Information for Health and Social Service Providers about East Toronto Care Network (EastTCaN)

East Toronto Care Network (EastTCaN) is an integrated care program that supports people living in and/or accessing care in East Toronto through:

Evidence-based integrated care pathways (ICPs) providing people with the best care to meet their needs. Current pathways include Chronic Obstructive Pulmonary Disease (COPD) Pathway, Congestive Heart Failure (CHF) Pathway, and Post-ICU Recovery (VENT+) Pathway.

Collaboratives: Building care team capacity for navigation and care planning.

EastTCaN works with people, their caregivers and their care teams to help plan and coordinate care, connecting clients to new services when required. Individuals do not need to have a family doctor or health card to be supported by EastTCaN.

EastCaN Integrated Care Pathways

Current pathways include the Chronic Obstructive Pulmonary Disease (COPD) Pathway, Congestive Heart Failure (CHF) Pathway, and Post-ICU Recovery (VENT+) Pathway.

Click here to view more details on EasTCaN's Integrated Care Pathways, including target populations and eligibility.

Primary care providers can refer to the COPD ICP by visiting the SCOPE website or calling the SCOPE Nurse Navigator at 416-603-6418 (press 5). Currently, other pathways are supporting Michael Garron Hospital patients only.

EasTCaN Collaboratives

A person sits in front of a computer on a virtual call.

EastTCaN Collaboratives work together as a system of care to build capacity for navigation and care planning for front-line providers and staff.

Front-line providers/staff attend the sessions to get support through topic- and case-based discussions
Participation is open to any health and social service provider or service navigator supporting people living in or accessing care in East Toronto.
EastTCaN operates three different Collaboratives, each with a specific focus.

How to participate

To join any of the EastTCaN Collaboratives, click here
To submit a case/scenario for discussion at one of the Collaboratives, click here
To present a topic at one of the sessions, please click here

Frequently Asked Questions

EastTCaN uses evidence-based integrated care pathways to help your clients manage their condition. This includes providing:

An action plan that will help clients know what to do if their symptoms get worse

Educational resources to help guide their self-management

Individual support from the EastTCaN Clinical Care Facilitator, who will:

- Help your clients self-manage their condition

- Work with your clients, their caregivers, you and other members of their care and support team to monitor and coordinate their care

For detailed information about each pathway, including how they address Health Quality Ontario (HQO) Quality Statements, see below.

CHF Pathway

A diagram outlining how patients with CHF get care through the EastTCaN program.

COPD pathway

A diagram outlining how patients with COPD get care through the EastTCaN program.

Through case- and topic-based discussions, the Collaboratives will help build your capacity around navigation and care planning so that you are better able to support your clients.

The Collaboratives will:

Provide navigation and/or care planning suggestions for cases/scenarios.
Strengthen cross-organizational and/or cross-sector relationships to support ongoing collaboration and coordination.
Increase your knowledge, skills and confidence around navigation and care planning.
Identify, document, and collectively problem-solve around system barriers and provider and system needs, leveraging existing resources.

We recommend you start by trying to get support through your established channels (e.g. internal social workers, care navigators, team rounds/huddles etc.). If, after that, you still need service navigation or care planning support, than please submit a case/scenario by clicking here.

If you have any questions or need support with obtaining consent, please email EastTCaN@tehn.ca.

If your client does not consent, you can still get some advice/support from the rounding tables by submitting a deidentified case for discussion through ETHP Collaborate. Instructions for how to submit a case are in the ETHP Collaborate Toolkit which you will have access to if/when you are registered user.