BRIDGES – Integrated Home-Based Primary Care

Bridging Care for Frail Older Adults: A Study Examining an Integrated Home-based Primary Care Model in Toronto

Team Members
  • Dr. Sabrina Akhtar - Toronto Western Family Health Team/MD
  • Dr. Mark Nowaczynski - Department of Family and Community Medicine of U of T, Mount Sinai Hospital
  • Dr. Thuy-Nga (Tia) Pham - Department of Family and Community Medicine of U of T, South East Toronto Family Health Team & Toronto East General Hospital Virtual Ward
  • Dr. Samir Sinha - Mount Sinai Hospital and University Health Network

The health care system in Ontario will be increasingly challenged in the coming decades to meet the needs of an aging society. A successful system will be one in which there is seamless integration and collaboration across care sectors. This project seeks to evaluate the effectiveness of a home-based primary care program at improving client, caregiver, team and system outcomes over a two-year period.


Evaluation of the SCOPE (Seamless Care Optimizing the Patient Experience) intervention

Team Members
  • Dr. Gillian Hawker - Women’s College Hospital
  • Dr. Noah Ivers - Women’s College Hospital
  • Dr. Ross Baker - Department of Health Policy, Management and Evaluation, University of Toronto
  • Dr. David Frost - Toronto Western Hospital, University Health Network
  • Dr. Irfan Dhalla - St. Michael’s Hospital
  • Dr. Steven Friedman - Toronto Western Hospital, University Health Network

A multi-faceted intervention was developed with the goal is to provide non-Family Health Team (FHT)/non-Community Health Centre (CHC) affiliated family doctors support to care for their patients with complex medical needs in order to proactively prevent and manage exacerbations of these conditions and thus limit ‘crises’ that result in ED visits and hospitalizations. This project seeks to evaluate the effectiveness of the SCOPE intervention at reducing the number of ED visits and hospitalizations after one year of implementation.

BRIDGES – TEAM Innovate Atrial Fibrillation

Transitioning Emergency Atrial fibrillation Management (TEAM)

Team Members
  • Dr. Dante Morra - University Health Network
  • Dr. Nazanin Meshkat - University Health Network and North York General Hospital
  • Dr. Paul Dorian - St. Michael’s Hospital

The Innovate Atrial Fibrillation (Innovate AF) Project is an interdisciplinary initiative to redesign and optimize the way care is provided to patients with atrial fibrillation (AF) in Ontario – from primary care through to subspecialty care and from Emergency acute care to chronic outpatient care.  The objective of this study is to assess the effectiveness of our AF intervention and transition program in reducing the composite endpoint of all-cause ED visits and hospitalization days (including the index hospitalization) within 6 months following the index date for all patients with primary atrial fibrillation who interface the Emergency Department.

The BRIDGES partnership with the HUB has been critical to making BRIDGES a success. It has provided us and our project teams with centralized access to a wide range of expertise and has helped us build stronger working relationships, increased the consistency of our work and enhanced our operational efficiency. Dr. Michael Schull - Co-Principal Implementer of BRIDGES