What Makes a Community Health Centre Successful?

Lessons for Canadian Community Health Centres (CHCs) on Value, Structure, and Measurement.

Community Health Centres are one of Canada’s most powerful engines for accessible, equitable, team-based primary care. While they are designed to meet the needs of populations that the health system often underserves, such as newcomers, low-income families, people with disabilities, seniors, people experiencing homelessness, and individuals with chronic or complex conditions, in smaller centres they also serve the broader community. CHCs are intentionally structured to be open, integrated, and welcoming to everyone, providing comprehensive primary care, health promotion, and social supports that strengthen both individual and community health.

But What does “successful” mean? 

Of course, it is first important to be clear about the definition of “success”; when we say “successful”, what does that mean?  Is it about increasing patient throughput? Reducing hospital visits? Improving chronic disease outcomes? Or strengthening social supports and enabling stability in people’s lives?

In the CHC world, “success” is not one-dimensional. It is measured through integration, equity, prevention, and wraparound impact. And increasingly, CHCs that stand out share a common trait:

They have strong, intentional structures for naming, measuring, and learning from the value they create.

This article explores what makes a CHC successful in the Canadian context and why clearly defining key indicators  (and building the internal capacity to measure them) is critical not only for tracking performance but also for making the centre’s value visible and demonstrable to funders, partners, and the community. In many cases, this may be the most high-leverage investment a CHC can make.

Defining Success in Community Health Centres

Unlike fee-for-service clinics or private providers, Community Health Centres (CHCs) operate under a community-governed, team-based, prevention- and equity-oriented model. A CHC’s “success” must therefore align with its purpose, which is not uniform across all CHCs but instead reflects the needs and priorities of the populations it serves.  For example, a CHC serving a neighbourhood with a high proportion of seniors may focus on chronic-disease management and fall prevention, while a centre serving a community with higher rates of substance use might offer harm reduction programs. In general, CHCs aim to:

• Address social determinants of health

• Reduce barriers to care

• Provide integrated primary care and social programming

• Improve health equity outcomes

Most experts agree that successful CHCs demonstrate three broad categories of impact:

1. Integrated Care That Reduces System Strain

CHCs reduce avoidable emergency room visits, dependence on walk-in clinics, and downstream acute-care costs. Successful centres show measurable improvements in:

• Continuity of care

• Management of chronic conditions

• Unplanned hospital utilization

Across several provinces, CHCs report lower ER use and higher screening rates for chronic disease compared to traditional primary care models, particularly among populations that face social or systemic barriers. While outcomes vary by jurisdiction, the consistent pattern is clear: CHCs catch issues early and prevent costly escalation, helping both individuals and the broader health system.

2. Addressing Social Determinants of Health Through Non-Clinical Supports

Successful CHCs are more than medical homes, they are community hubs offering services that address the social determinants of health specific to the populations they serve. For example, In communities with a high proportion of seniors, CHCs may provide supports such as:

• Care navigation for surgical procedures (e.g., hip or knee replacement waitlist management, coordination with specialists, post-operative follow-up)

• Memory and cognitive health programs (screening for early dementia, cognitive stimulation activities, caregiver support)

• Mental health and social engagement programs (peer groups, counselling, art or exercise groups to reduce isolation)

• Home support and safety initiatives (falls prevention, home safety assessments, coordination with home care services)

• Nutrition and wellness programs (meal delivery, grocery assistance, wellness education, group exercise tailored to mobility and chronic conditions)

Centres that excel in this area demonstrate measurable improvements in:

• Social connection and belonging

• Mental health and resilience

• Independence and functional ability

• Ability to navigate and access health and social services

These non-clinical outcomes often have strong predictive power for long-term health and quality of life, sometimes even more so than a single clinical intervention. By defining key indicators tailored to seniors’ needs and actively measuring impact, CHCs can make the value of their programs visible, actionable, and aligned with both community priorities and system-level outcomes. 

3. Strong Community Governance and Cultural Safety

What sets CHCs apart is that communities themselves govern the organization, ensuring that programming is rooted in local priorities and that services are culturally safe. Successful CHCs demonstrate:

• Decision-making informed by lived experience

• Programming tailored to the needs of the specific community

• Trust-building with populations that may have experienced exclusion

• Staff diversity aligned with client demographics

• Safe, trauma-informed care systems

When clients trust their CHC, engagement increases, adherence improves, and every other outcome, clinical, social, and system-level strengthens.

Success in CHCs is population-driven, context-specific, and measurable. Centres must define the indicators that matter for their community, implement systems to track progress, and align services with local needs — whether through clinical care, social supports, or governance practices. By doing so, CHCs achieve their mission: equitable, accessible, integrated care that meets people where they are and improves health outcomes across communities.

