Evolving Integrated Health Care Practices to Improve Client-Centered Care


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.