PROGRAM OVERVIEW
From our Community,
For our Community.
Locally Driven Population Health Models (LDPHMs) in Ontario are community-based, equity-promoting initiatives that aim to address the unique health and wellbeing needs of local populations—especially those facing barriers due to social determinants of health.
In Windsor-Essex, the Canadian Mental Health Association, Windsor-Essex County Branch (CMHA-WECB) acts as the backbone organization bringing together local community partners to co-design and deliver holistic services such as primary care, mental health support, chronic disease prevention and health literacy outreach.
BENEFITS
- Culturally-appropriate care – Programs are often bilingual or multilingual and tailored to local demographics.
- Wrap-around supports – Linking clinical care with navigation, social services, health education, and community outreach ensures whole-person care
- Capacity for scaling – Backbone organizations help pilot promising local models and then replicate them province-wide
Strategic
Framework
- Population Identification & Risk Segmentation – Define priority communities and their unique needs.
- Interdisciplinary Teams & Community Ambassadors – Combine clinical staff with lived-experience outreach workers for richer perspectives.
- Partnerships & Governance – Align with Ontario Health Teams, Community Health Centres, public-health units, and social-service agencies.
- Data & Continuous Evaluation – Use health data and research to assess progress and refine approaches.
- Scale & Sustain – Share best practices, convene provincial forums, and collaborate with backbone entities like Health Commons.
- Carefirst’s High Priority Communities Strategy: Rebranded as LDPHM, this initiative focused on mental health, women’s preventative care, COVID-19 response via culturally appropriate supports (carefirstontario.ca).
Why it
Matters
LDPHMs shift Ontario’s health system from a fragmented, provider-driven approach to a community-governed, equity-centered model. They ensure that interventions are culturally validated, data-informed, scalable, and truly responsive to local populations—especially equity-deserving groups.
INTERPROFESSIONAL LED OUTREACH TEAM (iLOT)
The teams, comprising nurses, social workers, peer supporters, and other healthcare professionals, aim to deliver culturally appropriate primary and preventive care in high-need neighborhoods. They focus on reducing health disparities through community-based interventions, providing health education, screenings, immunizations, and chronic disease management while addressing social determinants of health. The approach includes embedding community health navigators and integrating peer support within the hospital acute care system.
COMMUNITY HEALTH NAVIGATORS
Community members who build trust and share health resources within their neighbourhoods.
YOUTH MOBILE CLINIC
Youth-centered teams that bring health information and services directly to where young people live, learn, and gather.
PARTNERSHIPS
Collaborating with local organizations, leaders, and residents to co-create solutions that reflect community needs and strengths.
