report_admin | SRCHC Annual Report

Transforming Primary Care : Looking Forward

report_admin — Tue, 17 Jun 2025 21:36:47 +0000

In this section

Creating a Connected Healthcare Neighbourhood Across Many Diverse Communities
Looking Forward

Creating a Connected Healthcare Neighbourhood Across Many Diverse Communities

At SRCHC, as our annual report celebrates, we work with multiple partners and our community to create programs and primary care services that focus on providing low-barrier access to clients who are newcomers, living with chronic conditions, or facing substance use and mental health challenges. To improve access for clients, we provide care at multiple locations in our community, including at local shelters and in people's homes. As the province provides additional funding to increase access to team-based primary care services, we’ll continue to expand this vital work with our community partners.

By working as a team, we can collectively improve health outcomes for people who face barriers to care. About 30% of our clients are living with 10 or more medical conditions, yet despite this clinical complexity, we’re keeping people out of the emergency department. We’re proud to share that only 4% of emergency hospital visits are classified as best managed in the community (compared to 11% for CHCs across the province). We manage to keep our emergency department rates low with the support of a triage system managed by our clinic nurses. We offer same-day and drop-in appointments six days a week, deliver evening and weekend clinics, and provide on-call services for patients who have urgent health problems after hours.

Once someone becomes a registered primary care CHC client, they can access a full range of interprofessional care, including services like social work, chiropody, and physiotherapy – all at no cost. These supports, which often come with a fee in other parts of the healthcare system, are fully integrated into our team-based approach to community care.

Looking Forward

As we look ahead to the coming year, we’re energized by the opportunity to help shape the future of connected and community-based healthcare in Toronto. We’re excited to work with our CHC partners, Ontario Health Teams, Primary Care networks, community members, our partners and funders, as well as other stakeholders to bring this shared vision to life.

One important first step to expand our reach is the launch of our new mobile health clinic that will deliver primary healthcare, health prevention, screening, and vaccines directly to people in high-needs communities. We‘ll also continue building pathways to care for our important health promotion work, community-based and chronic disease programming, and strengthening support for mental health and substance use services — all while working alongside our community partners to remove barriers so people can access the compassionate, equitable, team-based care they need and deserve.

Year over year, our purpose remains rooted in what has always guided us: our community. The vision and the stories we’ve shared throughout this report are about more than delivering primary healthcare services — they’re about building trust, deepening connections, and creating a more inclusive health system guided by equity, compassion, and community.

The road ahead is full of possibilities and we hope you’ll join us on next year’s journey too.

Breaking Down Barriers and Building Up Hope

report_admin — Tue, 17 Jun 2025 21:36:21 +0000

In this section

Remembering Wanda Whiebird
Outreach and Harm Reduction Programs Bring Healthcare and Hope to People Wherever They Are
Primary CONNECT Provides Equitable Access to Wrap-Around Services

We’re committed to building stronger, healthier communities grounded in respect, equity, and hope. For more than 25 years, SRCHC has been delivering safe, evidence-based, trauma-informed harm reduction services. Our approach is rooted in compassion, supporting—without judgement—people who use substances as they navigate their physical, mental, spiritual, and social well-being. We offer low-barrier programs that foster social connection, creative expression, and community building, alongside access to wrap-around services, like primary healthcare, Hep C testing and treatment, mental health counselling, housing referrals, and social prescribing.

Remembering Wanda Whitebird

Did you know that “harm reduction is not about using drugs ... it’s about unconditional love and about being there on your own terms.”
– said Mi’kmaq Elder, Wanda Whitebird in Northern Feathers: Love, Culture, Harm Reduction.

A passionate harm reduction advocate, Wanda sadly passed away in November 2024. She taught us that there are major gaps within our healthcare system causing systemic harm to Indigenous peoples, making the need for culturally-relevant programs that address the health and wellbeing of Indigenous communities both obvious and urgent.

While we recognize that lasting and profound change to decolonize healthcare requires policy-level action, we ’re working at a programmatic level to address issues that intersect with substance use for our Indigenous clients through community-based, Indigenous-led, culturally safe programming, like our Northern Feathers and Moccasin-making workshops that ran from November 2024 to March 2025.

Outreach and Harm Reduction Programs Bring Healthcare and Hope to People Wherever They Are

The East Toronto Outreach Project (ETOP) is breaking down barriers to healthcare by meeting people exactly where they are—whether on the streets, in encampments, or at community events. Focused on supporting people who use drugs who are at risk of sexually transmitted and blood-borne infections (STBBI) across East Toronto, ETOP workers provide trauma-informed harm reduction-based care that is rooted in dignity and compassion, without judgment.

Since 2022, ETOP has become a lifeline for many. Over the past year alone, the ETOP has connected with 241 people through 781 outreach encounters, offering essential services, safer use supplies, and support with everything from health education to navigating the healthcare system.

