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Do doctors think they are doing well at connecting patients with social services?

Family physicians identified better integration of primary care with hospitals, mental health and community-based social services as top priorities in improving quality of care and patient access.


Meet Dr. Daniel Pepe, a family doctor in London, Ontario, and a leader in improving coordination of care between family physicians and the rest of the health care system.

Pepe believes the single most important thing that makes a difference in caring for a patient is “to follow a patient’s journey,” also noting, “We need to look at people as a whole person and build relationships with them.”

This starts by screening people for social services by age, income and where they live. After this screening, Pepe says it’s crucial to “identify a patient’s circle of care,” both health care and social services. “Then we can identify the means that’s convenient for all providers to facilitate that communication. In my practice, we’re using a secure text chat to create a virtual circle of care that includes the patients, their families and caregivers, and other providers.”



Pepe says when he started practising family medicine, he wasn’t aware of what services existed and how to properly refer people.

Everyone had a different form, and there were different processes.— Dr. Daniel Pepe, family doctor


“A lot of the challenges in the home care system are because the providers are caring for a patient in isolation,” Pepe says. “They don’t have the context about who this patient is or what’s their story. And they also don’t have access to ongoing support from other providers.”

Pepe says that the referral system in London, Ontario, where he works, is better now thanks to Community Social Services (CSS), a group of 50 community organizations related to areas such as transportation, meals and assisted care, among others.

“I can refer patients to this central entity and provide the context around the patient. Then an intake coordinator calls them to understand their needs and connects them to the right services.”


How to cite the survey results:
Canadian Institute for Health Information. How Canada Compares: Results From the Commonwealth Fund’s 2019 International Health Policy Survey of Primary Care Physicians. Ottawa, ON: CIHI; 2020.