting an initiative called the Comprehensive Care and Integration (CCI) Specialist Team. This team was established to provide intensive supports and enable integrated care for patients with complex health needs, including mental health and substance use issues. The team was also established to help those facing challenges related to the social determinants of health. The initiative aims to improve patient experience and health outcomes; reduce non-essential visits to the hospital; and increase access and use of primary care, community and social services.
In December 2020, new team members were added to better facilitate transitions from hospital to community for this population of patients. CCI Specialists from WoodGreen, Cota and St. Michaels’ Homes are matched with patients to provide short-term, intensive case management, connection to primary care, counselling, and coordinated care planning and management. ETHP hospital staff and other providers identify patients for referral, particularly those who require ALC (alternate level of care), at risk of requiring ALC or no longer need acute care. This is more important than ever as a result of the enormous pressures hospitals are currently facing.
I recently led an evaluation of this work which involved developing a logic model, monitoring patient and provider experiences through surveys and focus groups, and tracking hospital utilization of clients enrolled in the initiative. Michael Garron Hospital’s Decision Support team has supported this work — a quick shout out to Ash Roy — by providing hospital utilization data of patients connected to the team.
Preliminary results have found that the initiative is having a positive impact by supporting successful transitions back to community, reducing hospital readmissions and supporting clients with health system navigation. This data is important because it demonstrates the impact of our work and helps identify opportunities for improvement.
We work with an incredible team of CCI Specialists: Stephanie Gordon, Tia Ramaglia, Tazim Lakhani, Julie Guterres, Sandy Li and Sarah McMullen, plus management from WoodGreen, Cota and St. Michael’s Homes and hospital partners. I also want to recognize the awesome group of transition navigators at MGH. It’s amazing to see what we can achieve when we work together as one team.
Often, we see the hospital and community as distinct and separate, rather than a continuum of care. This work is about building bridges for patients, providers and across sectors. I look forward to continuing to participate in building this initiative over the coming year and supporting an increasing number of patients with complex health needs to successfully transition from hospital to home, and stay healthy at home.”