How North Toronto OHT is enabling primary care attachment at scale

For North Toronto Ontario Health Team, the challenge was clear: How can they leverage technology to tackle the tricky problem of high-volume patient attachment? Based on 2024 data, roughly 30,000 people in the region lack a primary care provider, including 1 in 5 patients visiting Sunnybrook's Emergency Department.

Kittie Pang, Project Manager for Community Integration, Partnership & Ambulatory Care at North Toronto OHT, describes primary care as "the front door to our healthcare system." In North Toronto, that front door has been out of reach for too many people.

With Ontario working toward 100% attachment by 2029, North Toronto OHT set out to create a more coordinated way to identify unattached patients, understand their needs, and connect them to the right clinic. 

North Toronto OHT needed a workflow that could support three main objectives: 

The team evaluated different technology options for centralized intake, including Sunnybrook's hospital information system. While the HIS was familiar to hospital staff, it came with higher cost, a longer implementation timeline, and no integration with primary care EMRs. 

For North Toronto OHT, Ocean offered a more practical path: The eReferral and central intake features were already familiar to staff, and the functionality to triage patient form submissions and forward them to accepting clinics is off-the-shelf. Plus with integrations to all primary care EMRs, the team could start attaching patients immediately.

How the Workflow Works

North Toronto OHT's supportive attachment model has three stages: 

First, individuals complete the intake form found through community outreach, pharmacy partners, hospital pathways, primary care clinics, QR codes, links, or a centralized intake phone number.

Second, the central supportive intake team receive submissions, review patient needs, and triage based on complexity or urgency.

Third, the patient is matched to a member clinic based on both patient needs and provider capacity. The clinic can review the information, accept the patient, and use Ocean's EMR integration to reduce duplicate data entry where supported. 

Within 6 months of launch, more than 1,100 individuals have signed up through the Ocean eForm as part of North Toronto OHT's community engagement work. Of those, over 820 individuals had been referred to a North Toronto clinic. The team has also established pathways for clinics that can support more complex patients. 

While there is much work to do, Kittie shared that the team had reached 99% of its current outreach target and is ahead of schedule on its annual attachment goal. 

Shared visibility across the referral Journey

One of the most valuable parts of the workflow has been shared visibility. Unlike faxes or paper forms, the entire attachment journey is tracked so every stakeholder can easily review the details. When a patient calls for an update, all it takes is a couple clicks to know exactly where they stand.

Clinics also appreciate having better information up front: "Each clinic is a little bit different," Kittie noted. That has made workflow redesign and quality improvement an important part of the implementation. Instead of assuming one process would fit every site, North Toronto OHT continues to adjust the intake model around what each clinic needs to make attachment sustainable. 

As North Toronto OHT looks ahead to Phase 2, the work continues: more targeted outreach, stronger conversion strategies, clearer governance, support for new clinics and physicians, and continued scaling across hubs, affiliates, and the broader primary care network. 

"Having a digitally enabled centralized intake form has been very helpful and important in this work," Kittie said.

The goal is ambitious. But with a connected workflow and a growing network of partners, North Toronto OHT is already showing how patient attachment can move from a fragmented process to a coordinated path into care.