PHM Advance

Completed in June 2026 via a partnership between Southlake Health, the Town of Georgina, and the NYSS OHT, this report presents a population health and wellness assessment for the Town of Georgina. It combines population trends, health service utilization patterns, service inventory information, and community input to provide a shared evidence base for planning, coordination, and decision-making.

The recommendations are intended to guide coordinated future planning and collaboration, while decisions regarding implementation, sequencing, and resourcing will be determined by participating organizations and partners based on their respective mandates, priorities, and available capacity. Similar reports are now being considered for each of the other communities we support, starting in Bradford West Gwillimbury.

Hospitals have experienced a series of barriers in investing in geoanalytics (data integration, technical capabilities, procurement, costs). Over the last four years Southlake Health has built HealthGAP, a web-based tool (no advanced skills are required for users) to easily geo-map a hospital's operational, utilization and cost data to inform planning, strategy, operations and evaluation. In addition to hospital clinical and financial datasets, HealthGAP includes the Ontario Marginalization Index, scoring for four key social determinants of health indicators at the neighbourhood level.

HealthGAP has been used at Southlake to support Population Health Management interventions, redevelopment planning and partnership prioritization. By making sophisticated geospatial analytics accessible to non-technical users, HealthGAP enables organizations to make faster, more informed decisions about where to target resources, design interventions and build partnerships that improve population health outcomes.

Connect with the PHM Advance to learn more about bringing HealthGAP to your organization.

Every day a person spends in a hospital bed unnecessarily is a waste of resources and is potentially harmful to the patient and the staff who care for them. It is also a sign of a healthcare system failing.

As we seek to use Population Health Management approaches to drive system change, we needed a way to measure the size of the challenge ahead of us and meaningful progress over time. Population Avoidable Days represents four commonly used hospital metrics rolled into one. It brings together information on admissions that could have been avoided, long lengths of stay, people who don't need hospital care but have nowhere else to go and people who are readmitted for something that could have been prevented.

Added together, they give us a measure of the problem. They also give us a target that we can use to do something differently for the people in these beds.

Care Management is a well-established discipline in other systems that has yet to be built in Ontario. Care Managers are (typically) registered health professionals (Nurses or Social Workers) who take on long-term accountability for a roster of high-needs individuals and support the coordination of care and services across the system.

What sets this role apart from similar ones in Ontario is their accountability to the people they support, not the organizations they work for. Taking a holistic approach to care, they get to know their clients in context and support them with diverse care that can range from active care (counselling or medical treatment) to care coordination, system navigation, and/or self-management.

As a key component of our Neighbourhood Health Home strategy, Care Managers have been hired in Georgina, Aurora, and Newmarket and are forming a local community of practice as their rosters form.