Ontario Health Team Expressions of Interest- Winter 2021

As expressions of interest from OHTs are submitted, they will be posted below for potential fellows to view. Please check back regularly for updates to this page.

OHT Name Location Project Summary Bilingual Need? Can Contact? Expression of Interest and attachments
South Georgian Bay OHT Collingwood, ON The SGB OHT is seeking a fellow’s expertise to support and lead the monitoring and evaluation of the SGB OHT strategic plan and assist in the development and measurement of our Collaborative Quality Improvement Plan. The work of the fellow will be integrated with all members of the SGB OHT leadership and Action Teams. Through the development of standardized and evidence-based tools, such as the balanced scorecard, the fellow’s work will demonstrate the success of the SGB OHT in meeting our community priorities, and help to inform future projects and activities as we continue to mature. No Yes

South Georgian Bay Ontario Health Team

SGB OHT Strategy

Nipissing Wellness OHT North Bay/Nipissing As part of our OHTs’ ongoing efforts to improve the care experience for our seniors, and to meet the system goal of reducing ALC rates, our OHT is looking to complete a retrospective data analysis of patients who have been designated ALC within our region over the last year. The information derived from this data analysis will be combined with the results of our ongoing community services gaps analysis to help develop a list of key early signs/risk factors for ALC within Nipissing, create a clinical algorithm, and identify upstream program changes that will help reduce risk. No Yes

Nipissing Wellness Ontario Health Team

PFCES Document

NWOHT Org Diagram

CDMA 3 Decision Making

Hastings Prince Edward County OHT







Hastings Prince Edward County

#1 Assist in the evaluation of virtual care implementation during the pandemic with a focus on evaluating transitions in care using virtual tools for residents in the HPE OHT and determining if technology enabled certain patient outcomes to support more efficient system use. The evaluation could include comparisons to other technology and national/international applications, risk assessment, cost/benefit analysis so the OHT would be in a better position to understand an over-arching strategic approaches and a potential roadmap as we mature.

#2 Assist in the development of a performance management framework to define the business and technical requirements for data that will support the OHT’s immediate and future objectives.

No Yes

Hastings-Prince-Edward-County OHT#1

Hastings Prince Edward County OHT #2

Western York Region OHT Richmond Hill, King, Vaughan Western York Region OHT has been building its integrated care portfolio in alignment with Ontario Health priorities and funding opportunities. The primary focus has been on developing programming for frail older adults and more recently the emerging need to address mental health and addictions in our communities. The goal of the fellowship project will be to develop an overarching evaluation plan, including an appropriate framework, set of methodologies and indicators that can capture the impact of our integrated care initiatives. Acknowledging the complexity of integrated care as a process, the evaluation will also identify what works, what doesn’t, and recommendations for future priority populations and improvements across WYR OHT, which could alhttps://ihpme.utoronto.ca/wp-content/uploads/2021/12/Western-York-Region-OHT-Richmond-Hill-King-Vaughan.pdfso be transferrable to other OHT groups. Fellows will have the opportunity to chose between several integrated care projects based on their skills and interests. No Yes Western York Region OHT
Northumberland OHT Northumberland County Expansion and implementation of an Outreach Strategy to Improve Access to Care and Population Health for Rural Vulnerable Residents in the Ontario Health Team of Northumberland. No Yes Ontario Health Team Of Northumberland
Huron Perth and Area OHT Huron Perth and Area (SW Ontario) The HPA-OHT is looking for OHT Fellow expertise to support and lead the development of an evaluation framework for the OHT structure, priority projects and other initiatives that have started since initiation in early 2020. The OHT Fellow will be fully integrated into the OHT Secretariat, leadership teams and working groups, where appropriate. We will look for fellow support to build evaluation tools to showcase the success of our priority work and build sustainable structure as we mature into the future. No Yes Huron Perth And Area
Hills of Headwaters Collaborative OHT Dufferin and Caledon The successful OHT Impact Fellow will be dedicated to engaging on a series of interrelated projects around performance measurement, quality improvement, and evaluation. The first component of work will be to implement our performance measurement framework to help tell our story and support reporting to the Ministry of Health, Collaborative Council, our various working groups, and the broader community. This work will include dashboard and report development, target setting, data collection, data analysis, establishing a regular reporting cycle. The second component of work will be to support monitoring and execution of our collaborative Quality Improvement Plan (cQIP) for FY22/23, while also facilitating planning and development of our FY23/24 cQIP. The third component of work will be to conduct a robust program evaluation on the Caregivers in the Hills program to inform future planning. No Yes


