How the Pandemic Inspired a Primary Care Model for Addressing Social Needs

A success story

By: Noor Ramji, Gary Bloch, Deborah Kopansky-Giles and Katie Dorman, Unity Health Toronto

The COVID-19 pandemic brought social and health inequities into stark relief. Challenges to health posed by poverty, racism, a lack of adequate housing, and insecure employment quickly became evident to front line health providers. The lockdown exhausted many patients' social supports, and they were left struggling to maintain housing and find adequate food.

Primary health care teams, while central to helping individuals maintain their health and wellbeing, also felt the impact of the lockdown. The St. Michael's Hospital Academic Family Health Team (SMHAFHT), which serves 50,000 rostered patients in downtown east Toronto, was forced to rapidly reduce its in-person clinical services to a fraction of previous levels.

SMHAFHT's health providers immediately recognized the need to ensure their most socially marginalized patients were not lost to the pandemic response. The team is a national and global leader in creating innovative primary care models to address the health and social needs of socially marginalized patients. This work, coordinated by a Social Determinants of Health (SDOH) Committee, has been integrated into a sophisticated infrastructure of leadership in education, research, and quality improvement.

A SDOH-COVID Working Group was created within two weeks of the World Health Organization's declaration of a pandemic, to ensure patients' health and social needs would not be neglected. This group aimed to apply a data-informed health equity lens to clinical operations, teaching, research, and quality improvement, while coordinating initiatives to address social needs and engaging the broader community in care provision and advocacy.

The SDOH-COVID Working Group's approach addressed three major priorities: individual patient needs, equity assessments of health team operations and social policy advocacy.  Here's how we did it:

Individual Needs

Patients were systematically identified for Wellness Check-ins using electronic health record searches and outreach to primary providers. Nurses, resident physicians and other staff conducted over 2000 checks from March to August 2020. They identified patient health and social needs and connected them to team and community resources. 

The Working Group also developed a robust real-time resource known as the Marginalized Populations and COVID Resource Drive. This set of documents, accessible to health team members, contains a list and description of local social support agencies and programs, and is updated on a regular basis.

The team's income security-focused health promoters supported over 70 patients with income-related concerns. Some patients received grocery cards and other necessary items such as cloth masks, phones and tablets.

The working group also created a COVID-19 Management toolbar in its electronic health record to provide FHT providers with one-click access to social resources for patients.  Wellness Check-ins are now integrated into routine nursing workflows. 

Equity Lens

The Working Group ensured a focus on equity at FHT operations and leadership meetings. Through a real-time equity-focused review of clinical operations, and regular consultation with leadership, the needs of the most socially marginalized patients were kept at the centre of pandemic planning.

A lived experience perspective is essential to ensure patients' social needs are identified and addressed. The FHT's Patient and Family Advisory Council provided substantive input in shaping the team's SDOH-oriented initiatives and helped the FHT to develop mechanisms to communicate resources directly to patients.

Community Support

The Resource Drive was made publicly available online to help other health teams and community providers.  The Wellness Check-in protocol was shared with other Family Health Teams and working group members supported the development of a provincial tool for the identification and management of social needs during COVID.

The team also created partnerships with COVID recovery sites for people experiencing homelessness to connect persons in need of a primary care team to ongoing care.

Social Policy Impact

COVID highlighted significant gaps in social support programs, such as income security and housing and systemic contributors to social inequities, such as racism. In order to ensure the social policy response to these issues was informed by health expertise, FHT members engaged in social policy commentary and advocacy, including a press conference on paid sick days, community actions on anti-Black racism, petitions advocating for basic income, and targeted initiatives to support indigenous health.

COVID-19 offered a perfect test of the ability of a social needs-oriented primary care team to draw on its expertise and non-hierarchical collaborative capacity to address urgent social risks to health. Through a multi-faceted, and multi-level response, the St. Michael's Hospital Academic FHT leaned on existing infrastructure for intervening in social determinants of health to address the specific needs of socially marginalized patients and community members.