Pictured above in second photo: We remember Rick Scott, who died in the past year

ETOP’s impact goes beyond STBBI prevention. Staff are leading community education efforts on safe sharps disposal and ramping up community clean-ups to reduce harm reduction litter in the surrounding community. This work is making a visible difference: this year, ETOP staff surpassed last year’s sharps container distribution and saw a 134% increase in the number of needles safely returned, reflecting strong community engagement.

Harm reduction is also about relationships, healing, and hope. That’s why we also work in partnership with many organizations to support people in holistic ways. One of our most unique collaborations is with the Toronto Humane Society which helps service users access veterinary care for their beloved pets. ETOP workers know that for many, their pets are family and supporting their pet’s health often opens the door to care for themselves. This kind of compassionate, barrier-free support is at the heart of the ETOP’s work to not only reduce harm, but to also build hope.

“This partnership has actively saved the life of numerous clients I have worked with, whether that be from reversing overdoses to providing safe supplies or building community in the face of stigmatization.”
– ETOP Partner

Primary CONNECT Provides Equitable Access to Wrap-Around Services

Primary CONNECT (Collaborative Navigation Network for Connected Treatment) is a new Interprofessional Primary Care Team (IPCT) created through a partnership between SRCHC, Parkdale Queen West Community Health Centre (PQWCHC), and the Centre for Addiction and Mental Health (CAMH).

The Primary CONNECT program is part of a historic and transformative province-wide investment towards fostering more accessible and equitable healthcare for everyone. The team works across multiple sites and includes a doctor, nurse practitioner, registered nurse, community health worker, case manager, service navigators, psychiatrists, and Indigenous healers. Together, they enhance support for people experiencing mental health and substance use challenges, prioritizing those who are marginalized, racialized, Indigenous, or living on low incomes. Their goal is to break down barriers to ensure compassionate, culturally safe care to those who need it most.

“I’m proud to be part of this new team. Our collective goal is to improve health outcomes for people who are generally underserved and don’t have direct access to comprehensive care and mental health supports,” says registered nurse Max Ering, who joined the team last fall. “By working as one connected primary care team across three sites, we intend to make sure no one we serve, no matter how complex and challenging their needs, falls through the cracks.”

Passionate about delivering high-quality care to everyone who needs it, Max strives to help clients manage chronic conditions, improve their independence, and enhance overall quality of life. “Primary CONNECT is all about breaking down barriers to care and meeting people where they’re at in their readiness journey,” he explains. “When people are ready for their next step, we are too – we work together to leverage each other’s experience and expertise to provide the best possible care.”

By working as one team with a support system to efficiently integrate people into pre-existing services across multiple sites, Primary CONNECT is leading the way toward a new future of connected healthcare. Together, SRCHC and our partners are creating transformative, positive change to achieve equitable care for marginalized people with complex health needs.

With a near-death experience triggering a desire to change, Tony Williams told the Toronto Star in March 2025 that it was trust and lack of judgement from SRCHC staff that has kept him going. “They stuck with me through thick and thin …I’ve known people who have died because friends and family rejected them. This place is family and they are behind me all the way.”

In the first six months of operation, staff working in the Primary CONNECT program provided team-based care to 2,599 service users and have attached 711 individuals to primary care services.

Inspiring Innovation and Increasing Access to Team-Based Primary Care

report_admin — Tue, 17 Jun 2025 21:35:54 +0000

In this section

The MATCH Program Inspires Collaborative Perinatal Care
DECNET Increases Access to Primary Care and Reduces Health Inequities
Diabetes Eye Screening: The First Home Visit

Serving approximately 15,000 people with complex health needs each year, SRCHC is a leader in providing high-quality, inclusive, and accessible team-based primary healthcare in East Toronto. Our services include midwifery, primary care, chronic disease management, allied health and mental health supports, and much more. We focus on empowering and improving the lives of diverse communities, including newcomers, people who are uninsured and people who use drugs. By treating the whole person, we work collaboratively to address physical, mental, spiritual, and social needs.

Did You Know: SRCHC programs and services are designed to help individuals who face significant challenges accessing healthcare services?

The MATCH Program Inspires Collaborative Perinatal Care

SRCHC’s Midwifery and Toronto Community Health (MATCH) Program is committed to facilitating very low barrier access to sexual and reproductive healthcare for people who often face systemic barriers. Our goal is to provide a seamless system of care without discharges where our clients are supported to move from the community to a hospital setting and back, without falling through the cracks. Our strong and positive collaborative relationships with our obstetric, midwifery, internal medicine, endocrinology, nursing, and paediatric colleagues at Michael Garron Hospital (MGH) means people are accessing primary and specialist care that’s well connected and continuous.

In the past year, the MATCH Program provided comprehensive perinatal care, including prenatal, labour, birth, postpartum, abortion, and neonatal care services. The team also offered testing and treatment for sexually transmitted infections (STIs), Pap tests, access to vaccinations during pregnancy, and managed first-trimester complications through MGH’s Outpatient Early Pregnancy Clinic.

