Information for People and Caregivers about East Toronto Care Network (EastTCaN)

East Toronto Care Network (EastTCaN) is an integrated care program of East Toronto Health Partners (ETHP), the Ontario Health Team (OHT) serving East Toronto. EastTCaN supports you and others living in and/or accessing care in East Toronto by:  

  • Using evidence-based integrated care pathways (ICPs) to provide you with the best care to meet your needs. EastTCaN is currently using an ICP to support people with chronic obstructive pulmonary disease (COPD).  
  • Creating a Coordinated Care Plan (CCP) for you that can be used by your care and support team members to plan and coordinate your care. 
  • Discussing your situation in an anonymous way with health and social care providers at an EastTCaN rounding table.

EastTCaN involves an evolution of the Primary and Community Care (PCC) Response Teams program. If you are currently receiving support from one of the rounding tables, this support will continue to be offered by EastTCaN. If you had a coordinated care plan developed through the (PCC) Response Teams program, EastTCaN will continue to support the use of this by your care and support team.  

How can EastTCaN help me manage my chronic conditions? 

EastTCaN uses evidence-based integrated care pathways (ICPs). This includes providing: 

  • An action plan that helps you know what to do if your symptoms get worse   
  • Resources that help guide your self-management 
    • These include the Living Well with COPD education package, smoking cessation and more. 
  • 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  

 Please note this is new support. At this time, this support is available only to people with chronic obstructive pulmonary disease (COPD) who are admitted to Michael Garron Hospital. In the future, EastTCaN hopes to offer this support to others.  

How does having a Coordinated Care Plan (CCP) help me? 

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 without you having 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 

What are EastTCaN rounding tables and how do they help me? 

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 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 who represent East Toronto Health Partners’ (ETHP) member organizations. 

Am I eligible for EastTCaN support? 

EastTCaN supports and creates Coordinated Care Plans (CCPs) for people living in and/or accessing care in East Toronto (see boundary details below) with other eligibility depending on the type of support being provided: 

  • Integrated care pathways (ICPs): People aged 40 and older who have been admitted to Michael Garron Hospital for chronic obstructive pulmonary disease (COPD) exacerbation. 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.

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. 

What do I do if I am not eligible for EastTCaN but I need support? 

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.