Why Measurement Is the Differentiator of Truly Successful CHCs

Most CHCs intuitively know their work matters, and CHC leadership can intuitively list the main needs of the population it serves because they see the impact everyday.  But the most successful CHCs go one step further:

They turn everyday impact into measurable, communicable value.

This matters for three reasons.

1. Measurement Protects Funding and Strengthens Advocacy

CHCs often rely on patchwork funding: provincial budgets, municipal partnerships, targeted grants, and multi-year contributions from foundations.

The centres that thrive long-term are the ones who can show:

• Specific changes in client outcomes

• Cost avoidance or system-level savings

• Improvements in access for priority populations

• Quantified social and economic benefits

Funders want clarity, credibility, and evidence of impact. CHCs that measure well can advocate more effectively for renewed or expanded funding.

2. Measurement Improves Internal Decision-Making

Strong measurement helps CHCs identify:

• Which programs have the greatest impact

• Where staff capacity is most needed

• Which barriers clients encounter most often

• Where equity gaps persist

• Whether new interventions are working

Without measurement, CHCs risk distributing energy across too many directions without knowing what is driving meaningful change.

3. Measurement Enables Community Ownership of Success

When clients, staff, and community boards see clear evidence of progress, they become active contributors in shaping next steps.

Measurement becomes:

• A tool of empowerment

• A validation of lived experience

• A roadmap that honours people’s stories with data

Successful CHCs make data visible, not as surveillance, but as shared accountability.

The Core Indicators Successful CHCs Prioritize

After reviewing the literature and the practices of high-performing centres, a pattern emerges: strong CHCs choose indicators that reflect both clinical outcomes and social well-being, specifically:

Clinical Indicators

• Timely access to primary care

• Continuity of care

• Chronic disease control (e.g., A1C, blood pressure)

• Vaccination and screening rates

• Reduced emergency department reliance

Social Determinant Indicators

• Housing stability

• Food security

• Income gained through benefits navigation

• Social connectedness

• Mental health status

Equity Indicators

• Access by priority populations

• Cultural safety and patient experience

• Reduced disparities in outcomes across groups

System-Level Indicators

• Avoidable hospital use

• Cost savings or cost avoidance

• Partnerships and integrations

• Workforce stability and burnout risk

No CHC needs all of these, but every CHC needs a short, intentional, strategic subset that reflects its community.

What CHCs Should Do Next

1. Name 8–12 core indicators

Not 200. Not “everything we do.”
A small set of indicators creates clarity and focus.

2. Build simple, sustainable measurement systems

Excel sheets are fine. Shared forms are fine.
The sophistication of the tool matters far less than the consistency of use.

3. Involve staff, clients, and Board in indicator selection

Shared ownership increases buy-in and practicality.

4. Align indicators to funding narratives

A CHC’s impact story should match what funders (and communities) need to understand.

5. Review results quarterly and adjust programs accordingly

Measurement is useless without reflection and adaptation.

Final Thoughts: Success Is Measurable, but Only If You Name It

Canadian CHCs play a vital role in reducing health inequities and supporting communities who are often left out of mainstream systems. But the centres that thrive by attracting stable funding, retaining strong teams, and meaningfully improving community health are the ones who treat measurement not as a chore, but as a strategic asset.

A successful CHC is not the one with the most programs or the busiest waiting room. It is the centre that can clearly articulate:

• Who it serves

• How their lives are changing

• How the system is benefitting

• And how it knows

Naming indicators and building a culture of measurement is not bureaucracy, it is empowerment. It allows CHCs to define their value, demonstrate their impact, and continue doing what they do best: improving lives and strengthening communities, one relationship at a time.

“The Pitt” and the patient: Reflections on Empathy and Health Systems

I may be late to the proverbial “party” on this one (as usual), but I recently watched The Pitt, (a show set over one 15-hour hospital shift in a hospital’s ER in Pittsburgh Pennsylvania), and given my work history in healthcare, some of the themes really hit home. I’ve never worked in a hospital, but I was struck by how the show pulls the viewer into every small moment, every decision, every bit of exhaustion and empathy that defines a day in healthcare.

Having spent much of my career on what’s often called the “admin side” of health, I found myself reflecting on the tension between clinicians and administrators that runs through the story. Though The Pitt is based on the U.S. system, I know the challenges and tensions aren’t unique to the United States, it’s something often felt in Canada as well.  Whether tracking performance indicators or caring for a patient in crisis, everyone’s under strain.