This year marked the MATCH Program’s second full year staffing the Early Pregnancy Clinic at MGH, providing 938 unique visits. The midwifery-led clinic provides follow-up care for anyone experiencing first-trimester pregnancy complications, whether referred from the emergency department or their primary care provider. In response to growing demand, we have expanded the clinic from two to three days per week, adding a seven-day-a-week phone line; revamped the website and referral forms; and developed standardized clinical protocols in collaboration with our obstetric colleagues.

For the upcoming year, plans are underway to add a fourth clinic day. To our knowledge, this is the first midwifery-led outpatient early pregnancy clinic in Canada and colleagues in Ottawa and London have reached out to learn how they might implement a similar model of care in their cities.

This year at SRCHC, the MATCH program provided care to 535 unique clients.

68% of our clients were uninsured, 25% were underhoused or homeless, 25% were single parents, and 61% were experiencing food insecurity, which we attempted to mitigate with grocery cards at visits and providing snacks in clinic.

DECNET Increases Access to Primary Care and Reduces Health Inequities

Diabetes Education Community Network of East Toronto (DECNET) breaks down barriers and reduces health inequities for people living with type 2 diabetes or prediabetes. Our multidisciplinary team of nurses, dietitians, social workers, and health promoters work together to provide evidence-based diabetes education to 2,062 unique clients annually. Last year, we received nearly 400 referrals from nurse practitioners and physicans from across East Toronto.

DECNET is committed to providing accessible care to those who need it most. Services are provided at multiple locations and we’re integrated into a number of primary care settings within CHCs and family practices. For people facing barriers to attend in-person visits, we offer transportation support, phone appointments, and occasional home visits. For clients who are uninsured or not connected to a primary care provider, DECNET bridges gaps by coordinating care and assisting clients in navigating the healthcare system.

Living with diabetes affects more than physical health. About 50% of people living with diabetes also experience anxiety from the constant demands of managing the chronic condition.

SRCHC is one of the only diabetes programs in Toronto that has a social worker integrated into the team. This connected approach allows us to offer clients short-term mental health counselling and case management for concerns related to income, housing, immigration, food security and more, addressing the full scope of health and well-being.

DECNET collaboratively engages people and communities impacted by or at risk of type 2 diabetes to optimize their well-being through accessible, equitable, and evidence informed education, self-management support and care.

Diabetes Eye Screening: The First Home Visit

In September 2024, SRCHC celebrated another innovative milestone — our Diabetes Eye Screening Program [DESP] provided its first home visit.

A woman in her 60s who uses a wheelchair was scheduled for an eye screening at our 1245 Danforth Avenue site. At intake, she and her referring physician raised concerns about her mobility and let us know that transportation would be a barrier that could prevent her from accessing our services. Thanks to new research by the University Health Network (UHN) and with the support of AI-based tools, including a state-of-the-art handheld camera, our team was able to bring the eye screening to her home.

We used a Snellen chart to check her vision, administrating dilating drops and capturing detailed images of her eyes using the portable camera. Within a week, a specialist reviewed her results and recommended follow-up care.

By meeting people where they are, we’re doing more than screening eyes for issues – we’re protecting against diabetes-related vision loss and improving access to sight-saving healthcare.

According to Diabetes Action Canada, 31% of Ontarians live with diabetes or prediabetes. Diabetes is the leading cause of blindness in Ontario. For more than ten years, SRCHC has partnered with UHN to provide eye screening to low-income and marginalized people living with diabetes.

DESP is currently the top-performing tele-ophthalmology program in Ontario and has screened approximately 4,600 people since its inception in 2017.

Did you know

For every dollar invested in DESP, the return on investment is $26.95 for screening and low-cost therapy, and $7.66 for screening and high-cost therapy?

Link to Study

Celebrating Cultures and Connecting Communities

report_admin — Tue, 17 Jun 2025 21:35:04 +0000

In this section

Cultural Celebrations and Congregate Meals Knit Communities Together, Reducing Isolation and Improving Food Security
Health Promotion and Social Prescribing Improve Outcomes for Seniors
The Benefits of Mindful Gardening
Harmony Community Food Centre: Serving Up Independence for Kids and Youth

Every year, SRCHC brings seniors together to celebrate diversity, enjoy cultural events, and share meals, fostering stronger, more inclusive communities and an unprecedented sense of belonging. These connections are meaningful and vital, with research showing they improve mental health, build resilience and can even increase life expectancy.

Many of the communities we serve also include newcomers who face higher than average rates of poverty and unemployment. Working alongside supportive partners, such as Community Food Centres Canada, SRCHC is tackling an urgent need – better access to healthy, affordable food for vulnerable groups like seniors living alone, newcomers, and people living with disabilities.

Cultural Celebrations and Congregate Meals Knit Communities Together, Reducing Isolation and Improving Food Security

Harmony Community Food Centre and the Seniors Active Living Centre (SALC) are powerful and welcoming spaces where food serves as a bridge that connects people.

