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Conference Abstracts

Evolving how we Partner with Patients, Family Members/Caregivers and Community Members in Designing Integrated Care in East Toronto


Yordanos Woldemariam ,

Woodgreen Community Services, Canada, CA
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Omar Khan

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East Toronto Health Partners (ETHP) is comprised of 50+ health and social organizations in East Toronto, with a leadership council consisting of patient/caregivers and six anchor organizations representing the continuum of care. In our Integrated Care (IC) model patients, family members/caregivers and community members are recognized and supported as active partners in the decision-making and planning for integrated care delivery.

Short description of practice change implemented

ETHP is co-creating an IC model where hospital, primary care, community providers and patients and families work together to improve population health, patient and provider experience, and value for money (Quadruple Aim). To support this, an interim Patient, Family/Caregiver and Community Member Group was established early on to advise on a broader community engagement strategy in East Toronto.

Aim and theory of change

As we live in one of the most diverse cities in the world, our aim is to develop an expanded Community Council and a diverse roster of community members who can partner in different aspects of our integrated care work. We developed a recruitment roadmap to engage harder to reach populations in East Toronto. Engagement methods used include: informal phone interviews, surveys, online co-design workshops, online information sessions and media translated in multiple languages.

Targeted population

We are specifically targeting our recruitment efforts in ethnically diverse neighbourhoods and in priority populations for our integrated care work, including seniors with chronic care needs and their caregivers, and individuals of all ages with mental health challenges and substance use issues.


Our strategy was implemented in the fall of 2020 and is ongoing.



Highlights (innovation, Impact and outcomes)

In order to co-design integrated care with our diverse communities, the ETHP conducted outreach with community organizations/grassroots groups to identify barriers in engaging hard-to-reach populations in East Toronto. Over 40 organizations/groups were contacted. Surveys and co-design workshops were used as a tool to identify barriers to engagement and to form collaborative solutions. Learnings have been used to inform the ETHP’s community recruitment process.  

Comments on transferability and sustainability

The ETHP’s engagement with patients, families/caregivers and community members has been integral in informing this IC model. Continued partnerships with community members and community organizations/grassroots groups in the engagement process will expand the reach of the ETHP’s engagement work.

Comments on Conclusions; Discussions; Lessons learned

Although ETHP has partnered with patients, families/caregivers and community members in many aspects of our work, in the early stages of the COVID-19 pandemic, the ETHP did not sufficiently engage our patients and community in designing our response to the crisis. As we moved into Wave 2 of the pandemic we increasingly broadened our engagement and have been leveraging multiple community voices for COVID-19 testing and vaccine planning. Participants in this session will be able to learn from our experience in recruiting diverse patients, families/caregivers and community members in the design of integrated care in East Toronto. Presenters will include community members who have been involved in our recruitment process.

How to Cite: Woldemariam Y, Khan O. Evolving how we Partner with Patients, Family Members/Caregivers and Community Members in Designing Integrated Care in East Toronto. International Journal of Integrated Care. 2022;22(S1):119. DOI:
Published on 08 Apr 2022.


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