Made-in-Essex County pathway aligns with Ontario’s Primary Care Action Plan

Erie Shores HealthCare (ESHC), in partnership with the Essex County Nurse Practitioner-Led Clinic (ECNPLC) and Windsor Essex Community Health Centre (weCHC), has launched a made-in-Essex County pathway to connect unattached patients with a primary care provider before they leave hospital.

Beginning at admission and finalized at discharge, care teams now help refer eligible patients to team-based primary care at ECNPLC or weCHC for post-discharge care.

The partnership supports Ontario’s Primary Care Action Plan to connect every person in Ontario to primary care by 2029 and advances safe, collaborative discharge planning and continuity of care.

Evidence shows that timely primary care attachment reduces emergency department (ED) returns, prevents avoidable readmissions, and improves patient outcomes.

“Attaching patients to primary care at the point of discharge is one of the most effective ways to improve transitions in care, reduce avoidable hospital use, and support people closer to home. By partnering with ECNPLC and weCHC, our teams can coordinate referrals while patients are still in hospital, so they leave with a clear plan for ongoing care—including newborns and adults who don’t have a regular primary care provider,” said Kristin Kennedy, President and CEO, Erie Shores HealthCare.

How the partnership works:

ESHC, ECNPLC and weCHC jointly designed a standard referral process. ESHC screens inpatients for primary care attachment, gathers intake information during admission, and provides referral information to patients during discharge.

Patients receive follow-up appointment details and information on accessing comprehensive, inter-professional primary care after leaving hospital. The approach advances Ontario’s goal of expanding access to team-based primary care, with a focus on unattached patients.

“This direct pathway will ensure continuity of care and minimize the risk of being lost to follow-up. This integrated approach is designed to promote seamless transitions from hospital to primary care, with the overarching goal of reducing hospital readmissions and emergency department visits while enhancing access to team-based primary care services for the community,” said Laura Levesque, , Executive Director, Essex County Nurse Practitioner-Led Clinic.