Our cultural celebrations bring community to life. From lunches to commemorate Chinese New Year and Tamil New Year to Pongal (Tamil Heritage Month) and the Dragon Boat Festival, these events are vibrant expressions of connection and care. They highlight the power of community celebrations and food to bring people from diverse backgrounds together to share healthy prepared meals, listen to music, and dance. More than a place to host celebrations, with the integration of the Harmony Community Food Centre, we’re working together, giving hope for a future where everyone can access good food and gain a true sense of belonging.

"Thank you so much for organizing a wonderful Tamil New Year celebration. It was a truly memorable and enjoyable event for everyone, such a positive and uplifting experience."
– Sheila

drop-in community meals served by Harmony Community Food Centre

congregate dining sessions

with

attendees

Did You Know:

The Seniors’ Active Living Centre (SALC) at Harmony Hall offers wellness programs, educational workshops, community engagement activities, cultural events, outings and more. Our SALC facilitators lead a wide variety of programs and services that help seniors keep active, engaged, and independent.

The SALC staff team are multi-lingual, with 1:1 services and group based programs offered in languages other than English (Cantonese, Mandarin, Tamil, and Bengali).

Health Promotion and Social Prescribing Improve Outcomes for Seniors

"Health promotion is a team-based approach that enables and empowers people to increase control over their own well-being. When people are supported to increase control over their own health and well-being, they improve their health outcomes."
– Shirley Cheng-Kerr, SRCHC Health Promoter

Staff work with clients to develop their personal skills and connect with communities to help create healthy environments. They also take an equity focus to help individuals and communities deepen community action. Collaborating with community members, partners and healthcare providers, health promoters use a determinants of health lens that considers the clients’ entire physical, mental, emotional, and spiritual well-being.

This team-based, people-centred approach to primary care empowers clients to improve their health, well-being, and social connections. One way health promoters play an important role is through social prescribing – this means that a primary care provider refers someone to a seniors’ community health program for example, instead of or in addition to prescribing them medication.

Social prescriptions are referrals that connect people to community health programs, such as Tai Chi, seniors’ ukulele groups, and other recreational activities that promote well-being. Social prescribing also bridges gaps between the broader healthcare system and other sectors. For example, through group sessions that help seniors access unclaimed benefits or communal meals that improve food security.

While the reasons for referral may be different, the goal is the same: to provide equitable access to group-based community health programs that reduce social isolation and build community connections.

Client Story: Mother’s Day

A 90-year-old mother is referred to a Tai-Chi class by her primary care provider to help her maintain good mental and physical health – it also becomes an activity she can do with her son. Participating together, the duo inspires other seniors in the group and across their community to keep moving and do exercises that continuously improve balance, fitness, and mobility.

Seniors’ Ukulele Group

“The seniors’ ukulele group keeps my mind active while I learn a new skill and have fun. I come to play and connect with people who are now my friends.”

The seniors’ ukulele group’s playlist of top five songs:

You are My Sunshine
Ukulele Lady
Pearly Shell
Jamaica Farewell
Wonderful World

Photo caption: Led by seniors providing peer-to peer support, the Ukulele group performed at a Chinese New Year celebration in February 2025 hosted by one of SRCHC’s partners, Woodgreen Community Services . Toronto Mayor Olivia Chow attended the event and recognized the powerful ripple effect the program has on clients and their communities.

The Benefits of Mindful Gardening

"Every time I practice mindful exercise in our rooftop garden, I notice the vegetables we grow; I feel the magical life in every plant; the sun, air, and our care are so important, and then comes the harvest. There are no words that can express the joy in my heart."
– Clement Liong, gardening program participant

SRCHC has been a pioneer in promoting the health benefits of gardening activities for more than two decades. In the early 2000s at our 955 Queen Street East site, the rooftop was converted into a stunning community garden. In 2016, we applied for and received a grant to renovate our secret garden into a paradise. The space was re-designed with large raised garden boxes to make the space more accessible with pathways that allowed for mindful walking and gardening at the same time.

The most notable impact of the gardening programs, according to participants, are the positive effects on mental health and well-being, along with access to healthy, fresh food. Through gardening together, people build new friendships rooted in shared interest and a sense of accomplishment. By working and learning together, we reduce social isolation and loneliness. Our focus on mindful gardening, harvesting and eating together also supports people to feel more grounded, calm, and relaxed. It can be remarkably transformative. Angie Seto shares: “I have a sense of fulfillment when I step onto the rooftop garden, seeing the seedlings grow well, turning the space green and bushy.”

Gardening programs build practical skills and improve access to fresh, organic fruits and vegetables, supporting people to eat healthier and save money.

By learning new skills, gardening group participants have started growing their own food on windowsills, balconies, and in their own gardens.

Did you know: last year SRCHC hosted 32 sessions across four gardening programs which served almost 300 participants?

Harmony Community Food Centre:
Serving Up Independence for Kids and Youth

At SRCHC we believe that everyone deserves the chance to learn and thrive. That’s why our Harmony Community Food Centre is more than a place to eat: it’s a hub where barriers come down and hope takes root. By bringing community members from all walks of life together to grow, cook, and share food in a welcoming, inclusive space, Harmony Community Food Centre strengthens food security, while nurturing connection and belonging for everyone. With nearly 12,000 meals served each year, an affordable fresh produce market, and activities for families, youth, and seniors, we offer hands-on learning that nourishes both body and spirit.

