Photo caption: BPSO President Tour
By: Tiffany Gartner-Duff, Chatham-Kent Ontario Health Team, Mallory Nowakowski, Chatham-Kent Community Health Centres, Jason Bartell, Chatham-Kent Family Health Team.
In 2019, Ontario launched a bold transformation of its health care system with the creation of Ontario Health Teams (OHTs)—an integrated care model designed to break down silos and redesign how care is delivered. The goal: better health outcomes, improved patient and provider experiences, and greater equity across communities. In this context, Chatham-Kent Ontario Health Team (CKOHT) stands out as a powerful example of local leadership co-designing care through collaboration, evidence-based practice, and community engagement.
A Unified Vision for Care
Chatham-Kent is a rural, aging community with a population of approximately 105,000. Like many regions, it faces increasing demand for primary care, chronic disease management, mental health services, and coordinated palliative care. In 2021, CKOHT committed to becoming a Best Practice Spotlight Organization (BPSO) through a formal partnership with the Registered Nurses’ Association of Ontario (RNAO). The goal: to implement and evaluate evidence-based best practice guidelines (BPGs) across the local health system to improve care outcomes. CKOHT brought together 13 diverse partners — including hospital, primary care teams, mental health, senior care organizations, emergency services, home care partners as well as community support service organizations — to work as one collaborative BPSO team. CKOHT received its official BPSO designation in May 2025.
Improving Health Care Through Best Practices Guidelines (BPGs)
Over four years, CKOHT implemented four critical BPGs focused on key system priorities. Examples below show the local initiatives implemented collaboratively to enhance and improve health care.
- Person and Family Centred Care: CKOHT’s annual ‘Let’s Talk Health, CK’ survey—co-designed with its Patient and Family Advisory Council—has become a cornerstone of engagement. Data from the survey highlighted the need for primary care access and informed the need for BridgeCare, a new walk-in clinic for those without a family doctor or nurse practitioner. Additionally, the survey data helped inform the expansion of MobileCare, a mobile walk-in clinic on wheels offering primary care and mental health services to rural communities across the region.
- Transitions in Care and Services: CKOHT partners developed a comprehensive Mental Health and Addictions Inventory of programs and services across the region and established a Central Intake system for seamless referrals. A standout innovation, Pathway2Care (P2C), launched in 2024 to support patients experiencing houselessness as they transition from hospital to community. In just seven months since P2C became operational in September 2024, it has served 153+ unique individuals who were clinically assessed (many of whom returned for additional support), and 29 clients referred to P2C upon hospital discharge.
- Preventing Falls and Injuries: Recognizing the risks faced by its aging population, CKOHT helped re-establish the Fall Prevention Network and developed a practical Fall Prevention Toolkit of resources, screening tools and assessments now in use across multiple care settings.
- A Palliative Approach to Care in the Last 12 Months of Life: With input from healthcare providers, CKOHT launched targeted virtual education series to build palliative care capacity. Topics ranged from advance care planning to managing complex symptoms. Additionally, a new Palliative Care Clinical Coach position was created, providing education and mentorship across organizations. CKOHT also leads a Home Care Modernization Leading Project to redesign palliative transitions with hospital, hospice, primary care and home and community service partners.
Evaluating the Impact of BPSO
To understand the impact of participating collaboratively for four years in system improvements, CKOHT conducted a survey in late 2024 among BPSO organizational leads and change champions. Key survey findings included:
- Strong Awareness and Engagement: Most respondents were familiar with the BPSO best practice guidelines implemented and reported clear improvements in care quality for patients.
- Enhanced Coordination and Safety: Respondents highlighted gains in patient safety, collaboration, and system navigation.
- Opportunities for Growth: While leadership commitment was high, some called for more inclusive staff training and better support for smaller organizations.
These findings reflect not only progress, but a culture of continuous learning and improvement—a hallmark of CKOHT’s approach.
A Community of Care, A Model of Leadership
CKOHT’s work exemplifies what’s possible when local healthcare leaders drive innovation with a shared vision. Their passion for improving patient care is visible in every initiative—from expanding rural access to designing new discharge pathways for vulnerable populations.
Behind these achievements is a leadership team deeply rooted in the community, working side by side with patients, providers, educators, and researchers. Their work is grounded in real-world needs and informed by the best available science—creating solutions that are practical, sustainable, and patient centred.
Looking Ahead
CKOHT is advancing a comprehensive, integrated approach to community-based care that connects providers and organizations across the region. As a designated BPSO OHT, it will continue to focus on strengthening healthcare systems, improving patient experiences, and promoting healthier communities through trust, collaboration, and innovation.
To learn more about CKOHT’s BPSO journey: https://www.ckoht.ca/best-practice-spotlight-organization/