For many people experiencing homelessness or precarious housing, serious mental illness or substance use challenges, the greatest barrier to health care isn't the lack of services. It's the lack of a system designed to help them access those services — and stay connected to them. 

That's where CMHA Toronto's Primary Care Clinics come in.  

Since 2015, the clinics have brought together family physicians, nurses, psychiatrists, and Housing First case managers in a model designed specifically for clients whose physical, mental and social health needs are intertwined. Delivered through a partnership between CMHA Toronto and Inner City Health Associates (ICHA), Primary Care Clinics fill a gap in Ontario's healthcare system, connecting people who often struggle to access healthcare with a team that understands the realities of their lives — and stays with them as they work toward better health and housing stability. 

Dr. Leslie Shanks helped establish the first clinic in partnership with CMHA Toronto's Housing First program in 2015, when she was ICHA’s Medical Director. At the time, there was scepticism about whether a clinic on Lawrence Avenue West could succeed. She explains that ICHA would usually work where people live, in shelters or drop-in centres. “The whole point is to reduce barriers to access," she says, not to choose a location that seemed to create them. Still, she thought they should try. 

The original vision was to provide a bridge to primary care until clients could transition to a permanent family physician in the community. From the beginning to now, more than a decade later, that transition rarely happens — not because of a failure of the model, but because Ontario's shortage of primary care providers means clients who get care through the clinic tend to stay. 

Today, the partnership behind the Primary Care Clinics provides something that is increasingly difficult to find elsewhere for these clients: consistent, integrated primary care designed to suit the realities of their lives. 

"Sometimes it's almost too low-barrier for our own good, but that's one of the strengths of the program," says Alexis Stern, a registered nurse and case manager with CMHA Toronto's Housing First program. 

Clients with a history of homelessness often struggle to keep appointments. That's not because they don't value their health, Alexis explains, but because daily life can be unpredictable. Unlike many healthcare settings, the clinic doesn't charge a fee or penalize clients who miss an appointment. 

"We welcome you to come back. We're very lenient if something comes up in your life or you can't make it," Alexis says. There is also no sobriety requirement. 

That flexibility extends beyond the clinic's attendance policy to other aspects of its operations. 

Following a Housing First intake, clients can usually see Dr. Shanks within one to two weeks. Appointments are longer than those typically available in community practice because ICHA operates outside standard OHIP funding. This allows clients to address multiple concerns in a single visit, important for people who may only be able to visit the clinic sporadically. 

While the no-show rate might be high, so is the quality of care. The clinic — staffed by Dr. Shanks, psychiatrist Dr. Tyrone Turner, administrator Irene Wu, and supported by the multidisciplinary Housing First team — specializes in the complexities of this clientele’s presenting issues.  

While many family physicians care for patients with mental health concerns, relatively few have the capacity to support clients with multiple medical, psychiatric, and social needs compounded by housing instability.  

"A lot of family physicians, given the complexity of our clients, are very hesitant to prescribe anything related to mental health and want a psychiatry consult first," says Alexis. "That can take a year, which means we're managing someone in the community for up to a year while they can be very unwell." 

Through CMHA Toronto’s clinic, clients can see Dr. Shanks quickly, begin treatment, and be referred to psychiatric care far sooner than would typically be possible through conventional pathways. 

The clinic's accessibility and flexibility are not the only things that make it different. Just as important is what happens once a client walks through the door. 

Since every client referred to the clinic comes through CMHA Toronto's Housing First intake, they are connected to a case manager who understands their history, knows their goals, and will remain involved throughout their care.  

Medical and psychiatric care become part of each client’s broader plan encompassing housing stability, recovery, other social determinants of health, and overall well-being — all coordinated by the Housing First case manager. 

A case manager is encouraged to attend the client’s appointments with Dr. Shanks or Dr. Turner, helping them ask questions, remember important information, and understand next steps.  

Their work continues between appointments, making sure “the bloodwork gets done, people follow up with specialists, and so on," says Alexis. "We might attend the dietitian appointment, attend the physiotherapy appointment, and then come back and attend the follow-up appointment with Dr. Shanks." 

