Person in wheelchair looking out window.

Information for People and Their Caregivers 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 the use of:

Evidence-based integrated care pathways (ICPs) to provide people with the best care to meet their needs.

- EastTCaN is currently using integrated care pathways to support people with chronic obstructive pulmonary disease (COPD) and congestive heart failure (CHF).

Rounding tables, made up of health and social service providers, to support care planning for people with unmet health and/or social needs.

All EastTCaN clients have a coordinated care plan (CCP). EastTCaN and others on the care and support team use this care plan to support information sharing, collaboration, and coordination of care.

EastTCaN works with clients, their caregivers, and others on the care and support team to connect clients to new services, as required to address unmet health and/or social needs.

EastTCaN uses evidence-based integrated care pathways (ICPs) which include:

An action plan that helps you know what to do if your symptoms get worse

Educational resources that help guide your self-management

Up to a year of individual, personalized support from the EastTCaN Clinical Care Facilitator, who will:

- Help you learn to self-manage your condition

- Provide advice to help plan how best to support your needs

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

This is a new program and, at this time, integrated care pathway support is available only to people with:

Chronic obstructive pulmonary disease (COPD) who are admitted to Michael Garron Hospital or have visited an Emergency Department at least once in the last year for COPD.

Congestive heart failure (CHF) who are admitted to Michael Garron Hospital.

In the future, EastTCaN hopes to offer this support to others.

A coordinated care plan (CCP) is a plan that contains some of your personal health information. Your care and support team may use this plan to:

Share information so everyone has a common understanding of all the factors affecting your well-being do you don't have to repeat your story multiple times

Identify any unmet needs you may have and support connection to helpful services (e.g. food and housekeeping support, financial services, housing, physical and mental wellness support, support for caregivers, etc.)

Talk to each other and work together to support you

The EastTCaN rounding tables are virtual calls between members of your care and support team and other health, social and community services providers in East Toronto. This may include family physicians, home care coordinators, nurse practitioners, case managers, social workers, mental health specialists and social/supportive housing workers.

During these calls, members of your care and support team present your situation in an anonymous way. They ask the rounding table for advice and recommendations around how to best meet any unmet health or social needs you may have. All information shared and recommendations made at rounds will be included in your coordinated care plan (CCP).

After the discussion at the rounding table, your care and support team members will connect with you to review any advice or recommendations provided. If any additional services are recommended for you, they will discuss the options with you and get your consent before making any connections.

Health, social and community services providers who may attend rounding tables include those from East Toronto Health Partners’ (ETHP) member organizations.

EastTCaN supports people living in and/or accessing care in East Toronto (see boundary details below).

Additional eligibility requirements are listed below:

Integrated care pathways (ICPs): Adults aged 18 and older with:

- Chronic obstructive pulmonary disease (COPD) who are admitted to Michael Garron Hospital or have visited an Emergency Department at least once in the last year for COPD.

- - Your primary care provider (doctor or nurse practitioner) can refer you.

- Congestive heart failure (CHF), who are admitted to Michael Garron Hospital.

In the future, EastTCaN hopes to offer this support to others.

Rounding table support: People aged 18 and older with unmet health and social needs.
- Any health or social service provider on your care and support team can refer you.

- - For rounding table support, you do not need to have a family doctor or health card.

This area is loosely bounded by Eglinton Avenue on the north, Lake Ontario on the south, Midland Avenue on the east, and the Don Valley Parkway/Millwood Road on the west.

If you are not eligible for this program but need support, we suggest the following:

If you live in East Toronto: Visit ethp.ca/FindServices to find health, social and community services in East Toronto, including services for seniors and caregivers, newcomer services, mental health supports and more.

If you live outside of East Toronto: Contact your primary care provider, case manager/worker, social worker or other healthcare provider to find out what supports are available to you.