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International Innovation


Ottawa Inner City Health


The mandate of OICH is to serve individuals who are chronically homeless and have medical issues — a population that often does not access services in a cost-effective manner. Run largely by nurses, personal support workers, and peer-support workers, the program provides 24/7 support to clients through safe injection sites, a managed alcohol program, an opioid program, and a palliative care program. Participants are recruited by word of mouth or by referrals from hospitals, shelters, street nurses, and various providers. Referrals go through an admitting nurse, who triages patients and conducts a comprehensive assessment of health and social needs. OICH has 14 different programs, each with a clear focus on patient-centered care and an emphasis on shared decision-making and self-management.


The program has been successful in achieving the Triple Aim, as indicated by multiple evaluations. Performance data are collected regularly for program evaluation and research and reported to funders, the board, and program managers. One published study found that an OICH homeless shelter palliative care program reduced costs. Another study, of an OICH managed alcohol program, found that it reduced alcohol consumption and emergency department use.  


For providers. The program brings together many care settings and providers, including: primary care, acute medical and surgical care, home care, community-based group or day care, nursing home care, and supportive housing. The program makes use of multiple teams of providers, who work independently but meet weekly to conduct rounds and learning activities and to coordinate care and assess client needs.

For patients/caregivers. Patient-defined care goals inform OICH’s individualized care planning. The program, which includes leaders from client advocacy groups, is committed to patient self-management and empowerment. OICH relies not only on conventional caregivers but also on peer workers and nurse practitioners who receive ongoing training and coaching.


Guided by consultations with members of the homeless population, OICH was developed by a multisector team comprising community partners and a regional health authority in Ontario. The program is owned and operated by a board that comprises the program’s collaborative partners. The board is responsible for oversight, budgeting, policies, and risk management.


OICH draws heavily from program partners for financial support, but primary funding comes from a regional health authority. Because the program is based on a nursing model — given that the homeless community’s need for preventive services and primary care can be met without high-priced physicians — payment is not restricted to fee-for-service. Instead, OICH is funded as a community health center, where all staff are paid through a global budget. The program employs all types of nurses, including nurse practitioners, registered nurses, and registered practical nurses, all of whom work at the top of their professional licenses and boundaries to deliver the majority of services. The program director, a physician, handles only acute medical issues.


Contact: Dr. JeffreyTurnbull
[email protected]

Additional information on impact: Shelter-Based Palliative Care for the Homeless Terminally Ill,; Shelter-Based Managed Alcohol Administration to Chronically Homeless People Addicted to Alcohol,

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