Photo Caption: Priscilla Adu-Poku, nurse navigator, conducting care for LTC+.
By: Sarah Kim, Communications Advisor, Women’s College Hospital
By now, the challenges facing Canada’s health care system are well known: overburdened emergency departments, overwhelmed primary care providers, and a growing number of patients left without timely access to care. But what’s less often highlighted are the solutions – and how reimagining care delivery outside the traditional hospital model could hold the key to a more sustainable future.
At Women’s College Hospital (WCH), innovation has never been confined to four walls. As an ambulatory care institution – purposefully built without in-patient beds – WCH is redefining what health care can look like. And through programs like LTC+, the hospital is extending that vision deep into the community.
“We are the hospital designed to keep people out of hospital,” says Mehwish Ali, clinical manager of SCOPE and LTC+ at WCH. “But that only works if we ensure people still get the care they need, when and where they need it. That’s what these programs do.”
LTC+ brings specialist expertise directly into long-term care homes by virtually connecting on-site nursing staff and care providers with hospital resources. The goal is simple: prevent avoidable transfers to the emergency department while ensuring residents receive high-quality care in place.
“The pandemic exposed deep gaps in the system, especially for LTC residents,” says Priscilla Adu-Poku, nurse navigator for LTC+ at WCH. “This program is about filling those gaps and supporting care teams with the expertise they need to keep residents safe and well.”
In collaboration with partners like Wounds Canada, LTC+ is developing targeted care pathways, including wound care and musculoskeletal support, while delivering training to Nurse-Led Outreach Teams (NLOTs). These teams, embedded in acute care hospitals, work alongside LTC+ to provide coordinated care and timely interventions.
Since the implementation of the program, LTC+ has supported thousands of care encounters for residents across 75 long-term care homes in Toronto, together with the NLOTs across eight acute care hospitals.
The program is also helping ease the burden on long-term care staff, who benefit from having faster access to clinical advice and specialist guidance when navigating complex cases.
The results are promising. According to Dr. Brian Wong, director of the Centre for Quality Improvement and Patient Safety (CQuIPS) and a member of the LTC+ leadership team, data collected over the past 15 months shows a measurable decline in emergency transfers from long-term care homes.
“When you strengthen community care, you strengthen the entire system,” says Dr. Wong. “This is about improving quality of life for residents while reducing unnecessary pressure on hospitals and LTC care teams.”
LTC+ may have begun as a local innovation, but its implications are broader. It demonstrates what’s possible when care is reimagined beyond the traditional hospital model: responsive, community-based solutions that meet patients where they are. And in a health care system that is stretched to its limits, that kind of innovation is not just helpful – it’s essential.
By supporting frontline providers, diverting avoidable ER visits, and expanding access to care in underserved areas, these programs are making tangible improvements in patient outcomes while contributing to long-term system sustainability.
“We’re innovating to solve real problems,” says Adu-Poku. “It’s not just about reducing hospital volumes – it’s about ensuring every person, no matter where they live, can access specialized care when they need it.”
As WCH continues to expand these programs across regions and communities, one thing is clear: with the right tools and partnerships in place, the future of health care could be more connected, more accessible, and more sustainable than ever before.
For more stories like this, read WCH's 2025 annual report – We Are Women’s, where you’ll learn more about the exceptional work taking place at WCH and the people who make it possible.