Programs and Partnerships

Here 2 Help (H2H)

 

H2H is an inter-agency partnership skilled in crisis intervention and de-escalation that supports the Church-Wellesly and Moss Park neighbourhoods by doing street outreach, rapid response, and check-ins for downtown east Toronto businesses. The H2H team incorporates a trauma-informed understanding of marginalized communities to provide support, follow-up services to enhance community connection, empathy and belonging. ICFHT also provides clinical and practice support to the H2H and responding partners.

In addition to ICFHT, the current H2H partners are Gerstein Crisis Centre, Homes First, Seeds of Hope, and Dixon Hall. ICFHT provides frontline nursing staff for the mobile response team, who contribute primary health care and expertise. This includes vitals checks, wound care, pain management and assisting with the treatment of overdoses.

Bridges to Housing

Since 2016, ICFHT has collaborated with Surrey Place, Developmental Services Ontario (Toronto Region), Family Services Toronto, Community Living Toronto, and the City of Toronto to create the Bridges to Housing program. This program provides residential and wrap-around supports to 25 adults with developmental disabilities who have transitioned from homelessness to stable, individualized supportive housing.

The Inner City Family Health Team (ICFHT) provides clinical leadership for the Bridges to Housing program.

ICFHT's neuropsychologists and clinical team:

• Conduct assessments for individuals with suspected or undiagnosed developmental disabilities or acquired brain injury
• Offer counselling and cognitive rehabilitation services
• Provide clinical oversight and lead interprofessional collaboration across developmental services, housing, and healthcare systems

This population often presents with complex and overlapping needs, including developmental disabilities, brain injuries, severe mental illness, substance use challenges, chronic health conditions and homelessness. The ICFHT team delivers person-centred care that addresses the full spectrum of these concerns.

 

Bridges to Housing has raised cross-sector awareness of developmental disabilities and homelessness, resulting in increased collaboration between the shelter system, the developmental services sector, ministries, and other community organizations.

IPCT Team

 

ICFHT is one of four primary care organizations participating in the Interprofessional Primary Care Team (IPCT) project, led by the Downtown East Toronto Ontario Health Team. This initiative is designed to improve access to and promote attachment to comprehensive, team-based primary care services for communities that have historically faced barriers to accessing primary care, specifically:

• Those facing financial & social barriers (e.g. poverty, housing precarity, unhoused, food insecurity)
• Indigenous and Black communities within target population
• Including but not limited to 2SLBTQIA+, disability, refugees, people who use drugs, etc. (intersectionality)
• Unattached/uncertainly attached

ICFHT, along with Sherbourne Health FHT, Regent Park CHC and St. Michael's AFHT, are collaborating with referring community partner organizations to co-design low-barrier and culturally safer pathways for the priority populations.

Our nurse practitioner and Case Manager work together to deliver to support access, engagement, and continuity of care in clinic and in community, including pop ups, weekly drop-in clinics, and walk-in services designed to improve access to care.

Shelter Outreach

ICFHT has a long-standing commitment to delivering primary health care in shelters and community-based settings across east Toronto. While we operate multiple outreach clinics, our most established partnerships are with Seaton House and Scarborough Village Residence (SVR). At Seaton House, our clinicians collaborate closely with ICHA physicians and shelter staff to provide on-site care, advocate for residents' often complex medical needs, and support continuity of care as individuals transition into alternative housing.

 

At SVR - a shelter for older adults - we hold three clinics weekly. Our nurse practitioner, physician assistant, and physiotherapist work as part of an integrated team addressing the needs of a geriatric population who often experience accelerated aging as a result of homelessness. Many new residents have gone years without consistent primary care and often present with long-neglected health issues.

In addition to Seaton House and SVR, ICFHT also provides care at Fred Victor and other community locations, expanding access to primary care for people who face significant barriers to traditional health services.