Poverty puts patients at higher risk for most chronic diseases, mental illnesses, and even accidents and trauma. Poverty: A Clinical Tool for Primary Care directs providers to use key questions to assess their patients’ living situations and current benefits, and includes links to key government and community resources to support positive interventions.

Question #1: In Ontario, what is the appropriate K code for filling out a Mandatory Special Necessities Benefits Application?

Question #2: In Ontario, what resource could you direct your patient to if applications to benefits are denied?

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Poverty: A Clinical Tool for Primary Care Providers
Poverty Download below
A powerful body of evidence shows that poverty puts patients at higher risk for cardiovascular diseases, diabetes and depression. Children in low income families are at higher risk of low birth weights, mental health problems, asthma, malnutrition, injuries and hospitalization. Providers should routinely screen patients and intervene for poor diet, lack of exercise, substance abuse and high-risk sexual behaviour. It is clear that poverty is another very important risk factor that requires screening and intervention. However, poverty is not always apparent. In Ontario 20 per cent of families or 1.57 million people live in poverty. Poverty is a high risk factor for new immigrants, women, Indigenous peoples, LGBTQ+ and children.

The first and most important step is to identify those who live in poverty.

Poverty: A Clinical Tool for Primary Care Providers is designed to be used over a series of visits to:

  • Screen all patients using a key question identified as a good predictor of poverty.
  • Consider that new immigrants, women, Indigenous peoples and LGBTQ+ people are among the highest groups at risk.
  • Understand that otherwise low risk patients who live in poverty are at higher risk for certain health conditions.
  • Intervene, educate and support patients to access tax and other government benefits, and connect them with resources and services.

The Centre for Effective Practice (CEP) and the College of Family Physicians of Canada (CFPC) have collaborated on an initiative to expand and disseminate the Ontario poverty tool for primary care providers across the country. The Ontario version of this tool has been modified for participating provinces/territories.

Social accountability and equity of care are important components of the College of Family Physicians of Canada’s strategic plan. Poverty screening plays a significant part in addressing these goals. See below to access these tools by province or territory.

Poverty tool by province or territory

Please click on the province or territory below to access the tool, which can be downloaded by clicking on the expanded thumbnail.

Alberta Poverty Tool
British Columbia Poverty Tool
Manitoba Poverty Tool
New Brunswick Poverty Tool
Newfoundland and Labrador Poverty Tool
Nova Scotia Poverty Tool
Northwest Territories Poverty Tool
Nunavut Poverty Tool
Ontario Poverty Tool
Prince Edward Island Poverty Tool
Saskatchewan Poverty Tool
Yukon Territories Poverty Tool

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Project Overview

 Poverty puts patients at higher risk for most chronic diseases, mental illnesses, and even accidents and trauma. A Statistics Canada study shows that income inequality is associated with the premature deaths of 40,000 Canadians per year. People living in poverty:

  • Are more likely to report having diabetes than higher-earning individuals.
  • Experience elevated risk of hypertension, arthritis, COPD, asthma, and multiple chronic conditions.
  • Experience cardiovascular disease at a rate 17% higher than the average Canadian.
  • Have 58% higher rates of depression than the Canadian average.
  • Experience higher rates of lung, oral, and cervical cancer.

Children in low-income families are at higher risk of:

  • Low birth weight
  • Mental health problems
  • Micronutrient deficiencies
  • Asthma
  • Injuries
  • Hospitalization

There is no internationally-accepted definition of poverty and no clear consensus on how it should be measured. In Canada many people use Statistics Canada’s low income cut-off lines as a way of understanding who is living in poverty. By this measure, approximately 15% of Canadians, including 1 in 7 children, live in poverty. New immigrants, women, Indigenous peoples and LGBTQ+ people are among the highest risk groups.

The most important first step in addressing poverty is to identify those who live with it. Poverty: A Clinical Tool for Primary Care Providers was developed to help primary care providers screen patients and link those living in poverty to important resources.