At our Harmony Community Food Centre, SRCHC runs a number of programs for children and youth – including Kids Can Cook and Mind Your Food – that serve up large helpings of independence and contribute to food security.

Kids Can Cook is a four-week program that runs in July and August every year. Children and their parents or caregivers gather to learn about food-related topics and prepare simple, budget-friendly recipes. Through experiential learning, families gain hands-on cooking skills and learn about proper nutrition, healthy eating habits, and the importance of social connection.

The Mind Your Food program engages youth aged 13-19 and helps them develop cooking and baking skills, and learn more about food traditions. It also enhances cultural pride, community action, and land-based knowledge sharing. Each session includes shared meals, plenty of snacks, and often food to take home. At its heart, the program is about building community and creating space for youth to form meaningful social connections and a sense of belonging.

As youth participants become more confident, they begin to share their own recipes and food traditions with the rest of the group. This past winter, they developed and prepared a number of recipes, including Chicken Biryani and Mango Lassi, Chocolate Chip Cookies and Apple Fritters, and a nutrient-packed version of Trifle.

Nothing compares to the unique joy and sense of hope that fills the room when children and youth come together in the kitchen. As they explore the food system and learn about food security, they’re also building friendships and gaining confidence and independence.

These programs are about more than food — they’re about learning, growing, and thriving, one recipe at a time.

The program has grown in its popularity with much interest from families in the community. “I’ve never had raspberries before and I like it!” “I’m going to make this at home for my mom!”

Welcome from New CEO Shannon Wiens

report_admin — Tue, 17 Jun 2025 20:20:04 +0000

After 24 years of working at South Riverdale CHC, starting as a health promoter and growing from there, I was honoured to accept the role of Chief Executive Officer (CEO) in November 2024. It’s in my new role that I’m excited to share SRCHC’s 2024-25 Annual Report.

It’s been a year of significant changes. We’ve taken bold steps forward, celebrating the launch of several new innovative programs, such as the Early Pregnancy Clinic at Michael Garron Hospital. But we’ve also faced some tough moments.

On March 21, 2025, we permanently closed keepSIX, the Consumption and Treatment Service (CTS) site we’ve operated since 2019, following a government directive. This vital service saved hundreds of lives and connected people who use drugs to essential wrap-around care. keepSIX is irreplaceable and its absence is deeply felt. SRCHC will continue to find ways to serve clients who used keepSIX as valued members of our community.

Our commitment to providing equitable access to healthcare remains strong and we’re encouraged by the government’s promised $1.8 billion investment to expand access to primary healthcare for everyone—a step in the right direction. This year, we launched Primary CONNECT, a partnership project with Parkdale Queen West CHC and CAMH that’s connecting underserved individuals to primary care.

As a community-based primary care organization, we see this transformation (which is led by Dr. Jane Philpott and the province’s Primary Care Action Team) as a game-changer. Their goal is to ensure that everyone in the province has access to a “health home” that includes a team of health professionals and links to social supports and community services.

At South Riverdale CHC, we embody this vision of a health home. Like many CHCs, we provide low-barrier, connected healthcare rooted in community to every person we serve, including newcomers, people living with chronic conditions, and individuals facing mental health and substance use challenges. The government’s new direction reinforces the work we’re proud to do in East Toronto.

Please keep reading to find out how we make it happen – just as we have for almost 50 years.

Board Chair & CEO Message

report_admin — Tue, 17 Jun 2025 20:09:26 +0000

What lies at the root of all we do?

The true value of the Community Health Centre (CHC) model of care is in its deep and lasting impact on the diverse and dynamic people we serve, on the communities where our programs and services come to life, and within the broader healthcare system we help strengthen and sustain every day.

Rooted in community and health equity, we deliver compassionate and connected healthcare in East Toronto, serving individuals from equity deserving populations and those with complex healthcare needs. Team-based primary care is the foundation of who we are and what we do. We take a holistic, whole-person approach to improving health and supporting physical, mental, spiritual, and social well-being within a healthcare system that continues to perpetuate systemic racism and discrimination.

Working alongside our many partners, we connect people with a range of services to reduce barriers to care and address the social determinants of health, including allied health services, social work, health promotion and education, mental health and support groups, and recreational and fitness programming. Through our strategic partnerships with organizations within the Ontario Health Teams (OHTs) and other CHCs across Downtown and East Toronto, we broaden our reach and contribute to meaningful systems transformation, providing supports and services when and where they are needed most.

Whether at one of our six locations, at our partner sites or out in the community, people not only receive the primary healthcare they need, they also build lasting social relationships – and some become active advocates for and volunteers supporting vulnerable populations.

