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.
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- 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.
Integrated care pathways support patients to learn how to manage their condition, connecting them to programs and services and monitoring their progress.
Key features include:
- Designated staff to provide support (Clinical Care Facilitators, Access Administrator, and, for VENT+, other interprofessional team members)
- Individualized holistic self-management goals and plans
- Remote care monitoring
- Action plans, exacerbation management and follow-up
- Case management and progress reporting
- Service connections and coordinated team-based rounds
- Equipment and patient education resources
Guiding principles include evidenced-based care, health equity, patient centered care, seamless transitions and self-management
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
EastTCaN Collaboratives are virtual spaces where front-line providers can come together to share information, collectively problem solve and support each other. Collaboratives work together as a system of care to build capacity for navigation and care planning for frontline providers and staff.
- Front-line providers/staff attend the sessions to get support through topic- and case-based discussions.
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Providers/staff can access the Enhanced Home Supports Program (EHSP)* through all Collaboratives. *EHSP leverages a grant, managed by WoodGreen Community Services, to provide one-time funds of up to $1,000 per client per fiscal year in an urgent situation, where alternative resources are unavailable.
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EastTCaN operates three different Collaboratives, each with a specific focus.
BEAM Collaborative (4 sessions each fiscal year): This activity has been certified by the College of Family Physicians of Canada and the Ontario Chapter for up to 4 Mainpro+® Certified Activity credits. This session has been certified for 1 credit.
How to participate
