This is an opinion column was written by Lynn Guerriero, President and CEO of Niagara Health, and Sabrina Piluso, Director of Niagara Ontario Health Team - Équipe Santé Ontario Niagara (NOHT-ÉSON). It was originally published in the St. Catharines Standard, Welland Tribune and Niagara Falls Review.
Just as it takes a village to raise a child, it takes an entire region working together to keep Niagara residents healthy and supported at every stage of life. From family doctors and pharmacists to home care providers, hospitals, social services and long-term care facilities, every part of the system has a role in ensuring healthcare works effectively.
Niagara’s healthcare challenges are significant. Our population is not only aging but also growing and becoming more diverse, which brings new complexities to the care we provide. Rates of chronic illnesses, such as diabetes and heart disease, are higher than the provincial average. At the same time, we face a shortage of family doctors, specialists and home care services. These pressures are compounded by healthcare workforce challenges, with many professionals experiencing burnout, leaving healthcare altogether, or unable to participate to their full capacity due to increasing family and social demands.
No single organization can tackle these challenges alone. The most meaningful progress happens when every part of the system works together to ensure patients receive the right care in the right place at the right time.
Imagine an older adult in Niagara living with diabetes. They begin noticing small changes in their health but face barriers accessing a family doctor. Instead of heading straight to the Emergency Department (ED), they turn to other options. Perhaps they speak with their pharmacist, who provides expert advice, helps them understand their medications, and points them to one of the many Diabetes Education Programs in Niagara. Or they connect with an Ontario Health @Home care coordinator, receiving support where they’re most comfortable — at home. These are just two examples of how our healthcare system can collaborate to guide people to the right care at the right time.
Niagara Health is working hard to make collaboration a reality. Programs like SCOPE Niagara connect family doctors with hospital specialists in real-time, helping to manage complex cases and prevent unnecessary hospital visits. The Geriatric Assessment Program conducts a comprehensive physical and cognitive assessment that helps older adults maintain their health and independence, reducing avoidable hospitalizations. Social workers in EDs connect patients with community services before hospital admission becomes the default, while ED techs — trained paramedics — help limit ambulance off-load delays, ensuring timely care and freeing up emergency responders.
We know hospitals can’t do it all. Consider alternate level of care (ALC) patients — individuals who no longer require hospital care but remain admitted due to a shortage of community supports. This creates a ripple effect: EDs back up, ambulance off-load delays increase, and patients needing acute care wait longer. Solving this requires collaboration across the entire system, from home care to long-term care and community services.
Outside of hospitals, the Niagara Ontario Health Team – Équipe Santé Ontario Niagara (NOHT-ÉSON) is helping to reshape how healthcare is delivered in our region. This collaborative network brings together more than 45 partners, including healthcare providers, social service agencies, educational institutions and patient, family and caregiver representatives. This focus on collaboration ensures services are better coordinated, barriers are reduced, and care is more accessible. By working as one, it is easier for residents to navigate the system.
As an example, many residents in Niagara do not have access to a family doctor or nurse practitioner, and the NOHT-ÉSON is working to connect these residents to primary care teams. Regular access to primary care often means less reliance on the ED. The program has connected nearly 4,000 individuals to primary care across the region this year, with planning underway for additional supports in Fort Erie and Port Colborne.
As another example, our community is breaking down barriers between hospital care and home support through the Let’s Go Home (LEGHO) program. This initiative helps seniors who are seen at one of Niagara Health’s EDs return home sooner and with the support they need to recover. By connecting patients aged 65 and older to services like Meals on Wheels, transportation, respite, homemaking and dementia-specific resources of the Alzheimer Society, LEGHO eases the transition from hospital to home while reducing strain on caregivers. The program has already served 220 individuals this year.
Hospitals will always be here for those who need them, but the true measure of success is how often we can prevent the need for a hospital visit in the first place.