It’s this vision for a caring and inclusive future where everyone feels welcome, seen, and heard that continues to inspire us. Each day our dedicated staff turn insights into action: through research, innovation, and knowledge-sharing, our goal is to ensure our work resonates meaningfully across the healthcare system and within the lives of people we’re here to serve.

In this report, we’re proud to share highlights from our most forward-thinking programs and services that best reflect our impact and commitment to meeting people where they are and growing a healthier and happier community, together.

Thank you for taking part in the journey.

Sincerely,
Shannon and Emily

Board of Directors
Emily Hill (chair)
Bella Bereket
Matthew Yun-Chun Cheng Arman Hamidian Rebecca Ho
Aparna Kajenthira Rishma Pradhan
Dr. Philip Berger
Nisha Hariharan
Riannon John
Edward Speicher
Anne Simard

Pictured (left to right)
Back row: Anne Simard, Bella Bereket, Edward Speicher, Emily Hill
Front row: Shannon Wiens, Nisha Hariharan, Rebecca Ho

Welcome from New CEO Shannon Wiens

Our commitment to providing equitable access to healthcare remains strong and we’re encouraged by the government’s promised $1.8 billion investment to expand access to primary healthcare for everyone—a step in the right direction. This year, we launched Primary CONNECT, a partnership project with Parkdale Queen West CHC and the Centre for Addiction and Mental Health (CAMH) that’s connecting underserved individuals to primary care.

Please keep reading to find out how we make it happen – just as we have for almost 50 years.

Expanding and Revitalizing Services to Support Community Needs

report_admin — Tue, 18 Jun 2024 22:35:51 +0000

Following a lengthy period of COVID-19 precautions, the Substance Use and Mental Health team was able to shift towards more in-person group programming this past year. Service users benefited from a range of programming across South Riverdale Community Health Centre (SRCHC) sites, including low-barrier drop-in programming, arts-based programming, Indigenous Circles, gender-specific programming, educational workshops, trauma-treatment groups, Hep C treatment groups and writing circles. These initiatives were led by interdisciplinary teams comprised of community health workers, trauma social workers, health promoters, community support workers and harm reduction workers.

Other programs were also revitalized through collaboration this year. After an extended closure, the Oakridge Health and Harm Reduction Hub resumed services at 52 Cataraqui Crescent in early 2023. The Hub and its partners hosted a spring information session for service users to solicit feedback about what services and opportunities were most impactful. As part of the East Toronto Outreach Program, SRCHC partnered with different organizations to provide a wide range of services that broaden the scope of harm reduction services. These services include housing support through COTA, legal aid services and support with Sound Times, case management with The Neighbourhood Group, and on-site crisis support with Gerstein Crisis Centre. In December 2023, the Hub partnered with Second Harvest to address food insecurity by distributing food donations through a weekly food bank. This holistic range of services offers a one-stop shop, reducing barriers for people in need of accessing a range of supports.

SRCHC’s Harm Reduction Worker Training and Apprenticeship Program wrapped in 2023. The program saw two cohorts graduate with 39 total participants in the training program, 22 of which went on to apprentice at various organizations in the city. The project has increased participants’ harm reduction knowledge, self-confidence, sense of community and purpose. Congratulations graduates!

The Toronto Community Hep C Program (TCHCP) continues to expand its programming and research partnerships across the city. The TCHCP partnered with University Health Network, Michael Garron Hospital, St. Michael’s Hospital and several community health centres to amplify promising and best practices. Through outreach efforts, the TCHCP has reached a broader range of clients, including individuals living in Toronto Community Housing, accessing emergency room departments and experiencing barriers to accessing testing and treatment.

The KeepSIX Consumption and Treatment Service has been working with the community to address the needs of neighbours and service users through the Community Advisory Committee, the Community Liaison Committee and open houses at our 955 Queen St E location, which gave visitors the opportunity to take a guided tour of KeepSIX. On average, between 75 and 85 unique clients access KeepSix each month. Service hours have been expanded and the site now operates from 8am to 8pm on Mondays, Tuesdays and Thursdays. KeepSIX is often the entry-point for people who use drugs to access healthcare. In addition to overdose response services, KeepSIX offers brief case management services, clinical care, and information and referrals including onsite access to addiction medicine doctors in partnership with the Comprehensive Treatment Clinic.

Over the past year, SRCHC has moved forward on several environmental, safety, and community engagement activities as part of a comprehensive quality improvement process. Changes include increased community needle sweeps to twice-daily Monday through Friday. In addition, SRCHC worked with the City of Toronto to install a needle kiosk at Jimmie Simpson park to support the safe disposal of used supplies in the Leslieville community.

Our team is looking forward to another exciting year guided by relationships, communities and the people who use our services!

Statistics at Glance

unique clients accessed the Hep C program

diagnostic tests were administered for Hep C, Hep B and HIV to clients

diagnostic tests were administered for Hep C through outreach testing

Working Collaboratively with Local Partners to Provide Integrated Care Across East Toronto

report_admin — Tue, 18 Jun 2024 22:30:37 +0000

At South Riverdale Community Health Centre (SRCHC), a strategic priority for the organization is to “lead systems transformation through building and nurturing partnerships that support an inter-sectoral approach to addressing the social determinants of health.” SRCHC is involved in multiple partnership projects with agencies and community that focus on improving the well-being of clients and community members. We work with communities and research partners to build knowledge and evidence that inform practice, leadership and transformative change.

