Creating Capacity in Primary Care: Big Impact Can Happen through Small Changes

By Kathy Irwin, Integrated Care Manager, Amplify Care, supporting Grey Bruce OHT

Across Ontario, there is a shared goal of connecting more people with primary care. Grey Bruce OHT is not simply trying to attach patients one at a time, but rather, we are developing a system-level roadmap that aligns partners, team-based care, nurse practitioner capacity, digital infrastructure, navigation supports, referral pathways, and shared accountability around a common access goal. This roadmap brings partners together around team-based care, clinician  capacity, digital infrastructure, navigation supports, referral pathways, and shared accountability for improving how people connect to primary care.

For attachment to be successful, primary care teams need the capacity to provide ongoing, high-quality care. That means looking beyond the number of available clinicians and asking a different question: How can we better support the teams who are already caring for our communities?

Creating capacity requires us to think differently about how care is delivered.

Every member of the primary care team plays an important role. Administrative staff answer phones, coordinate appointments, manage referrals, and help patients navigate the system. Nurses and allied health professionals provide essential clinical care and support. Physicians and nurse practitioners manage increasingly complex patient needs. Community organizations extend care beyond the walls of the clinic, helping patients access the services and supports they need. When one part of that system is slowed down by inefficient processes, unnecessary administrative work, or communication challenges, it affects the entire patient journey. Even small improvements across multiple touchpoints can create meaningful gains in capacity.

That’s where my work begins.

I work alongside clinicians and healthcare teams to understand how patients move through their practice, where bottlenecks exist, and what challenges are making it harder to provide care. Together, we explore opportunities to improve workflows, strengthen communication, and identify practical solutions that fit the unique needs of each team. Sometimes those solutions involve redesigning a process. Sometimes they’re about connecting people with existing resources. And often, digital health tools become an important part of the solution.

Across Grey Bruce, we’ve worked collaboratively to develop more than 120 digital resources that support primary care teams, including customized EMR tools, referral pathways, documentation supports, OCEAN eForms, and secure web-based forms. These resources weren’t created simply to add more technology; they were developed in response to challenges identified by clinicians and designed to reduce duplication, simplify workflows, improve information sharing, and give teams back valuable time.

Technology can also help strengthen connections across the healthcare system. Whether it’s optimizing EMRs, improving referral processes, supporting secure information sharing, or helping clinicians navigate digital health resources, the goal is always the same: make it easier for teams to work together so they can focus on caring for patients.

Some of the most meaningful innovations aren’t expensive or complicated. They’re practical solutions that fit within existing workflows and address a real need. When technology is paired with thoughtful process improvement and strong relationships, small changes can have a significant impact.

Supporting patient attachment also means recognizing that not every patient’s needs can (or should) be met through a traditional primary care appointment alone. Strong partnerships with community organizations, mental health services, outreach teams, palliative care, paramedicine, and many others help ensure patients can access the right care at the right time. Patient attachment is about building a healthcare system that works together. It means creating pathways that are easier for patients to navigate, reducing unnecessary burdens for clinicians, improving communication across organizations, and using technology where it creates meaningful value.

When we create capacity across the system, we create more opportunities for people to connect with the right care, through the right pathway, at the right time.

That’s how we move closer to the shared goal of patient attachment: not by asking clinicians to do more with less, but by supporting them with better processes, stronger partnerships, and digital solutions that make caring for patients easier.

Learn more about our integrated Care management service