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In-Home Health and Outreach Team

Monday - Friday: 9:00am – 5:00pm ​


Who Are We?

The KW4 Community Ward provides primary care providers an opportunity to have their most complex patients assessed and supported in their homes. We offer collaborative support through a multi-disciplinary team approach to care. We bring services and care to patients in a customized and tailored way by understanding the patients’ needs first. 

In-home visits

Available Monday through Friday

Currently accepting referrals

Short waiting


Diverse team of professionals

Why The Name KW4 Community Ward?

Vulnerable community members in Kitchener-Waterloo-Wellesley-Wilmont-Woolwich (KW4) are falling through the health system gaps. These patients are often home-bound or unable to access healthcare/social systems.  As an opportunity to break the boundaries of traditional healthcare services, the interdisciplinary team brings services to patients in their homes. A "community" effort serving a "ward" of patients in the KW4 area. Hence the name KW4 Community Ward. 

The program was designed in 2013 through a collaborative effort of what was known as the Waterloo-Wellington  LHIN along with the Centre for Family Medicine Family Health Team. Both joined together to bring healthcare and outreach services to home-bound patients within KW4's catchment area. 

Our Goals

Support primary care providers by:


Providing high quality comprehensive primary care consultation and assessment to patients with complex needs within their homes


Intervening to improve the social determinants of health needs of patient population

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Understanding patients' complex needs from an in-home perspective​

What Our Clients Say

Client A

“This team is wonderful. I couldn’t have done it without them. They helped me wean off my opioid, especially when... I wasn’t able to tolerate the plan [my primary care provider] had in place. They also helped me quit smoking. It’s been almost 1.5 years since I quit smoking and I haven’t taken a puff since. I feel great now. I am thankful for the team’s efforts.” 

Client B

“I am so happy to you ‘guys’ in my life, because you care about me. Outreach worker reached out when I felt I was experiencing an anxiety attack. It was the perfect timing when they called me because he made me feel calm and was a friendly voice that made me feel so much better. It was a voice I knew and trusted”

Client C

"Since my last discharge from grand river hospital your efforts helped me to achieve goals I couldn't have done not for the tireless contribution.  Whether helping me to acquire essential documents or keeping track of appointments, I could count on your efficiency and promptness. Because of it now I am living an easier reality." ​
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