SRCHC works closely with partner agencies with in the East Toronto Health Partners Ontario Health Team (OHT) and the Downtown East OHT to plan and coordinate services. East Toronto Health Partners (ETHP), the OHT serving East Toronto, is a collaborative initiative that brings together more than 100 health, social and community service providers and organizations who work together to improve the ways in which community members find and receive care in East Toronto.

SRCHC is an anchor partner within the ETHP and represents one of five community health centres (CHCs) in East Toronto including Access Alliance, East End Community Health Centre, Flemingdon Community Health Centre and Vibrant Healthcare Alliance. CHCs in East Toronto have a long history of working together in an integrated and collaborative manner. SRCHC has worked with local CHCs on a range of healthcare initiatives with a focus on health equity, health promotion, community governance and team-based care for socially vulnerable and medically complex residents. By working as one coordinated team, rather than separately, we aim to make finding and receiving care more connected across the spectrum of care and easier to navigate. This approach helps to improve access to services, as well as reduces delays, mitigates duplication in care and addresses gaps in service delivery.

SRCHC staff support a number of projects within the ETHP OHT, including:

Working with OHTs in our community to redesign integrated care pathways for chronic obstructive pulmonary disease, congestive heart failure and diabetic foot care.

Working with ETHP on a year-long consultation that will help to advance the OHT’s work across equity and anti-racism. This work will inform how we work together to co-design a more inclusive health system that delivers high-quality care with equitable health outcomes for everyone.

ETHP has partnered with the Registered Nurses' Association of Ontario (RNAO) to embark on a four-year journey to optimize patient outcomes through evidence-based practice and robust staff engagement across multiple ETHP member organizations. This partnership has been informed by the implementation of Best Practice Guidelines, which provide evidence-based recommendations and implementation tips pertaining to infrastructure, knowledge exchange, capacity building, dissemination, evaluation and reporting. SRCHC is currently working with our OHT partners in East Toronto on a falls prevention toolkit to help inform organizational fall prevention programs across our OHT partner organizations. The toolkit also contains a series of image and text-based handouts to help people prevent and respond to falls at home.

SRCHC’s partnerships are paramount to achieving the organizational vision to create empowered, healthy and thriving communities where everyone belongs. It is through collective efforts with ETHP that we strive to amplify the work being done at the Centre and expand our impact throughout East Toronto by enhancing integrated care for its community members.

Meeting Community Needs with Diverse Programs and Services

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Creating a space for connection and inclusion is vital to the work we have been doing within the Community Health and Chronic Disease portfolio over the past year. The loosening of COVID-19 restrictions provided an opportunity to evaluate how programs were offered in the past and to reconsider how programs could be offered moving forward.

We asked ourselves “how do we ensure that our programs are easy to access?” and considered various service delivery options, including in-person, virtual and hybrid. Feedback from community members and clients made the answer simple – all of the above! The pandemic forced us to learn how to provide quality virtual care quickly and the takeaway is that virtual care is here to stay, as it often expands access to programs and services to a greater range of clients. Needless to say, the merit of in-person appointments and groups will always remain. The in-person space allows many community members, especially in group settings, to foster a sense of safety and belonging, and to receive valued peer-to-peer support.

Collaborative efforts with community members are imperative to ensure that our programs and services are responsive to the unique needs of the diverse populations we serve. Food insecurity is a pressing issue within our catchment area, which we aim to address through the programs offered at our Community Food Centre. Through programs such as the weekly community meal program and the Good Food Market, we provide freshly cooked nutritious meals, and affordable and accessible produce. Additionally, we have opened our doors to our neighbours at 500 Dawes Rd, providing space for tenants to gather and host educational workshops on tenants' rights—an essential aspect of community connection and inclusion.

Our Senior Active Living Centres are a testament to our commitment to inclusivity and accessibility. Recognizing the diversity of our senior population, we have established four different language advisory committees (Tamil, Bengali, Chinese and English) that meet regularly to discuss and recommend changes to better meet our clients' needs. In response to their feedback, we recently installed grab bars in all washrooms and replaced old chairlifts, ensuring that our facilities are safe and accessible for all.

Over the past year we have increased access to services by embedding chronic disease programs and services within priority neighbourhoods in our catchment area. Consultation with community agencies and data analysis are crucial to identify areas with the greatest need, such as Taylor Massey and Oakridge neighbourhoods. We recognize that we cannot achieve significant change in these areas alone. It is with support from internal programs, collaborative partners and the voices of our community members that we are able to make our programs and services accessible, and achieve a greater impact.