In the show, Dr. Robbie lashes out at hospital leadership for being too focused on quality scores.  Those macro-level KPIs can seem detached from the person needing immediate care, but as someone who’s worked in health system operations, I couldn’t help but think: it all matters. The metrics, the money, the moments are all part of the same ecosystem.  The challenge is aligning them and balancing them with the same goal.

Most of my own work has been in what I would call the “private but not private” side of healthcare — leading integrated medical centres that bridge universal coverage and patient-paid services. It’s a space that doesn’t always fit neatly into policy conversations or appeals for funding or support, but it’s where I learned that if we are truly to solve our healthcare crisis, we need to recognize the unique role that all providers and organizations play in the patient's journey. Healthcare truly does depend on effective collaboration, humility, and respect across every level.

In the end, The Pitt reminded me that no health system is immune to stress and conflicting demands. Yet amid all the pressure and complexity, one truth that connects everyone working in healthcare: the patient is the reason for the work.  Whether a physiotherapist supporting a post-op patient in a private setting, a nurse working a night shift or the head of a health authority, we must ensure that the patient never gets lost between the spreadsheets and the stretchers.  As Canada’s health system becomes increasingly disjointed, spanning public, private, non-profit, and hybrid arrangements, it is imperative to keep the patient at the centre of it all and begin looking at the system from this higher level lens - not simply the universal system or with the hospital lens.

The patient journey doesn’t end when the patient leaves the hospital.  As care becomes more distributed across public, private, and community settings, improving that transition is critical and offers a huge opportunity to improve the patient’s journey and outcome.

If you work in allied health or integrated care and also recognize a huge opportunity to improve the patient journey, lets connect and exchange ideas.

Using Systems Thinking to Bridge the Gap between Family Medicine & Allied Healthcare

One of the challenges with our Canadian healthcare system is how disjointed it can be at certain points in a patient’s care journey. Within the hospital system, roles exist to examine and resolve these handoff points, but one area I’ve grappled with throughout my career as a leader of health centres is the disconnection between Family Practice and allied health practitioners. When patients are referred for services such as physiotherapy, chiropractic, or pedorthics, they often leave the clinic with a prescription or referral and must then navigate insurance coverage, find an appropriate provider, and hope their GP receives feedback to close the loop and support better chance for healing.

This disjointed patient experience creates several challenges: patients end up coordinating their own care, communication gaps emerge between providers and patients, and the overall patient experience suffers. This challenge has been near and dear to my heart: how to ensure patient compliance once they “exit” the universal system, close the communication loop with external providers, support follow-up despite service costs, and measure outcomes? Finding answers to these questions is central to delivering effective, patient-centered care. Improving the connection between GPs and allied health practitioners not only enhances patient outcomes but also strengthens the healthcare system overall.

At first glance, this may seem like a simple referral problem. Yet when we apply systems thinking, it becomes clear that the issue is far more complex—a structural gap affecting patient outcomes, clinic efficiency, the effectiveness of GP-allied provider relationships, and ultimately a missed opportunity for improving patient care and experience.

Systems thinking allows us to look beyond surface-level symptoms and examine interconnections, feedback loops, and leverage points contributing to the problem. In this scenario, the system includes:

• The Family Practice clinic – the public-care hub, coordinating care and capturing patient outcomes.

• Allied healthcare providers – physiotherapists, chiropractors, pedorthists, and massage therapists operating largely in private streams.

• The patient – navigating insurance, scheduling, and essentially forced to be the hub of their own continuity of care.

Feedback loops are critical: delayed or missed physiotherapy can lead to repeat GP visits, additional strain on the public system, and frustration for patients. Small changes in the system can produce outsized benefits—but only if we address underlying structures rather than isolated symptoms.

So, what’s the solution? While fully shared EMRs can help, the reality is that fully integrating EMR systems across all private and public providers in the province is unlikely in the near term. Instead, here are some practical alternatives:

• Referral Tracking Dashboards – Internal trackers combined with patient follow-up can measure the percentage of referrals successfully booked within a set timeframe.

• Patient Navigators – Clinic staff can help patients navigate insurance, recommend vetted physiotherapists, or pre-book appointments. Measurement: completion rates and patient-reported ease.

• Relationships with Allied Health Providers - Relationships with trusted providers streamline scheduling and feedback. Measurement: time-to-first-appointment.

• Feedback Loops from Allied Providers – Short progress notes returned to the GP allow clinics to close the loop and track patient outcomes. AI can help highlight relevant notes for physicians during the next patient visit.

These interventions are measurable, implementable, and strengthen the GP’s role as the hub of patient care. Of course, physicians’ EMRs must be configured to properly track these activities.