HOH OHT Collaborative Agreement

Network 24 Renfrew County (less the Arnprior area) plus South Algonquin Township (part of Nipissing) The OHT Impact Fellow will augment an existing academic team to undertake the work required to better understand the scale and scope of the problem of insufficient attachment to comprehensive primary care in the region. This will include the expansion of analysis using geospatial mapping techniques and analysis of the relationship between access to a patient’s medical ‘home’ and the social determinants of health. The Impact Fellow will support further detailed evaluation of existing innovative programs as well as assisting the Project Working Groups with the development of new and innovative initiatives to advance the vision of the OHT. This will include clinical and economic impact analysis, provider evaluation and patient evaluation to ensure that these programs meet the quadruple aims of healthcare reform. The OHT Impact Fellow will lead the development of a review and implementation process for new proposals to improve attachment and access to comprehensive primary care. No Yes

Network 24

Collaborative Decision Making

Letter of Support

Letter of Support 2

Sarnia-Lambton OHT Sarnia-Lambton The Fellow will help lead a series of initiatives that will support the adoption and maturation of a decision support and performance evaluation framework. The Fellow will work closely with, and be supported by, a number of OHT working group senior leaders in establishing a balanced scorecard including equity and diversity measurements and a process for population segmentation to identify specific projects. No Yes

Sarnia Lambton OHT

Org Chart

Appendix A OPCN

Appendix_B_Driver Diagram

Connected Care Halton Ontario Health Team (CCHOHT) Halton Region (Oakville, Milton and Halton Hills) Demonstrating a collaborative model, Virtual Home and Community Care will provide a flexible model of care using existing, simple technology. Partners will ensure that virtual care is appropriate, meets the needs of the patient, and considers the client’s preference, support, and circumstances. Utilizing effective change management and comprehensive clinical pathways, the aim is to design a thoughtful and thorough evaluation and expand this service delivery model to appropriate patients of the Mississauga Halton Home and Community Care Support Services, including the Mississauga Ontario Heath Team after evaluation and full implementation in Halton. The program will be in alignment with the Quadruple Aim goals, as it will monitor, measure, and improve the patient experience and provide a flexible model of care utilizing the capacity and resources of Service Provider Partners, while creating efficiencies and reducing per capita patient costs. The program will be evaluated to ensure virtual care is optimized. No Yes

Connected Care Halton Ontario Health Team

CCHOHT Strategic Plan

Cambridge North Dumfries OHT Region of Waterloo, Cambridge North Dumfries The proposed project will be to engage with primary care clinicians to co-design a primary care engagement strategy for CND OHT. This will include (1) formalizing a Primary Care Council that meets the needs of the diverse primary care clinicians in our communities, (2) development of guidelines on how the CND OHT will effectively and sustainably include primary care clinicians in OHT planning including Co-Design Groups & Collaborative Quality Improvement Plans. The engagement strategy will also require an evaluation plan. Preferred but not required Yes Cambridge-North-Dumfries-OHT
Kawartha Lakes OHT Lindsay, City of Kawartha Lakes The fellow would conduct a current state analysis of pathways and support for older adults living with frailty, work with primary care provider champions on a population health management approach to identify areas within clinical workflows that would benefit from a proactive approach, and provide support in the implementation of tests of change at the practice level as collaboratively identified with primary care champions. The fellow will work to support a number of change initiatives as identified in the KL-OHT cQIP. Population health management, quality improvement, change management/primary care engagement, basic data analysis, and implementation science are key skill sets that the fellow will bring to the process. No Yes


Org Chart Gov Model May 2020

Oversight Committee

Workplan Operating Committee

All Nations Health Partners OHT Northwestern Ontario (inclusive of All Nations Health Partners – Kenora, Rainy River District and two emerging OHTs – Thunder Bay) A unique opportunity to develop foundational structures and methodologies to support a regionally and locally integrated care system (including linkage to multiple OHTs). Areas of research/support include developing a regional data inventory and supporting infrastructure, a value-based evaluation framework to support population health management and research, and quality improvement initiatives. No Yes All Nations Health Partners OHT
Southlake Community OHT Aurora, Bradford West Gwillimbury, East Gwillimbury, Georgina, Newmarket • Conducting an environmental scan of emerging research with respect to evaluation of healthcare integration initiatives including review of emerging evidence through RISE
• Developing an evaluation framework for integration initiatives along with an implementation plan for spread and scale of integration initiatives
• Developing a 5 year roadmap for the OHT
• Leveraging the OHT website to spread and scale knowledge and emerging best practice information
• Determining how integration initiatives can influence the cQIP measures
• Developing a process to incorporate cQIP measures, Balanced Scorecard measures and the quadruple aim into all integration initiatives
No Yes Southlake Community OHT
Algoma OHT Sault Ste Marie The Fellow would be expected to contribute to an overall program of work related to complex chronic disease, while supporting the building of evaluative capacity. The Fellow would be based out of the AOHT Transformation Office, while working on a daily basis across many of the health and social partners, including external stakeholders in Algoma and provincial stakeholders. Due to the nature of the work, there would be a high level of interaction with primary healthcare partners, including physician leads. The Fellow would be expected to leverage data to help segment the identified subpopulations, support the use of best practices, and engage caregivers, clinicians, and patients on discrete parts of care model redesign. Similar work has already been done with the AOHT’s first target population, frail older adults and their caregivers, which can serve as a template for the work on complex chronic conditions. No Yes Algoma OHT
Upper Canada, Cornwall, and Area Ontario Health Team (UCCA OHT) Eastern Ontario: Counties of Stormont, Dundas and Glengarry, City of Cornwall and Akwesasne Supporting and Building Capacity in Primary Care
As primary care is the foundation of the health system, an organized and integrated primary care network is essential to our OHT local health system improvements. Statistics show that our area has a shortage of primary care and specialist resources, including French Language Practitioners and a sizable number of unattached patients. Our goal is to ensure that all our population is attached to a primary care home/team. To do that, we will need to build capacity and engagement of primary care. To that end, our Fellow will focus their efforts on developing the following: A full understanding of the types and locations of resources within the OHT area, A Primary Care Human Resources Planning and Recruitment Strategy. Primary care network organization, A plan to leverage Digital and Virtual Care to better serve our population.
Bilingual preferred but not required Yes

