Program overview

Own Health delivers integrated primary care to patients who are unattached to a family doctor or nurse practitioner. Through a combination of virtual and community-based care, our program ensures clinical continuity while patients navigate specialty care pathways or recover post-discharge.

System challenge addressed

When patients lack a primary care provider, routine responsibilities such as prescription renewals, wound follow-up, chronic condition management go unfulfilled. In Canada this figure can represent up to 30% of the population of some provinces. This leads to higher ED utilization, delays in treatment, and complications that could have been prevented with basic continuity of care. These issues are compounded when they do have primary care but it’s in the form of episodic telehealth that is disconnected from the local systems and relies on urgent care when it’s too late – especially for those dealing with chronic illnesses.

Model of delivery

Patients referred to vascular services who are unattached are formally rostered to an Own Health nurse practitioner within 48 hours. These NPs provide comprehensive primary care, operating virtually or in the community, supported by real-time access to hospital discharge summaries, Doppler results, and pharmacy histories via Doctor Dash. Weekly case reviews include Own Health vascular surgeons, allied health, and social supports to ensure a 360-degree care plan. This service model meets the requirements of Ontario’s Interprofessional Primary Care Team expansion strategy.

Impact and value

Over 90% of unattached patients remain actively managed within the first month. Emergency visits related to missed follow-ups and prescription lapses decrease, and leadership can report rapid attachment success under the Primary Care Action Plan. The model also supports equity by embedding NP support in high-marginalization areas and offering services in multiple languages.

How to get started

If your system faces persistent gaps in care for unattached vascular patients, contact Own Health. We will outline how this service can be layered into your existing funding envelope, meet provincial attachment goals, and provide immediate relief for overloaded teams.