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.