Upper Canada Cornwall And Area Ontario Health Team

Background Information

UCCA OHTMembership

Press Release

UCCA Structure

Niagara Ontario Health Team – Équipe Santé Ontario Niagara (NOHT-ESON) Niagara As we evolve, the expectation is that the NOHT-ESON will continue to “onboard” new priority populations with each passing year. We would like a fellow to develop a toolkit and/or guidance document that details the steps involved in a “population health management” approach (i.e. segmentation, gap analysis) and that describes continuous quality improvement methods and tools and when/how to employ them. Bilingual preferred but not required Yes

Niagara Ontario Health Team

NOHT ESON Roadmap To Maturity

West Toronto Ontario Health Team West Toronto This is an exciting opportunity to bring your creativity, research, and evaluation abilities to help shape the work of West Toronto OHTs Partners for Better Care Council (the Council) Community Engagement implementation and evaluation. Our Council consists of a group of diverse, passionate individuals with lived experience – who share a desire to partner with health and social care organizations to improve the experience for patients, caregivers, community, and staff. This partnership will ensure our health and social care system is inclusive, effective, transparent, and respectful. West Toronto OHTs Patient, Family and Caregiver Partnership and Engagement Strategy submitted to the Ministry end of September 2021 demonstrates a commitment to collaborating with patients, caregivers, and community in true partnership to gain a deep understanding of what matters to them in their care and experience and to redesign a better system that is more patient, caregiver, and community centered. No Yes

West Toronto Ontario Health Team

Patient Family And Caregiver Partnership And Engagement Strategy

Terms Of Reference

West Toronto OHT Background

Ottawa West Four Rivers OHT Western part of Ottawa and surrounding rural areas

With a focus on addressing inequities that result from the complex challenges surrounding rural healthcare, our fellow will seek to understand the characteristics of those living with diabetes in our area, the available resources and gaps in resources, and barriers and facilitators to accessing care. They will identify areas of opportunity for collaborative interventions and drive our key performance measures as well as our collaborative quality improvement plan.

The fellow will have an opportunity to choose methodologies based on their areas of expertise and interest and work with a diverse group of healthcare leaders with experiences with healthcare design and evaluation.

No Yes

Ottawa West Four Rivers OHT

OHT Engagement Framework

OHT Geographical Depiction

Guelph Wellington OHT Guelph Wellington

1. Evaluation of the Integrated Primary Care Team (IPCT) model on population health level outcomes within the Quadruple Aim and through an equity lens.

2. Risk segmentation of GW OHT attributed population, at the IPCT level, according to the Kaiser Risk Pyramid (including MH&A, palliative, home & community care, chronic disease).

No Yes

Guelph Wellington OHT

Integrated Primary Care Teams

Central West Ontario Health Team Brampton, Bramalea, Malton, North Etobicoke, West Woodbridge A priority for the CW OHT is to improve the care experience for older adults experiencing frailty by implementing a model of integrated care through a population health management approach. As an OHT Impact Fellow supporting the CW OHT, you will have a unique opportunity to help the CW OHT achieve success by supporting the following initiatives: 1. Evaluate an integrated care models for older adults experiencing frailty and recommend strategies for further development of the model in addition to the scale and spread of the model for other segmentations. 2. Identify and implement appropriate digital solutions that meet the needs of the priority population and evaluate their effectiveness. 3. Strategic planning and analysis to determine the next priority population and its segments for the CW OHT in addition to informing future closely related projects of the CW OHT. No Yes Central West Ontario Health
Ottawa Health Team – Équipe Santé Ottawa Ottawa, ON The OHT Impact Fellow will support the Ottawa Health Team – Équipe Santé Ottawa in developing a decision-support data system that will apply a social determinants of health perspective towards guiding the allocation of improvement efforts and resources to where they will have the most impact on overall population health. Bilingual preferred but not required Yes Ottawa Health Team
Greater Hamilton Health Network Hamilton The fellow will be working with GHHN in the implementation, monitoring, and evaluation of the GHHN Health Equity Framework and Action Plan. In this role, the fellow will be assisting the collection and analysis of socio-demographic and race-based data, providing support to working groups of the GHHN Health Equity Council, and coordinating with the project management staff to identify opportunities and develop strategies for enacting the recommendations given in GHHN’s Health Equity Report. No Yes

