#ScarboroughStrong in Focus: Locally Driven Population Health Model II
January 24, 2025
By: Amy Stephenson, Community Health Teams Manager
Locally Developed Population Health Model at Scarborough Centre for Healthy Communities is known to the community as the Health Team. Our interdisciplinary team aims to support client’s health and well-being holistically. We are client-centered, addressing what matters to residents with a focus on preventative care.
Our diverse team benefits from having different roles—nurses, mental health case workers, ambassadors, and health system navigators—and lived experiences representing the Scarborough community, speaking more than 10 languages.
Client Support
We collaborate with residents throughout their health journey, focusing on the entire circle of care. By supporting clients along their path, we can monitor the effects of referrals, health coaching, or lifestyle changes to ensure that every health decision brings about its full benefits.
Working with community partners, we have also been able to bring Health Literacy to more people by hosting info series on Cancer Screening and other chronic health conditions for groups, helping to break the stigma and silence on tough topics.
Testimonials from clients connected to the preventative care program demonstrate how they have benefited from the team. Take for example, one client who has been supported by a nurse and mental health case worker to address their chronic diseases, mental health and isolation and expresses, “Through this program, I learned how to properly follow my medication instructions.” Taking the time to engage with the client we are able to address gaps created by aspects of the health care system.
Taking the time to engage with the client we are able to address gaps created by aspects of the health care system.
Testimonials
Knowing it takes a village we work with caregivers to help wrap around services and supports to those most vulnerable and who face challenges in engaging with the healthcare system. Testimonials from clients connected to the preventative care program mental health case workers show their satisfaction with their help from the program. The client shared how important it was for the family to work with a case worker who understood the cultural components of positive care for them. They express that the case manager’s effective communication “alleviates any need for worry on my part.” The client’s caregiver shared they felt “extremely comfortable with the caseworker’s thoughtfulness and care in her wellbeing,”
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