From On Lok to Ontario: How 50 years of evidence-based lessons learned from PACE (Program of All-Inclusive Care for the Elderly) can advance community-based primary health care transformation “closer to home” – September 24, 2026
Matthew Anderson (President and CEO, Ontario Health) laid out the vision for a wider primary care system in Ontario, one where partners in prevention, community care and team-based care work together so patients receive coordinated and timely care.
This symposium was presented by Toronto Metropolitan University (TMU), the Master of Health Administration (Community Care) program at TMU, Carefirst Seniors and Family Health Team, AdvantAge Ontario, the Ontario Community Support Association (OCSA), and the Association of Family Health Teams of Ontario (AFHTO). It brought together international health system leaders and frontline practitioners to explore how integrated, community-based care can improve population health and health equity, support people with complex health and social needs, and strengthening health system capacity and resilience.
Matthew Anderson, President and CEO of Ontario Health, outlined Ontario’s vision for a more connected and inclusive primary care system. The goal is to attach two million more people to primary care by 2029 and ultimately ensure that every Ontarian has access to a family doctor or primary care nurse practitioner within a publicly funded team. Key priorities include expanding interprofessional teams, modernizing digital tools and referrals, improving information flow, and supporting the recruitment and retention of primary care providers.
Dr. A. Paul Williams, Professor Emeritus at the Dalla Lana School of Public Health, University of Toronto, set the stage by making the case for moving from primary care to primary health care, which also addresses the social conditions that shape health. He compared On Lok and Carefirst. Both are built on community hubs, interdisciplinary teams and integrated care, but they differ in funding: On Lok’s consolidated, outcome-based model gives it flexibility. He pointed to an enabling policy environment featuring flexible funding and cross-sector partnerships as enablers for change.
A highlight from the Symposium was the On Lok PACE model, a world-leading approach to integrated, team-based health and social care for seniors with complex needs. Grace Li, CEO of On Lok, presented how PACE provides a comprehensive continuum of services delivered by interdisciplinary teams, enabling seniors to remain safely and independently in their communities.
Helen Leung (CEO, Carefirst), Sherlyn Hu (Executive Director, Carefirst Family Health Team) and Dr. Emilie Lam (Family Physician and Carefirst Board Director) shared how Carefirst has adapted key principles of PACE to advance primary care transformation in Ontario. Carefirst’s Comprehensive Integrated Service Delivery Model brings primary care, community programs, home care and social supports together through community-based care hubs, creating a “circle of care” centred on each person’s needs.
A key lesson from Carefirst is the value of interprofessional team-based practice and integration across the health and social care continuum. Carefirst brings together physicians, nurse practitioners, nurses, allied health professionals, and pharmacists with chronic disease management, preventive health education, community wellness programs, transportation, caregiver support, home care, assisted living, Meals-on-Wheels, and other community services. Carefirst’s hub-and-spoke model and trusted partnerships with Ontario Health Teams, Ontario Health atHome, hospitals and community providers support an “all doorways to care” approach. Together, they give seniors seamless access to coordinated services and help them stay healthy and independent in their communities.
Overall, the symposium demonstrated how integrated, community-based care models can contribute to a more connected, inclusive, responsive, and sustainable primary care system by strengthening community care hubs, interdisciplinary teams, integrated services, and cross-sector partnerships.