Information for Health and Social Service Providers 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 people living in and/or accessing care in East Toronto by: 

Using evidence-based integrated care pathways (ICPs) to provide people with the best care to meet their needs. EastTCaN is currently using an ICP to support people with chronic obstructive pulmonary disease (COPD).

Creating a Coordinated Care Plan (CCP) for each person (containing some of their personal health information) that can be used by their care and support team members to plan and coordinate their care.

Discussing people’s situations in a de-identified case-based way at an EastTCaN rounding table to get care planning support if/when needed.

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

Who is eligible?

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 (see details below about specialized rounding tables).

People 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.

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): At this time, only referrals from Micheal Garron Hospital are being accepted. In the future, EastTCaN hopes to accept referrals from other organizations and providers.

How do I refer a client to EasTCaN for rounding table support?

IMPORTANT: If this is the first time you are submitting a referral or a de-identified case, and/or accessing the Coordinated Care Plans (CCPs) for any of your clients, you need to register for ETHP Collaborate. Please click the green button below to learn more. The approval process for this can take up to three business days but only needs to be done once.

Once you are a registered user of ETHP Collaborate, sign in to ETHP Collaborate and submit a referral. If your client does not consent to being referred, you can choose to submit a de-identifed case to discuss at rounds (see ETHP Collaborate Toolkit for instructions).

After you submit a referral or a case, you will immediately receive an email confirmation that will outline next steps. 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 care planning discussion.

Tip: If you are an Ocean eReferral user, you can use the "Add to Favourites" function to add the EastTCaN listing to your main page of the Ocean Healthmap, making it easier to access this webpage when you are using the directory.

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

Living well resources to help guide their self-management (e.g. Living Well with COPD)

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

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

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).