The active involvement of a case manager is “a huge bonus,” says Dr. Shanks. "I have lots of complex people in my other practice but I don't have anyone to support them to check in on them, monitor them when we change medications, or help them book appointments."  

Physicians, psychiatrists, nurses, and case managers work together as one team, communicating regularly and coordinating care rather than expecting clients to carry information from one provider to another.  

That support means clients are more likely to follow through on treatment plans and don’t have to navigate an increasingly complex and fragmented healthcare system alone. 

For many clients, their first appointment with Dr. Shanks isn't prompted by a medical crisis. It's prompted by paperwork. 

Applications for the Ontario Disability Support Program (ODSP) and other benefits often require detailed medical documentation. Physicians often charge to complete these forms — an expense beyond the reach of many Housing First clients. 

"If they don't have a relationship with a doctor who is going to spend the time to fill in their disability form, then that closes a lot of doors," says Dr. Shanks, "and some of those are critical to helping them keep their housing." 

While clients may arrive focused on getting a signature on a form, Dr. Shanks sees those forms as a gateway to much-needed medical care. "I use those forms as a way of engaging with people," she says. 

A referral for psychiatric documentation to support an ODSP application may become an opportunity to identify untreated depression. A conversation about benefits can uncover unmanaged diabetes, chronic pain, or other physical health concerns.  

What begins as paperwork often becomes an entry point into comprehensive care. 

The partnership also creates continuity of care. This is something both Alexis and Dr. Shanks describe as essential for clients whose health needs have often been de-prioritized given their circumstances, and for whom the emergency room frequently serves as the most accessible healthcare option. 

“We’re not a short-term case management program. We support individuals who are very vulnerable,” says Alexis. “I've been in this job for seven years, and I've had some people on my caseload for all seven years,” she adds. That continuity gives both the case manager and physician the opportunity to build a relationship that lasts beyond a single visit. 

Dr. Shanks recalls seeing one client recently who hadn’t attended the clinic since 2017. Because they had stayed connected to CMHA Toronto, they were able to reconnect seamlessly to care. 

For Alexis, that's one of the model's greatest strengths. The long-term case management approach means that clients are rarely, if ever, discharged. “We try our very best to support people for as long as we can," she says, because these are often the individuals who have nowhere else to go.  

That continuity not only benefits the client, but it is a strong motivator for the professionals involved in their care. “You see recovery happen,” says Alexis. “Because we have such a long-term relationship with our clients, and we get to know them so well, you really see nuanced changes in behaviours. You see wins, you see successes, you see long-term outcomes. You really get to see a long-term trajectory. I think you have to believe in the recovery process in order to do this work.” 

One of Housing First's key indicators is reduced hospital utilization. "The idea is that if people have access to primary care, low-barrier services, and psychiatry, we can help them stay well in the community and reduce visits to emergency departments," Alexis explains. 

According to a 2022 review, the approach is having the desired effect.  

Among clients who obtained housing and were connected with primary care, just three percent had a repeat unplanned ER visit within 30 days for mental health conditions and just one percent for substance abuse.   

Those data reflect reduced pressure on the healthcare system but also better health outcomes among Housing First clients.  

For Dr. Shanks, one particular patient stands out as an example of why the partnership between the clinic and Housing First matters so much. “She was so ill,” Dr. Shanks reports. “She was sleeping rough, and she had burned her bridges with every single case management agency in the city. She wasn't able to get into a shelter [because of violent behaviours]. I said ‘we're going to hang on to her, because there's nobody else in the city who will work with her. They all know her, they have all tried.’” 

Dr. Shanks says it was the commitment of the Housing First team and their practice of staying with people as long as required that allowed this woman to gain some stability.  

Low-barrier care gets people in the door.  

Partnership keeps them there. 

And for people whose physical, mental, and social health needs are too often addressed separately — or not at all — that partnership creates something that remains surprisingly rare in Ontario's healthcare system: care that is coordinated, sustained, and built to meet the needs of people’s complex, often messy, lives, rather than asking them to fit into a complex, often broken, system.