This year, South Riverdale Community Health Centre (SRCHC) partnered with Diabetes Action Canada (DAC) to become their first official Knowledge User partner. This partnership will allow SRCHC access to resources within the DAC network, to inform policies related to provincial-level diabetes eye screening and limb preservation work, and advance diabetes management and care for our clients. This will build upon our existing Diabetes Eye Screening Program, which is currently the top-performing tele-ophthalmology program in the province based on recent fiscal numbers screened and total numbers screened since the programs started.

Evolving Integrated Health Care Practices to Improve Client-Centered Care

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At South Riverdale Community Health Centre (SRCHC) our primary care team works collaboratively on care planning for clients with complex needs. Our healthcare practices ensure coordinated delivery of the highest possible quality of care and inter-disciplinary referrals, supporting clients to be co-designers of their own care plans.

SRCHC joins a movement of over 20,000 member agencies worldwide of the International Federation for Integrated Care working diligently to improve individual and population health through co-designing and coordinating care planning and delivery with individual and communities.

This evolution of integrated health care within SRCHC can be exemplified in our work to improve: real-time access to care, supports for discharge planning, in-home services for patients and inclusive health services.

Real-time access to care

SRCHC operates clinics that support same day or next day access to care. These include our outreach clinic which is intended for registered patients who face barriers to care and experience challenges keeping scheduled appointments. We also offer six days a week urgent care clinics that allow patients with acute health episodes, that cannot wait for regular appointments, to see a primary care provider. Such practices ensure real-time access to quality health care, which in turn reduces the number of emergency department visits and improves health outcomes by preventing the escalation of health conditions.

Discharge planning

SRCHC continues to work with our hospital partners to support discharge planning. Efficient discharge planning and processes are critical to ensuring smooth patient flow, continuity of care and reduction of the likelihood of patient readmission to hospital. Discharge notes communicate crucial patient information such as reason for visiting the emergency department, tests conducted and diagnoses, care provided, changes to medications and follow-up recommendations. Timely and confidential transfer of discharge notes between hospitals and attending primary care providers has been a critical practice to ensure continuity of care following discharge and has reduced medical errors during care transitions.

Home Care

SRCHC continues to work closely with East Toronto Health Partners, the Ontario Health Team serving East Toronto, to improve the quality of healthcare for homebound individuals. Our team-based model of care enables a Registered Nurse, Nurse Practitioner/Physician and where relevant, a Social Worker/Dietitian or Health Promoter, to plan a joint visit to a patient’s home to provide wrap-around care. These visits also provide caregivers with tips on how to better provide care to their patients and family members. Our work in this area continues to evolve and we are able to provide some homebound patients of the centre access to virtual group-based heath promotion and education sessions.

Inclusive health services

SRCHC continues to build strategic primary care partnerships with community organizations to address social issues that affect clients’ health. Pertinent initiatives involve providing culturally-sensitive care for 2SLGBTQ+ service users, reducing barriers related to racism and discrimination, integrating Indigenous models of care within competency training, expanding virtual and community care for individuals with mobility challenges, and improving food access.

These efforts exemplify SRCHC’s client-centered approach to care, which aims to take into consideration the diverse health needs, barriers to care and cultural contexts experienced by our community. This approach helps to ensure more equitable access to and greater quality of care for our clients.

We look forward to continue building and deepening relationships and engaging with new community members. We continue to strive to provide the highest quality care and adapt to our clients’ changing needs.

report_admin | SRCHC Annual Report

Transforming Primary Care : Looking Forward

In this section

Creating a Connected Healthcare Neighbourhood Across Many Diverse Communities

Looking Forward

Breaking Down Barriers and Building Up Hope

In this section

Remembering Wanda Whitebird

Outreach and Harm Reduction Programs Bring Healthcare and Hope to People Wherever They Are

Primary CONNECT Provides Equitable Access to Wrap-Around Services

Inspiring Innovation and Increasing Access to Team-Based Primary Care

In this section

The MATCH Program Inspires Collaborative Perinatal Care

DECNET Increases Access to Primary Care and Reduces Health Inequities

Diabetes Eye Screening: The First Home Visit

Did you know

Celebrating Cultures and Connecting Communities

In this section

Cultural Celebrations and Congregate Meals Knit Communities Together, Reducing Isolation and Improving Food Security

Did You Know:

Health Promotion and Social Prescribing Improve Outcomes for Seniors

Client Story: Mother’s Day

Seniors’ Ukulele Group

The Benefits of Mindful Gardening

Harmony Community Food Centre: Serving Up Independence for Kids and Youth

Welcome from New CEO Shannon Wiens

Board Chair & CEO Message

What lies at the root of all we do?

Welcome from New CEO Shannon Wiens

Expanding and Revitalizing Services to Support Community Needs

Statistics at Glance

Working Collaboratively with Local Partners to Provide Integrated Care Across East Toronto

Meeting Community Needs with Diverse Programs and Services

Evolving Integrated Health Care Practices to Improve Client-Centered Care

Real-time access to care

Discharge planning

Home Care

Inclusive health services

Harmony Community Food Centre:
Serving Up Independence for Kids and Youth