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 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 will use this care plan to support information sharing, collaboration, and coordination of care.

EastTCaN will work 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.

Who is eligible?

EastTCaN supports 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): 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.
- 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 (see details below about specialized rounding tables).
- For rounding table support, people do not need to have a family doctor or health card.

Referrals from primary care providers for COPD ICP and rounding table support are now being accepted through SCOPE.

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.

Who can refer to EastCaN?

Rounding table support: Any health or social service provider on the client's care and support team can submit a referral. Providers may include case manager, outreach worker, primary care provider, social worker, supportive housing worker and others.

Integrated care pathways (ICPs):
- CHF ICP: At this time, only referrals from Michael Garron Hospital are being accepted.
- COPD ICP: Primary care providers (MD, NP referrals via SCOPESCOPE) and Michael Garron Hosptial referrals are being accepted.
- In the future, EastTCaN hopes to accept referrals from other organizations and providers.

How do I refer a client to EasTCaN?

Primary Care Providers (MD, NP) referring for COPD ICP and/or rounding table support:

- Referrals are submitted through SCOPE

- - Current modes of submission through SCOPE include:

- - - Faxing or securely emailing the referral form on the SCOPE webpage

- - - Calling the SCOPE Nurse Navigator at 416-603-6418 (pressing 5)

- - Coming soon: Ocean eReferral

Other health and social service providers referring for rounding table support:

- Referrals are submitted through ETHP Collaborate

- - IMPORTANT: You need to be a registered user for ETHP Collaborate in order to submit referrals. If you are not already a user, go to the ETHP Collaborate webpage to register (noting that this is a one-time process that can take up to 3 business days).

- - Instructions for how submit a referral are in the ETHP Collaborate Toolkit which you will have access to as soon as your registration is approved.

You will receive an email confirmation via email. Once you receive the invitation for rounds, please feel free to share it with other members of the client’s care and support team who would like to participate in the client’s de-identified care planning discussion.

Submit a referral or de-identified case

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

Resource 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.

A Coordinated Care Plan (CCP) is a plan that contains some of your client’s personal health information. You and the rest of your client’s care and support team may use this plan to:

Share information so everyone has a common understanding of all the factors affecting their well-being without them having to repeat their story multiple times
Identify any unmet needs they 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 your shared clients

Coordinated care plans (CCPs) for your clients are accessed by signing into ETHP Collaborate.

IMPORTANT: You need to be a registered user for ETHP Collaborate in order to access the CCPs. If you are not already a user, go to the ETHP Collaborate webpage to register (noting that this is a one-time process that can take up to 3 business days).

Clients you are currently supporting who have a CCP in ETHP Collaborate will be visible on/accessible from your “Client” list.

Instructions for how use the CCP are in the ETHP Collaborate Toolkit which you will have access to when you are registered user.

EastTCaN supports use of the CCPs, so if you need help please email EastTCaN@tehn.ca

The rounding tables help you and other members of your client’s care and support team figure out how best to support your client’s unmet health and social needs. All information shared and recommendations made at rounds will be included in your client’s Coordinated Care Plan (CCP).

EastTCaN operates two different types of rounds:

Primary and Community Care Response Teams (PCCRT) rounds, for people aged 18 and older living in East Toronto with unmet health and social needs

Senior Mental Health Collaborative (SMHC) rounds, for people aged 50 and older living with cognitive and/or mental health factors affecting their well-being

You can get care planning support from one or both of the rounds whenever it is required along your client’s care journey.

There are currently two different Primary and Community Care Response Teams (PCCRT) rounding tables, which support care planning for people living in and/or accessing care within specific East Toronto neighbourhoods (see below).

We recommend you start by trying to get support through your established channels (e.g. internal social workers, care navigators, etc.). If, after three months, your client’s needs are not met or if you are experiencing challenges determining how to meet their needs, consider referring to EastTCaN for rounding table support.

Clients need to consent to be referred to EastTCaN for rounding table support (and CCP creation).

Consent documents are in the ETHP Collaborate Toolkit which you will have access if/when you are registered user.

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.