Greater Hamilton Health Network

GHHN Health Equity Framework

Barrie and Area OHT Barrie, Ontario The Barrie and Area OHT is seeking to develop a data dictionary for metrics of change in the OHT. Working with the multiple organizations a Fellow will develop a toolkit to measure and track: i) health outcomes; ii) health behaviours; iii) service utilization; iv) neighbourhood characteristics; iv) demographics and social determinants of health; v) human healthcare resources; and vi) patient experience. The Fellow will identify existing data streams as well as opportunities to introduce new measurement tools. No Yes Barrie And Area OHT
Oxford & Area OHT Oxford County Serve as lead support to the overall Strategic Plan development. Support the environmental scan process through research and data analysis, and participate as a team member in stakeholder engagement sessions to inform the development of a strategic plan. Then with an understanding of care pathways and service delivery gaps in focused areas, participate as a team member to begin implementation and evaluation of change using a Population Health Management approach. No Yes

Oxford Area OHT

Driver Diagram Palliative Care

Driver Diagram

Proposed Work Plan

Brantford Brant OHT Brantford, Brant County The BBOHT is streamlining access to mental health and addiction services and re-designing care pathways in order to provide an integrated system of care. We require expertise to support the design, iteration and evaluation of this change, with a focus on developing specific metrics that allow evaluation of quadruple aim: improving patient/caregiver experience, improving health of populations, reducing per capita cost of health care and improving work life of providers No Yes Brantford Brant OHT
Durham OHT Durham Region The Durham OHT provides an ideal learning environment to test new models of integrated care and play an essential role in building our capacity as a learning health system. The fellow will use developmental evaluation methodology to study the implementation and evolution of our model for integrating the delivery of home and community care services in Durham Region. This evaluation framework will be used to assess the impact of creating locally developed care networks that can be adapted based on population health needs and service provider skills and competencies. We believe that transferring the provision of HCCSS to the OHT will advance our collective goal of creating a co-designed system rooted in a vision of becoming one connected system of health and social care and support for residents of Durham Region. No Yes

Durham Ontario Health Team

Durham OHT Host Mentor Bio

Ottawa East OHT Ottawa East The OHT Impact Fellow will support the development of an integrated engagement strategy that will apply an equity and social determinants of health perspective towards the implementation of viable co-designed solutions (including health literacy and digital capacity) to improve the wellbeing and health outcomes of the vulnerable rural population in Prescott Russell. Bilingual preferred but not required Yes Ottawa East OHT
Elgin OHT Elgin County Project 1 – Development of Collaborative Quality Improvement Plan and Performance Measure framework and methodology. EOHT is committed to establishing its Performance Measurement Framework to meet MOH/OH performance and quality improvement reporting requirements. The Fellow would support the development of an inventory of relevant data assets across partners, an assessment of data quality across partner data sources, and the development of the data management and reporting methodology for both the cQIP metrics and the established EOHT performance measures. Project 2 – Development of the Year 1 Target Population Program Evaluation Framework and Methodology. EOHT’s priorities for Year 1 including transforming the model of care for individuals with respiratory health issues. The Fellow would support the development of a program evaluation framework and methodology to help the Elgin OHT measure the impact of new models of care on the patient and provider experience, patient outcomes, system resources and population health. No Yes

Elgin OHT

Elgin OHT Vision

Frontenac Lennox & Addington OHT Kingston, ON The FLA OHT is seeking a Fellow to lead the operationalization of our evaluation framework. The Fellow would be a key member of both the Evaluation and Digital Support Structure working groups. The Fellow would first review and finalize our draft evaluation framework, which focuses on the evaluation of the FLA OHT as a whole, and then iterate that framework to support the ongoing evaluation of our four working groups (Aging Well in the Community; Addictions and Mental Health; Palliative Care; Coordinated Discharge) and future projects. A large component of the work would be identifying existing data sources for indicator measurement in addition to identifying appropriate patient-reported experience and outcome measures (PREMs and PROMs) and planning additional data collection strategies as needed. No Yes Frontenac Lennox Addington OHT

Home | Program DetailsWhy participate | How to apply | FAQs | Contact us