top of page
Beach Run
Two Wave Wide Block

Conditions Better Managed in the Community

Working to improve care for Algoma residents living with chronic conditions.

Jump to:

Chronic disease and mental health and addictions conditions are prevalent in Algoma.


Many Algoma residents are living with chronic diseases such as angina, asthma, COPD, diabetes, epilepsy, heart failure, and hypertension – also known as “Ambulatory Care Sensitive Conditions (ACSC)”. These diseases are particularly prevalent among Algoma residents ages 65+.


Algoma's rate of hospitalization for mental health and addictions is triple the provincial rate.

Graphic: Chronic disease in Algoma.

Citizens living with complex chronic disease, including mental health and addictions issues, are an AOHT priority population.

Our long-term aim is to improve quality of life for those living with complex chronic diseases and mental health and addictions issues by providing high quality care for patients families and caregivers that includes:

  • 24/7 coordination and system navigation;

  • Seamless transitions;

  • Patient access to information where and when they need it; and

  • A full continuum of care for for all but the most highly specialized conditions.

In Ontario, much of the burden of chronic disease is related to cancers, cardiovascular diseases, chronic lower respiratory diseases and diabetes. These account for almost 65% of all deaths and over 85% of chronic disease related deaths and have direct annual healthcare expenses over $10 billion in Ontario alone.

Patients with multiple chronic diseases experience significant treatment burden in terms of:

  • Understanding and self-management of chronic conditions,

  • Attending frequent healthcare appointments, and

  • Managing complex drug therapies.


In addition to a decrease in quality of life, having two or more chronic conditions increases fragmentation of care, care or treatment burden, and can affect relationships. For healthcare providers, the complexity and intensity of interventions for complex chronic patients can also present challenges.

In the same vein, mental health and addictions issues have emerged widely as being influential on chronic disease risk factors and outcomes and are increasingly being considered a life-long chronic condition. As an ongoing concern in Algoma communities, and in conjunction with the burden of the COVID-19 pandemic, mental health and addictions initiatives are being accelerated as a priority of the AOHT.​

Graph: Mood disorders in Algoma

Algoma has a higher percentage of residents diagnosed with mood disorders such as depression, bipolar disorder, mania, and dysthymia (persistent depression disorder).

Graph: Rate of hospitalization in Algoma vs. Ontario.

In Algoma, the rate of hospitalization for drug toxicity (per 100,000) is more than double the provincial rate.

Asset 31@4x.png
Graph: Rate of hospitalization for opioid toxicity in Algoma vs. Ontario.

In Algoma, the rate of hospitalization for opioid toxicity (per 100,000) is more than triple the provincial rate.

Older adults doing yoga.
Friends leaning on each other.
Complex Chronic Disease
Graph: Rate of hospitalization for ambulatory care sensitive conditions (ACSC) per 100,000 in Algoma vs. Ontario.

In 2017-18, the rate of hospitalization for ambulatory care sensitive conditions (ACSC) per 100,000 was notably higher in Algoma than in Ontario as a whole.

Avoidable hospital visits for chronic disease

Data shows that patients are accessing hospital services for chronic conditions that could be better managed in the community. This could be for reasons such as:

  • Difficulty accessing primary healthcare (including lack of transportation, inadequate hours of availability, or not having a regular primary care provider);

  • Lack of patient self-management skills; or

  • Poor care management for those with chronic conditions.


In Algoma, ACSC hospitalization rates are notably higher than in Ontario as a whole. While there are many patients who are currently being managed well with complex chronic disease in the community, this data shows that there are still many patients with chronic disease that have not yet transitioned to community care. Evidence shows that the ongoing care support received by having a regular primary care provider is fundamental to good chronic disease management. Conversely, the hospital is best positioned to provide episodic care. By taking a more proactive management approach and improving access to primary healthcare in the community, we hope to reduce the number of avoidable emergency department visits and ACSC hospitalizations, and allow for better health system use.

Project: Integrated Complex Chronic Disease Management

Graph: Chronic disease in Algoma.

In 2018, there were more than 26,000 cases of chronic disease in the Algoma OHT attributed population.

As of 2018, there were over 26,000 documented cases of chronic disease in the AOHT’s attributed population. A large portion of these cases represent individuals who have multiple chronic conditions. To date, we have segmented the top users of the emergency department who present with exacerbations of chronic disease and grouped them into five patient populations (cardiovascular, lung, diabetes, mental health and addictions, and neurological) in order to get a better understanding of our target population.


After much research, the key elements of effective complex chronic management disease initiatives have been identified as: 

  • Providing a patient-centered approach;

  • Supporting patient self-management;

  • Developing training for healthcare providers;

  • Enhancing an interdisciplinary team approach; 

  • Providing case management and discharge planning; 

  • Specialized nursing; and 

  • Integrating information technology


We are currently working on staffing a team to lead in the development of one or more interventions related to the key elements listed above to support better management and integrated care for those with complex chronic disease.  

Project: Community Wellness Bus


The Community Wellness Bus represents a new way for AOHT partners to come together to address unmet needs in Sault Ste. Marie and area. An evidence-based model of outreach services, this project is grounded in an approach of primary health care that looks at physical, mental and social well-being. Due to the large homeless and underhoused population who suffer disproportionately from the burden of mental health and addictions, a major area of focus will be providing basic levels of care and interventions from a primary care nursing, addictions, and peer support perspective. There will also be a heavy focus on engaging patients in further services based on their needs. This will support patients in receiving the appropriate level of care at the right time, thus reducing unnecessary emergency department visits and escalation in acuity of needs due to inaccessibility.


The Community Wellness Bus officially launched in April 2021. It provides a safe and welcoming presence – particularly in areas where residents struggle to access services and overcome barriers to care. We expect program growth through an increased scope of care, integration of community partners, and increased hours and availability. This project has been designed as a proactive outreach model on wheels to increase continuity of care for those experiencing access issues.

Community Wellness Bus
bottom of page