Ontario Health at Home

At Ontario Health at Home (previously known as Home and Community Care Support Services and Community Care Access Centres), I served as a leader in healthcare integration efforts aimed at strengthening connections between primary care and home care services.

I led a major initiative that ensured every family physician’s office in the Kitchener-Waterloo region had a dedicated home care coordinator directly linked to their practice. These coordinators worked collaboratively with physicians to support their shared patients, particularly elderly and medically complex individuals who required close monitoring outside of clinical visits.

Through this model, home care coordinators served as the "eyes and ears" for physicians in the community — providing timely updates, flagging concerns, facilitating in-home assessments, and ensuring smoother transitions between clinical and home environments. This approach not only improved patient outcomes but also enhanced communication, reduced hospital admissions, and strengthened continuity of care for frail and high-risk populations.

This project highlighted the critical importance of building trusted, operational partnerships between sectors to deliver truly patient-centered care.