Osler partners with Central West OHT to connect patients with primary care

One of the most effective ways for people to maintain a healthy lifestyle, manage chronic illness, and access specialized health care is through a family doctor, nurse practitioner or multidisciplinary family health team. Yet many people in our region do not have a primary care provider despite the region having enough to meet the needs of the population. William Osler Health System (Osler) and the Central West Ontario Health Team (OHT), a network for health system partners in this region, are working together to change that.

“Many in our communities only use services like walk-in clinics and the urgent care centre to handle their day-to-day health concerns as they arise,” said Dr. Shane Teper, Primary Care Attachment Co-Lead, Central West OHT, Osler’s Deputy Chief of the Department of Family and Community Medicine, and a family doctor with Queen Square Doctors and Family Health Team. “But what they’re missing in that approach is the opportunity to build a relationship with a primary care provider or team who understands their health care needs in the context of their entire health history. This holistic approach can help identify and address issues before they become significant medical problems, facilitate timely access to specialized care when needed, and provide essential follow-up care following a discharge from hospital.”

Identifying patients without a primary care provider

With the Ontario Government’s commitment to match all Ontario residents with a primary care provider by 2029, the Central West OHT was quick to get the ball rolling by taking steps to identify who in our communities is without one.

As a starting point, Osler reviewed registration records from 2025 and identified over 13,000 patients who said they did not have a family doctor or primary care provider. Then, over a five-week period in February and March of this year, Osler’s call centre took to the phones in an attempt to reach every patient on the list, leveraging the language line to speak with those who responded in a language other than English.

Matching patients with the right primary care provider

With the support of Central West OHT partner WellFort Community Health Services, patients were connected to a family doctor or nurse practitioner from among five Interprofessional Primary Care Teams (IPCT), which are clinics that received funding from the government to help take on more patients.

“The Central West OHT is matching patients with the primary care provider that will best meet their needs based on the individual’s language, where they live, and what their unique needs are, and that’s particularly important in a region as culturally diverse as ours,” said Mary Jane McNally, Osler’s Chief Patient Experience Officer.

Making primary care part of the patient journey Moving forward, to further support this work, Osler is focussing on connecting with patients in the hospital ‘where they are’ and being more proactive in talking about primary care during the registration and/or discharge processes in areas like Osler’s Emergency Departments, Urgent Care Centre and outpatient care areas. Throughout 2026, the call centre team will continue to follow-up with patients who indicate they don’t currently have a primary care provider.

The Central West OHT is also working closely with other programs across Osler, including the Women’s and Children’s Program, with a particular focus on Labour and Delivery, the Neonatal Intensive Care Unit and Paediatrics.

“There are so many health benefits for women, babies and children to be regularly supported by a family doctor, nurse practitioner, paediatrician or multidisciplinary family health team,” said Lindsay Hogeboom, Osler’s Director of Women’s and Children’s Program. “From preventative care for women including cervical and breast cancer screening, to pre and postnatal care, childhood immunizations, monitoring a child’s growth and development, and treating childhood illnesses, connecting patients with comprehensive primary care will ultimately lead to healthier families.”

Hogeboom notes that Osler is committed to holding conversations with women about primary care during the program’s registration process and again upon discharge, reinforcing the impact it can have on a woman’s and child’s health and wellbeing throughout their lifespan.

Rishika Thakur Malhi, Executive Lead, Central West OHT, shared that they are also working with the Women’s and Children’s Program to develop a central intake process to help connect pregnant women with the primary care provider best suited to their needs as their pregnancy progresses, whether that’s a midwife, a primary care obstetrics group, an obstetrician or a high-risk obstetrics centre. “We want to make it easier for women to access the right care at the right time throughout their pregnancy,” she said, crediting the OHT’s Primary Care Network and physician leaders like Dr. Teper for working with primary care providers across the region to strengthen access to care.

Raising awareness across the community

The Central West OHT and IPCT partners also launched a broad public awareness and education campaign, with a strong emphasis on outreach and engagement within local communities to help people in the region better understand the importance of having a family doctor, nurse practitioner or family health team to help manage their care needs. To date, the CW OHT has attached 25,954 people to a family doctor or nurse practitioner in the region.

A true demonstration of the power of partnership, Osler and the Central West OHT are working together to help connect more people to primary care providers, so they have access to the trusted support and resources needed to stay healthy, get the right care sooner and experience better health outcomes.