In response to province-wide reforms to advance integrated care, the Eastern York Region North Durham Ontario Health Team launched an innovative integrated home-based primary care (IHBPC) program for frail homebound seniors in Markham and Stouffville. Findings from patient, caregiver and provider surveys – along with hospital avoidance data – demonstrate that utlizing a team of family physicians and interdisciplinary providers working across community and hospital sectors is an effective approach to addressing the complex needs of high-cost users of health services. A key feature of the program's success is embedding person-centred care across the macro, meso and micro levels of integration, providing lessons learned that can be applied to other integrated care initiatives. To ensure equitable access to high-quality care, IHBPC programs must be a core component of health systems in every jurisdiction where homebound older adults live – not merely an afterthought.

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