Anyone may sign up for MyCareSteps through referral from a primary care provider, a hospital-to-home referral after discharge, or by self-referral.<\/p>\n
Published May 07, 2026 \u00a0\u2022\u00a0 Last updated 1\u00a0day ago \u00a0\u2022\u00a0 5 minute read<\/p>\n
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Brightshores Health System’s Owen Sound hospital shown in this file photo. Brightshores is evaluating a year-long health care navigation pilot project which seeks to help smooth the way for people through the health care system. Photo by Rob Gowan \/Postmedia NetworkArticle content<\/p>\n
A one-year pilot project has begun in Grey-Bruce to make navigating the health care system easier for patients by assigning them their own care co-ordinator.<\/p>\n
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Serefin Health is piloting its \u201cMyCareSteps\u201d project in Grey-Bruce until next March 31 at no charge, in partnership with Brightshores Health System. It\u2019s hoped to improve health outcomes while relieving pressure on hospitals and family physicians.<\/p>\n
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The pilot involves an assigned nurse navigator who stays with the patient and will try to smooth the way for them through the complicated health system.<\/p>\n
Patients with complex or ongoing care needs, particularly during transitions between care settings, were accepted into the pilot program when it started April 1. The project is interested particularly in reaching people recently discharged from hospital.<\/p>\n
\u201cAs those patients transition home, sometimes there are services that can be provided to them in the community that they aren\u2019t always aware of or have access too,\u201d said Rebecca Brookham, who leads a Brightshores team that will\u00a0 evaluate the project.<\/p>\n
\u201cAnd without some of those resources, their risk of re-admission increases,\u201d said Brookham, director of research and innovation at Brightshores.<\/p>\n
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The service is open to all Grey-Bruce residents, part-time residents such as cottagers, the estimated 23,000 locally without a family doctor or even those who have a doctor they haven\u2019t seen in a long time.<\/p>\n
People living in Grey-Bruce can register to be part of MyCareSteps through referral from a primary care provider, a hospital-to-home referral after discharge, or by self-referral at www.mycaresteps.ca\/greybruce<\/a>.<\/p>\n People experiencing a health issue or supporting a loved one with their health would benefit from MyCareSteps, Brookham said.<\/p>\n \u201cIt\u2019s going to help support these people because trying to co-ordinate the appointments, understand the care plans, figure out what services are even available to me locally, can be really overwhelming,\u201d Brookham said.<\/p>\n A dedicated nurse care co-ordinator helps the resident navigate the health care system and support their personalized care plans \u2014 so helps them connect to the services and supports that they need along the way\u201d and prepare for appointments, she said.<\/p>\n Advertisement 4<\/p>\n This advertisement has not loaded yet, but your article continues below.<\/p>\n Article content<\/p>\n If patients consent, the navigator may access their medical records, might speak with the patient\u2019s care providers and could help patients connect with services. It\u2019s up to patients what they share. The service is intended to complement physician and other care.<\/p>\n There\u2019s no limit on the number of times a patient may call their nurse navigator, Brookham said.<\/p>\n \u201cThere will also be prompts for the care co-ordinator to reach back to the patient or the individual if they know they have an upcoming appointment, they haven\u2019t heard from them in a while, they might call and check in or schedule an upcoming follow-up with them.\u201d<\/p>\n Brookham said from a system perspective, it\u2019s hoped if care is better managed outside the doctor\u2019s office and hospital but still within the community, doctors might be freed up to spend more time on patient care, and people would make fewer hospital visits.<\/p>\n The navigator could advise someone if they\u2019d benefit by seeing a dietician, as an example, that doesn\u2019t need to come through the patient\u2019s family doctor. This helps free up a bit of the doctor\u2019s time, she said. But people would continue to consult their doctor.<\/p>\n Advertisement 5<\/p>\n This advertisement has not loaded yet, but your article continues below.<\/p>\n Article content<\/p>\n Brookham said this pilot is trying to improve the \u201cclunky\u201d transitions between their doctor and other care providers. A doctor may not know what\u2019s happening with their patient once seen by another provider because they don\u2019t all share the same electronic medical records system.<\/p>\n Access to care, including to specialists, Grey-Bruce and in other rural areas is another challenge. But Brookham said the nurse navigator will know the area and know about you, find local resources, or the next closest or virtual options.<\/p>\n Brookham said what\u2019s learned from this project will help refine the program, better support patients and demonstrate how this model could be applied across vast rural areas \u201cand adapt it and share it with other communities who can take this on as well.<\/p>\n \u201cWe\u2019re all struggling from a health system capacity standpoint, so this may be a beautiful example of how we can support our patients through this co-ordinated care.\u201d<\/p>\n
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The Serefin Health pilot project leads from Brightshores, the Grey Bruce Ontario Health Team and Serefin. Photo by SUPPLIED \/THE SUN TIMES\/POSTMEDIA NETWORK<\/p>\n