Canadian Organizations supported by CFHI:
BC Children's Hospital, Complex Care Program (British Columbia)
  • Project Lead: Dr. Tammie Dewan, Pediatrician, Complex Care Program
  • Evaluation and Measurement Lead: Karyn Epp, Performance Management and Reporting Lead
  • Sponsor: Barb Fitzsimmons, Senior Vice President, BC Children's Hospital & Sunny Hill Health Center for Children
  • Population Focus: Children and youth with complex health care needs who require the services of multiple tertiary care agencies and provider groups (mental health, developmental or rehabilitation health, outpatient/inpatient medical services).
Alberta Health Services (Edmonton, AB)
  • Project Lead: Crispin Kontz, Manager for Support and Clinical Systems
  • Evaluation and Measurement Lead: Eric Van Spronsen, Primary Care Manager
  • Sponsor: Stephanie Donaldson-Kelly, Director, Primary Care & Chronic Disease Management
  • Population Focus: Top 5% of healthcare users in the Eastwood community as well as people with no fixed address in Edmonton Zone, who make multiple visits to Emergency Departments and/or identified with transition issues from inpatient stays at the Royal Alexandra Hospital.
Mosaic Primary Care Network (Calgary, AB)
  • Project Lead: Bushra Ghaffar, Project Lead for IHI/Triple Aim
  • Evaluation and Measurement Lead: TBD
  • Sponsor: Jason Shenher, Executive Director, Mosaic PCN
  • Population Focus: Ethnic population from South Asia with high prevalence of chronic diseases and related co-morbidities, which does not have family doctors, lack routine care and often seek episodic care in Emergency Departments.

At Mosaic Primary Care Network, we live our mission of “Better Health for All”. As an ultimate leader of Mosaic PCN, I look forward to working with CFHI to achieve organization-wide commitment to better health and experience of care for our most vulnerable South Asian community. Partnering within the BHLC collaborative will allow us to meet our mandate while being effective stewards of tax payer dollars.

Jason Shenher, Executive Director, Mosaic Primary Care Network
Executive Sponsor, IHI Triple Aim


Winnipeg Regional Health Authority (Winnipeg, MB)
  • Project Lead: Alanna Baldwin, Project Lead for Research, George and Fay Yee Centre for Healthcare Innovation
  • Evaluation and Measurement Lead: Colleen Metge, Director, Evaluation Platform, George and Faye Yee Centre for Healthcare Innovation
  • Sponsor: Debra Vanance, Community Area Director, Access River East/Transcona, WRHA
  • Population Focus: Two sub-populations:
    • Frequent users and potential frequent users of Emergency services such as those that can be identified from existing Emergency Medical Services (EMS), Hospital ERs, and Emergency Department Information System (EDIS) data sources, and;
    • Frequent users and potential frequent users of hospital bed days (including those with lengthy hospitalizations) as identified from existing hospital and community databases.
Hamilton Health Sciences (Hamilton, ON)
  • Project Lead: Kelly O’Halloran, Senior Advisor, Quality & Performance
  • Evaluation and Measurement Lead: Tim Dietrich, Senior Advisor, Quality & Performance
  • Sponsor: Sharon Pierson, Vice President, Quality & Performance
  • Population Focus: Frail older adults living in Grimsby, Lincoln and West Lincoln, Ontario.

Like other healthcare organizations, we face challenges in providing the best possible care to our patients who have complex health issues. The Better Health and Lower Costs Collaborative will enable us to offer patients a coordinated series of community services in partnership with other social and healthcare providers. We believe that this approach will be cost effective and, more importantly, it will help to ensure that our patients have optimal outcomes.

Brenda Flaherty, Executive Vice President and Chief Operating Officer,
Hamilton Health Sciences


Belleville and Quinte West Community Health Centre (Belleville, ON)
  • Project Lead: Mary Woodman, Project Lead, Quinte HealthLink
  • Evaluation and Measurement Lead: Dr. Kieran Moore, Associate Medical Officer of Health, Kingston, Frontenac, Lennox & Addington (KFL&A) Public Health
  • Sponsor: Marsha Stephen, Belleville and Quinte West CHC
  • Population Focus: Individuals with advanced chronic diseases, addictions and mental health needs and those with hospice palliative care needs.

As a professor and a national leader in knowledge exchange as well as a clinical lead in a province-wide initiative for responsive behavior in older folks, I hope to take the experience and learning to these other initiatives locally. I aim to improve transitions for the identified patients and, as a teacher and researcher, I hope to use what I learn in my academic pursuits.

Dr. Kenneth Le Clair, Clinical Director, Geriatric Psychiatry Services, Providence Care, Kingston, Ontario and Professor and Chair, Division of Geriatric Psychiatry and Division of Community and Primary Care, Queen’s University


The QHL (Quinte Health Link) team is excited to participate in the Learning Collaborative as part of the CFHI Canadian cohort. We are looking forward to learning better methods to improve care for patients with complex medical and social needs. The QHL will initially focus on patients with advanced chronic diseases, palliative care needs and mental health needs.

Mary Woodman, Project Manager, Quinte Health Link,
Southeast Ontario Local Health Integration Network, Ontario Ministry of Health and Long-Term Care


South Simcoe and Northern York Region Health Link (Newmarket, ON)
  • Project Lead: Mary Bayliss, HealthLink Project Lead
  • Evaluation and Measurement Lead: Julius Veracion, Decision Support Analyst, South Simcoe and Northern York Region Health Link
  • Sponsor: Annette Jones, Vice President, Southlake Regional Health Centre
  • Population Focus: Older adults  with mental health & addictions and Chronic Physical Illness (e.g. COPD, CHF) living in the area of Aurora, Newmarket, Georgina, East Gwillimbury, Bradford, West Gwillimbury, Alliston & New Tecumseth areas
“Collaboration Quebec” (Quebec)

A regional coalition of the Quebec Joint Action Group for Population-Based Responsibility (IPCDC) and five Centres Intégrés de Services de santé et Services Sociaux (CISSS) from Abitibi-Témiscamingue, Saguenay-Lac-St-Jean, Montérégie Centre and Ouest and Lanaudière. The coalition is led by the Public Health Agency of QC (INSPQ).

  • Project Lead: Gylaine Boucher, Manager for IPCDC
  • Evaluation and Measurement Lead: Danièle Francoeur, researcher, INSPQ
  • Sponsor: Jocelyne Sauvé, associate Vice President, Scientific Affairs, INSPQ
  • Population Focus: Adults with the diagnosis of one or more chronic diseases with potentially low to very high risk of complications who require the services of primary through tertiary care programs.
Health PEI (PEI)
  • Project Lead: Donna MacAusland, Project Lead, Health PEI
  • Evaluation and Measurement Lead: Sharon Chuu, Health Information Specialist, Health PEI
  • Sponsor: Marilyn Barrett, (Acting) Executive Director, Community Health, Health PEI
  • Population Focus: Patients with new or existing diagnoses of hypertension, anxiety and/or diabetes who require primary care services.
Breton Ability Centre (Sydney, NS)
  • Project Lead: Millie Colbourne, Executive Director
  • Evaluation and Measurement Lead: Harman Singh, Executive Director
  • Sponsor: Mary Lee, President & CEO, Health Association Nova Scotia
  • Population Focus: Individuals ages 19 to 65 with neurodevelopmental or mental health / dual diagnoses challenges who also cope with multiple health and wellness problems.