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Inventing the Future of Health Care for Ontario and Beyond: Strategic Plan 2018-21
Hospital  >  Welcome  >  Safety, Quality, Strategy, and Management  >  Strategic Plan 2018-21  >  Integrated and Sustainable Models of Care

Strategic Direction:
Integrated & Sustainable Models of Care

Sunnybrook understands that a visit or stay in the hospital may only be a small part of the patient’s journey through the health care system. Regardless of where a patient’s pathway through the system may lead, this Strategic Direction aims to ensure people find their way and have consistent care throughout their experience.

This Strategic Direction is about Sunnybrook building partnerships with fellow hospitals, nursing homes, and other health care providers to ensure patients do not get lost in the system. The intention of this Strategic Direction is to create ‘wrap around’ care for patients that ensures consistency in quality and access to services across the system of care.


Work with partners to create an integrated health system

Sunnybrook will improve access to the specialty care services available at the hospital. This involves partnering with family doctors in the hospital’s neighbouring community and with teams in other institutions across the province. Sunnybrook recognizes the importance of sharing information with a patient’s health care professionals in the community and through this goal, the hospital is committed both to improving how information is provided and to ensuring the institution is as accessible as possible to community providers for referrals.

Lead in transitions of care

For many patients, Sunnybrook is one of several stops on their care journey and this goal is dedicated to improving how care is transitioned from hospital to another care provider. This may involve creating better relationships with family physicians in the community or with the hospitals that are closer to a patient’s home. Regardless of where patients are in their care, Sunnybrook is committed to ensuring the transition from hospital to the next step is one where everyone involved is informed and confident about the care plan.


Opportunities to conduct research in this Strategic Direction centre around the development of a system of care and how relationships among care providers, patients and their families, can contribute to optimal outcomes. Population-based research that examines issues impacting a community’s health and well-being such as the ability to access care based on cultural and economic factors for example, figure prominently in this Strategic Direction. Partnering with community care providers and organizations such as the Institute for Clinical Evaluative Sciences, are important to discovering how to shape this area over the three-year outlook of this plan and beyond


Educating students about the need to work within a system of care and the necessity to think past the walls of a single institution are fundamental to this Strategic Direction. There are opportunities to complement existing programs with partners in the system to expand the knowledge of the hospital’s learners to encompass care that stretches into the community and outside of an institutional setting. Working with the University of Toronto and other educational partners, Sunnybrook will look to redefine education that includes the perspective of the entire system of care.

Sustainability / Opportunities

Sunnybrook has taken a partnership approach to providing a system of care. As each player on a team has unique strengths, the hospital is keenly aware, it does not have the resources or expertise to provide all aspects of care along a person’s experience with the health care system. By partnering with those who are experts in the provision of different levels of care, Sunnybrook can focus on what it does best and play both its community and specialized care roles for the system.

Tu Nguyen

Patient Story

Tu Nguyen smiles and admits his default answer, when asked how he’s doing, is “I’m okay”. But after experiencing increasingly severe heart pains, to the point where the healthy 65-year-old couldn’t sleep, he finally admitted he needed help.

Read more of Tu's story »

“I’ll never forget the pain,” says Tu. “I could barely walk a couple of yards.”

Tu, who was living at a shelter at the time, boarded a TTC bus and went to a local hospital. After some tests, it was determined he needed heart surgery. He was sent to Sunnybrook by ambulance where he had surgery the next day.

“I’m so, so lucky, I feel much better,” says Tu. Four days after his surgery at Sunnybrook, Tu transitioned to Pine Villa, a 69-bed facility providing short-term stays for alternate level of care patients. The facility is a partnership between SPRINT Senior Care, LOFT Community Services and Sunnybrook.

Tu’s days are spent on a range of activities including recreation therapy and getting him up to speed on his new medication regime following surgery. Tu is an accomplished pianist, playing for other residents at Pine Villa. Staff have set up a routine time for Tu to play the piano, as music has become an integral part of his recovery and enjoyment here at Pine Villa.

Tu says it’s much easier to rest at Pine Villa than the hospital. His social worker is helping Tu to determine his next steps, whether it’s returning to a shelter or finding other housing in the community. Tu is confident he will resume his active lifestyle, which included daily jogging and pushups.

For now, the supportive care at Pine Villa is just what he needs. “I’m thankful for not only my surgery, which has me feeling so much better, but also all of the support I’ve received in other ways. I’m appreciative of the staff at Pine Villa, from the person who helps me shower, to the staff who help me figure out what will happen next. It really has been incredible.”

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Strategic Direction 2 - Integrated and Sustainable Models of Care »

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