How Health Homes are connecting more people to the care they need

June 12, 2025.

Across Frontenac, Lennox and Addington, the way people access primary care is changing. The Frontenac, Lennox and Addington Ontario Health Team (FLA OHT) has introduced a new way of organizing care called the People-Centred Health Home. This framework is helping thousands of people connect to care teams in their own neighbourhoods in a way that is more coordinated, responsive, and equitable.

In 2024, more than 13,000 people in our region were newly connected to primary care teams in Health Homes—far exceeding the original goal of 9,000. This achievement reflects the region’s ongoing work to ensure every person has access to the right care, at the right time, from the right provider.

“This isn’t just about improving access—it’s about transforming the experience of care,” says Dr. Kim Morrison, Executive Lead of the FLA OHT. “A Health Home isn’t just a clinic or building—it’s a team of providers who know you, work together, and are committed to helping you live your healthiest life.”

So what exactly is a Health Home—and why does it work so well?

What is a Health Home?

A Health Home is a person’s front door to the health-care system—connecting them to a local team of providers who work together to support their individual health and wellness needs.

The Health Home framework is built around three key features:

• People-centred care: Care focused on the whole person—not just illnesses.
• Team-based care: A group of providers working together to provide care.
• Care close to home: Helping people access care in their neighbourhood.

Health Homes in our region

Health Homes are taking shape in different ways across the region. Some existing clinics, like Greenwood Medical Centre in Kingston, are evolving to the Health Home framework by offering care to a specific neighbourhood, offering care close to home. Others, like the recently established Midtown Kingston Health Home, are expanding access by creating new spaces where people can be connected to a team of primary care providers. 

Some Health Homes are also designed for specific populations, such as the Portable OutReach Care Hub (PORCH) and Street Health Centre, which provide care for people experiencing housing insecurity, and the Indigenous Interprofessional Primary Care Team, which supports Indigenous individuals and families with culturally safe care.

See the full list of current Health Homes in our region here.

Why Health Homes work: Three key ingredients

While Health Homes continue to grow across the region, we’ve already seen strong early results. What’s driving the success? Three key ingredients: team-based care, care close to home, and a commitment to equity.

Team-based care: The right care from the right provider

In a Health Home, care isn’t just delivered by one doctor or nurse practitioner. Instead, a team of interdisciplinary health professionals—such as nurses, social workers, dietitians, mental health professionals, and others—works together to meet each person’s needs. This allows people to get the right care from the right provider and creates a more supportive environment for care teams. For example, at Greater Napanee Health Home, team-based care is already making a big difference for both people and providers.

“The interdisciplinary, person-centred team at the Greater Napanee Health Home is working diligently to serve the community while navigating the complex, ongoing challenge of supporting people who previously lacked access to primary care,” says Jordan Beattie, Director of Regional Services and Partnerships at Kingston Community Health Centres. “This coordinated, compassionate model has strengthened service delivery and empowered providers through teamwork and shared expertise.”

Care close to home: Accessing care in your neighbourhood

Health Homes also make it easier for people to get care close to where they live. By using tools like Health Care Connect, neighbourhood mapping, and community coordination, people are matched with nearby providers.

At Greenwood Medical Centre, this approach has made a big difference. In 2024, the clinic connected more than 1,700 people in Kingston’s east end to primary care by transitioning to the Health Home framework, organizing care differently and working with local partners. In February and March of this year, they connected another 1,700 people.

“At Greenwood Medical Centre, our neighbourhood-based attachment model reflects a commitment to delivering care that is accessible, continuous, and rooted in community,” explains Dr. Veronica Legnini, family physician. “By attaching people to physicians in their local area, we’ve brought the concept of the People-Centred Health Home to life. This approach will improve access by reducing geographic and systemic barriers. People will be able to connect more easily with their primary care providers and receive timely support from a collaborative network of physicians, nurses, and other allied health care professionals.” 

Equitable care: Reaching those who need it most 

Health Homes also help ensure that people who face the biggest challenges accessing care get the support they need. This includes people without a primary care provider, newcomers, those with complex medical or mental health needs, or individuals experiencing poverty or housing instability. This means doing outreach and using community connections to reach people who may otherwise fall through the cracks.

“Since its inception, Midtown [Kingston Health Home] has prioritized meaningfully attaching people, both by postal code and through community partnerships,” says Dr. Eileen Nicolle, family physician at Midtown Kingston Health Home. “This ensures that comprehensive, team-based care is provided to those who face the highest barriers to access.”

By focusing on those most in need, the Health Home framework ensures that limited resources are used where they’ll have the greatest impact—improving health outcomes for those who have been historically underserved and creating a more equitable health system for everyone.

Behind the scenes: Building the foundations for Health Homes

Building Health Homes takes planning, collaboration, and support. That’s where the FLA OHT comes in. The OHT is working closely with every primary care team in the region to help them adopt the Health Home framework—step by step.

Through a Current State Assessment, the FLA OHT is building a centralized collection of the services  each clinic offers today, the supports they have, and the needs of the community members they serve. Working collaboratively with all of primary care through the Primary Care Network, we then build a plan to organize care in a more team-based, connected way—with ongoing support from the FLA OHT. This will equip primary care with the information it needs to ensure services and community needs are appropriately matched. 

The FLA OHT also creates opportunities for teams to learn from each other. In early 2025, more than 90 primary care providers came together at the Primary Care Summit to learn about Health Homes, share ideas and strategies, and work together to create solutions.

The FLA OHT’s Primary Care Network and Primary Care Physician’s Council continue to guide this work and ensure that provider voices are at the table.

“The shift to Health Homes isn’t just about adding more primary care providers—it’s about rethinking how we organize and deliver care as a team,” says Dr. Anna Chavlovski, Chair of the Health Home Support Structure and family physician at Loyalist Family Health Team. “The FLA OHT helped bring people together, align priorities, and support practices to move the puzzle pieces into place. When care is delivered by the right provider at the right time—and when everyone works to their full scope—people receive more connected, effective care. And for providers, this model helps reduce burnout, strengthen teamwork, and improve the care experience for all.”

What’s next 

While we’ve made strong progress, this work is still ongoing. Many clinics are in the process of transitioning to Health Homes, and the FLA OHT continues to support them with tools, guidance, and one-on-one help—so that every person in our region can be connected to a care team that meets their needs.

This effort is part of Ontario’s Primary Care Action Plan, which aims to ensure that everyone in the province is attached to primary care close to home. In our region, that means continuing to grow Health Homes that are team-based, people-focused, and built around equity. Because when care is easier to reach, better coordinated, and centred on people—our communities are healthier, stronger, and more connected.