1.      Reaching Vulnerable Populations

  • Identifying individuals who are not attached to a primary care team but would like to be;

  • Communities experiencing barriers to receiving primary health care; and

  • Exploring preventive and therapeutic interventions targeted at high use and high needs patients of all ages that are effective and efficient.


2.      Models of Care Emphasizing Health and Disease Prevention Including the Social Determinants of Health in Primary Care

Developing and evaluating primary care-centred systemic innovation:

  • Integrated system re-design to support and promote community based patient care, and methods that promote self-management;

  • Intersectoral and integrated care pathways and communication protocols for disease prevention and management in community-basedprimary health care settings;

  • Intersectoral collaboration leading to health solutions,

  • Appropriate specialist referral and integrated communication and transition back to primary care; and

  • Evaluation of integrated funding models.


3.      Data Sharing and Liberation

  • Utilizing health and social data that inform and evaluate primary health care-centred innovative health and social system redesign;

  • Improving the process of how best to share, integrate, link and use primary care data;

  • Innovative methods to analyze primary care health data, including social determinants; and

  • Evaluating the utility of mechanisms that allow patients to access and use their own medical data.


Our fundamental principle is to address Social Determinants of Health (SDOH): income and income distribution, education, unemployment and job security, employment and working conditions, early childhood development, food insecurity, housing, social exclusion, social safety, health services, aboriginal status, gender, race, disability.

Our vision is to develop a primary health care system which incorporates preventative health care integrated with non-health agencies and with hospital and specialist services.


(Banner image by Dien Nguyen)