One of the transformative initiatives undertaken as a result of Capital Health’s strategic plan was the implementation of Community Health Teams (CHTs) in Primary Health Care. CHTs were created to improve citizens’ confidence in self-managing chronic conditions and increase access for underserved groups, supporting individuals and families to build knowledge, confidence, and skills in making healthy lifestyle choices and managing risk factors common across chronic conditions. The Health and Wellness Program Framework serves as a structure for learning programs. The framework was based on extensive review of evidence, stakeholder feedback and engagement, and an audit of local data. The 3 components of the model are: Wellness Programming -CHTs provide support with chronic disease prevention and self-management through access to a range of free wellness programs in the community. Wellness navigation -Wellness navigators assist citizens to navigate key components of the community resource base, thereby building capacity, knowledge, and awareness. CHTs work collaboratively with physicians, community groups and other providers to make linkages with appropriate services, supports, or programs. Community Connections -CHTs build strong relationships with community champions, grassroots initiatives and services that promote a broad definition of health and can improve the health and well-being of the community. The programs focus on risk factor management through a wellness approach aimed at changing health behaviors through self-management. The programs are free, clients can self-refer and they are offered during the day, evenings and weekends at many locations, including libraries and food banks, to reduce the barrier of transportation. The CHT offers over 35 programs in over 29 community spaces. Navigators meet clients at public locations close to them to reduce the barrier of transportation. We offer our space at no cost to other groups to offer their programs to the community. An advisory group of health care and community members reviews the submissions. On average there are 25-30 community partner programs being offered in CHT space in a schedule. The model recognizes that each community has different needs, and therefore may require different programs, services and supports to build capacity. The model takes into account that citizens and providers need to be involved in tailoring programs and enabling connections in the community.

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