For allied healthcare providers: it pays to get to know the Family Medicine physicians in your catchment area. In a previous post on LinkedIN, I discussed marketing tips for physiotherapists and other allied health providers; this one is a winner. Improving these systems doesn’t just help GPs and patients—allied healthcare providers also benefit:

• Reduced lost patients/no-shows, improving revenue predictability.

• Clearer communication, minimizing duplicated assessments and aligning care plans.

• Enhanced reputation and patient experience, generating referrals and trust.

My suggestion: start small, with 5–6 Family Medicine Clinics. After years of developing relationships with Family Medicine physicians to support better referral pathways, I can attest that this approach works.

Things are progressing; we have seen some pockets of innovation in Canada. Certain Health Authorities, Divisons of Family Practice (Primary Care Networks), and Collaborative Service Committees are exploring ways to better integrate the patient journey between Family Medicine and allied health providers. However, much of this work remains localized, leaving many clinics fragmented.

The GP-to-allied health referral gap illustrates a broader principle: systems thinking is not just an abstract concept—it is a practical tool for improving outcomes, efficiency, and patient-centered care. By mapping interconnections, identifying leverage points, and implementing feasible, measurable solutions, clinics can strengthen both public and private care streams, creating a healthcare ecosystem that truly serves patients, providers, and communities alike.

If you are an allied health or family medicine clinic looking to improve referral pathways, enhance communication, and strengthen patient outcomes, Afya Consulting can help. Or, if you’re also super passionate about this topic - I would love to chat more. Let’s work together to transform how your clinic coordinates care across the patient journey. 

Navigating the Rise of Corporate Care: Support for Independent Veterinarians and Health Practitioners

The Canadian health landscape - for both humans and animals - is changing.

Veterinary medicine and many human allied health services in Canada traditionally had something in common: they were independently owned and operated by the professionals who provided the care. These practices weren’t just businesses—they were cornerstones of their communities. Personalized, relationship-based, and practitioner-led. But in recent years, we’ve seen a growing trend toward corporatization. From urban veterinary hospitals to physiotherapy clinics to multi-disciplinary health centres, large investor-backed groups are consolidating the market.

The Data: A Snapshot of a Shifting Landscape

• Veterinary Clinics: Today, about 1 in 5 veterinary clinics in Canada is corporate-owned, and nearly 40% of veterinarians now practice within these models. (Competition Bureau Canada, 2024)

• Physiotherapy Clinics: Though private practices still dominate, corporate-backed regional chains—like LifeMark (owned by Loblaw/Shoppers Drug Mart)—are expanding rapidly. As of 2025, there are approximately 18,600 physiotherapy businesses in Canada. (IBISWorld, 2025)

• Chiropractic Clinics: Roughly 69% of chiropractors in Canada still operate as sole proprietors, meaning approximately 31% are now part of multi-site or corporate-owned operations. (Canadian Chiropractic Resources Databank, 2024)

What This Means for Independent Clinics

If you’re running an independent clinic, these shifts are more than just headlines.

You might be:

• Feeling pressure to match corporate pricing or hours.

• Struggling to recruit or retain staff.

• Wondering how to plan for growth—or succession.

• Working harder than ever but feeling unsure how to compete.

The truth is, independent clinics still form the majority in most sectors. But the rise of corporate care is advancing—and fast. That creates a strategic imperative for small, practitioner-led clinics to adapt smartly, without losing what makes them special.

Why Independent Clinics Still Matter

Corporatized clinics may offer standardization, access to capital, and marketing muscle—but they can’t replicate the deep community ties, continuity of care, and values-based service that independent providers deliver every day.

Your clinic doesn’t need to become corporate to thrive.  But it does need to be clear, focused, and supported in how it operates, grows, and evolves.

I work with independent clinic owners in both human and animal health—from physiotherapists to veterinarians—who want to stay small, local, and practitioner-led without burning out or falling behind.

Together, we tackle:

• Strategic planning and business model refinement

• Team building and staff retention

• Operational efficiency and process improvement

• Sustainable growth—or right-sizing for peace of mind

I support your clinic’s goals with clarity, calm, and strategy—while always centering the values that led you into care in the first place.

Let’s Connect

If you're an independent clinic owner feeling the weight of change, I’d love to connect. And if you're thinking about starting a practice in today’s competitive landscape—veterinary, physiotherapy, or any of the allied health sectors—but feel uncertain about how to stand out, let's talk.

Together, we can strengthen and protect what makes your vision meaningful, while building the clarity, structure, and strategy your clinic needs to thrive in a changing market.

Send me a message or book a FREE 30 minute conversation. I’m here to support your success.