Development Process

This Tool is one of several resources developed as part of the 2014 to 2017 Knowledge Translation in Primary Care Initiative. This multi-year initiative was a collaboration between the Centre for Effective Practice (CEP), Ontario College of Family Physicians (OCFP), and Nurse Practitioners’ Association of Ontario (NPAO). Funded by the Ministry of Health and Long-Term Care, this initiative supported primary care providers with the development of a series of clinical tools and health information resources. Learn more about the Knowledge Translation in Primary Care Initiative.

As part of this initiative, CEP conducted a Primary Care Needs Assessment to determine topics of interest to primary care providers. In this survey providers identified the need for more effective resources to help patients who are living in poverty.

The Poverty Tool was developed using CEP’s integrated knowledge translation development methods. CEP ensures that health care providers are engaged throughout the tool development process, using a User Centered Design methodology to test the usability of tools from a provider perspective.

Meet the Team

 The need for a more effective approach to addressing poverty was identified by primary care providers in Ontario as part of the Knowledge Translation in Primary Care Initiative. The Centre for Effective Practice enlisted the collaboration of a clinical lead to develop a resource for providers.

Clinical Lead

Dr. Gary BlochGary Bloch, MD, CCFP, FCF
Gary Bloch is a family physician with St. Michael’s Hospital in Toronto, and co-Chair of the OCFP’s Committee on Poverty and Health.  His clinical, education, program development, and research interests focus on the intersection between poverty and health, and specifically on what primary care providers can do to address poverty as a health issue. Dr. Bloch is an Assistant Professor at the University of Toronto and a founding member of the advocacy group Health Providers Against Poverty and of Inner City Health Associates, a group of physicians who work with the homeless across Toronto.  He has developed curriculum for medical students, residents and practicing physicians on poverty interventions.  He has also been heavily involved in the creation and evaluation of health team interventions into the social factors that impact health.  He is frequently asked to speak on these topics, to health provider and public audiences.  His work has been featured in the Toronto Star, the Globe and Mail, the CBC, and other media outlets.

Copyright & Disclaimer

CEP fully supports the use of Poverty: A Clinical Tool for Primary Care Providers by providers, educators, decision-makers and others. Please read the following information prior to use of the Tool to ensure appropriate permission is sought and appropriate citation is used.

Creative Commons License

Creative Commons Poverty: A Clinical Tool for Primary Care Providers is a product of the Centre for Effective Practice. Permission to use, copy and distribute this material for all non-commercial and research purposes is granted, provided that all copies, modifications, and distributions contain full reproductions of this Creative Commons License and the following Disclaimer along with appropriate citations. Use of the Poverty: A Clinical Tool for Primary Care Providers for commercial purposes or any modifications of the tool are subject to charge and use must be negotiated with Centre for Effective Practice (Email: [email protected]).

For statistical and bibliographic purposes, please notify the Centre for Effective Practice ([email protected]) of any use or reprinting of the tool.

Please use this citation when referencing the tool:
Reprinted with Permission from Centre for Effective Practice (May 2016). Poverty: A Clinical Tool For Primary Care Providers. Toronto: Centre for Effective Practice.


Poverty: A Clinical Tool for Primary Care Providers (the “Tool”) contains links to websites and other external resources (“Third Party Resources”) that are operated by and/or created by third party organizations. These third party organizations are solely responsible for the information contained in, and the operation of (as applicable), their respective Third Party Resource(s).

This Tool was developed for licensed health care professionals in Canada as a guide only and does not constitute medical or other professional advice. Primary care providers and other health care professionals are required to exercise their own clinical judgment in using this Tool.

Neither the Centre for Effective Practice (“CEP”), College of Family Physicians of Canada, Ontario College of Family Physicians, Nurse Practitioners’ Association of Ontario, Government of Ontario, the contributors to this Tool, nor any of their respective agents, appointees, directors, officers, employees, contractors, members or volunteers: (i) are providing medical, diagnostic or treatment services through this Tool; (ii) to the extent permitted by applicable law, accept any responsibility for the use or misuse of this Tool by any individual including, but not limited to, primary care providers, or entity, including for any loss, damage or injury (including death) arising from or in connection with the use of this Tool, in whole or in part; or (iii) give or make any representation, warranty or endorsement of any of the Third Party Resources, that are owned or operated by third parties, including any information or advice contained therein.