New EPPiC Team will support Halton’s most vulnerable populations through an innovative and integrated approach

FOR IMMEDIATE RELEASE:  Support House, with the Connected Care Halton Ontario Health Team (CCHOHT), Halton Physicians Association, Oakpark/Churchill Neighbourhood Centre, Mental Health and Addictions Alliance and people with lived experience including family and caregivers has been granted $1,647,310 through the Interprofessional Primary Care Team (IPCT) funding. The funding will form an Enhanced Primary Care Pathways and Integrated Care (EPPiC) Team to expand and enhance vulnerable populations’ access to primary care in Halton.

“The EPPiC Team is a robust demonstration of collaboration between the Connected Care Halton Ontario Health Team, its partners and the Halton Physicians Association explained Dr. Briana Howarth MD, FRCPC Geriatric and Consultation Liaison Psychiatry, Halton Healthcare. “Front of mind in the development of EPPiC was how our team will foster trust and relationship building between its clients, primary care and the healthcare system at large.”

The EPPiC team will provide support through encampments, local shelters, the Churchill Neighbourhood Centre, Milton and Halton Hills. Community and assertive outreach will also be conducted in Halton’s most vulnerable encampment areas. Referrals will be accepted from community partners, primary care providers, specialists, ERs, and other acute care services. The referral process will emphasize a “no wrong door” approach and will not require a physician’s referral. An assertive outreach model will form the foundation of the Team.

“Our IPCT funding will expand and enhance access to primary care through an integrated team of nurse practitioners, social workers, peer supports and primary care physicians and psychiatrists”, explains Paul Gregory, Executive Director of Support House.  “This includes improving service delivery and care pathways for people who are unhoused with complex mental illness, substance use and other medical concerns. Improving access to primary care will help improve people’s health outcomes and our overall community wellness.”

EPPiC draws on elements of the Chronic Care Model (CCM), a framework designed to improve care for people living with chronic mental health and non-mental health medical conditions. With a focus on individuals with severe and persistent mental illness and substance use, the clients served by the EPPIC team includes individuals diagnosed with schizophrenia, bipolar disorder and schizoaffective disorder, substance-induced psychotic disorders and severe personality disorders.

“Re-establishment of trust, and by extension relationship, between the individual and primary care is the principal goal of EPPiC,” explains Dr. Kris Martinuik, Oakville's representative for the Halton Physicians’ Association and past co-chair of the CCH OHT . “If an individual is attached to a primary care provider in the community, every effort will be made by the team to reestablish the trust and relationship to facilitate ongoing, proactive, and effective care and to reconnect people back into our existing system. If an individual is not currently attached to primary care, the EPPiC interprofessional team will provide primary care and build that trust."

Improving primary care services to vulnerable populations was identified as a community need and is community-driven. Halton Public Health reports that one in 10 Halton adults (18-64) have been diagnosed with a mood and/or anxiety disorder, and from 2006 to 2015, the rate of ER visits for mental illness increased by 24%, with the rate of hospitalizations increased by 36%.

EPPiC: Meeting people where they’re at

EPPiC is a great example of people coming together as one team to ensure quality of care and quality of life for those often most at risk.” - Michele Sparling, Chair, Patient Family/Caregiver Advisory Committee, CCHOHT. “For those who are vulnerable and underserved, whose issues are often not given the attention needed, EPPiC will help remove the barriers to accessing care by meeting people where they are at in the community.”

EPPiC will be supported with Support House’s Response Team, which has successfully worked to house people living in encampments and shelters. The Response Team obtains referrals through the Region of Halton’s By-Name database, which prioritizes services for the unhoused/homeless population based on the highest acuity.

 Supporting a Local Strategy for More Connected Health

EPPiC aligns with the Ontario government’s Your Health: A Plan for Connected and Convenient Care strategy, which includes a commitment to connect more people to primary care by creating interprofessional primary care teams to make access to care more convenient for those with the greatest need. These interprofessional primary care teams will provide direct care to vulnerable and marginalized people and those without a family doctor. This will help connect people to care without having to visit emergency rooms and experience long wait times. This will include identifying barriers to people accessing their primary care provider, attending appointments with the client and primary care provider, and facilitating virtual appointments, among other strategies.

The Primary Care EOI submission was embraced by the CCHOHT and worked on through a highly collaborative and multidisciplinary group including the Halton Physicians Association, The Mental Health and Addictions Alliance, Oakpark/Churchill Neighbourhood Centre, Halton Region and people with lived and living experience including family and caregivers. The proposal was supported by many physicians, specialists and Family Health Teams across the Region of Halton.

“The EPPiC Team proposal was a true expression of a community coming together to identify a need and working collaboratively to address it. This interprofessional project will bring together health professionals who have not traditionally worked together, enhance care for an underserviced population, and build strong relationships. This was a massive undertaking on a tight timeline and 47 partners and community agencies made it happen. Karin Swift Director, Connected Care Halton Ontario Health Team”

About Support House
Support House ( has provided support services and housing for people with mental health, substance-use and addiction concerns in Halton since 1984. Support House provides low-barrier, harm-reduction approaches to providing accommodation and support to people with multiple needs to address housing stability issues.

Everyone deserves and has a right to housing.

Paul Gregory, Executive Director, Support House
1-833-845-9355 ext 134
[email protected]