Primary and Community Care (PCC) Response Teams

Vulnerable adults with unmet health or social needs in East Toronto may be referred to our Response Teams by a family physician, outreach worker, supportive housing worker, community health ambassador or other health care or social services professional within their care and referral team, a group of individuals who provide care to a person. These adults have complex needs and may require the assistance of multiple care providers.

Once referred, the client is assigned to one of four Response Teams depending on the neighbourhood where they live. The Response Teams are comprised of family physicians, home care coordinators, nurse practitioners, case managers, mental health practitioners, supportive housing workers, volunteer community health ambassadors and other health care and social services workers in East Toronto.

The Response Teams may also include the Senior Mental Health Collaborative, optional and separately scheduled specialized sessions with integrated geriatric psychiatry and behavior support specialists that offer care plan consultations and/or case discussion.

With the client’s consent, the Response Team meets online with the client’s care and referral team to discuss the client’s needs.

Together, the group pools their knowledge, resources and expertise to develop a coordinated care plan for the client. This care plan may involve connecting with existing providers to coordinate care; introducing new providers or services; and coordinating income, housing and other assessments to improve the client’s ability to find and get care. Once approved by the client, the care plan is carried out by their care and referral team.

The client’s referral source and other members of the client’s care and referral team continue to meet online with the Response Team to share updates on the client’s health outcomes and ensure their evolving needs are being met. The result is healthier, happier clients whose health and social needs are met in a timely, integrated and culturally sensitive manner in the communities where they live.

Our Response Teams involve family physicians, home care coordinators, nurse practitioners, case managers, mental health practitioners, supportive housing workers, volunteer community health ambassadors and others who work together to improve health outcomes for vulnerable adults. Our teams work with clients and their existing care providers to provide additional resources and supports that are integrated, close to home, culturally sensitive and help the client reach their health goals.

Our Response Teams pool their knowledge, resources and expertise to support vulnerable adults’ comprehensive health by developing coordinated care plans that look beyond medical needs and address factors that may affect overall well-being, such as food insecurity, housing and income security.

In addition, our Response Teams conduct follow-up discussions with the clients’ care and referral team to ensure clients’ evolving needs are addressed in a timely and collaborative fashion. During their time in the program, clients are involved in decisions related to their care and are welcome and encouraged to provide feedback. This ensures the care they receive meets their evolving needs.

Our doors are open to all adults. We prioritize people who are:

• Vulnerable adults with complex needs
• Living in the area loosely bounded by Eglinton Avenue on the north, Midland Avenue on the east, Lake Ontario on the south and Bayview Avenue on the west (please refer to the below map)
• Facing barriers to health and wellness
• Experiencing unmet health and/or social needs

You do not need a family doctor or health card.

If you meet the eligibility criteria for this program, please ask a member of your care team to refer you to the Response Teams by visiting this page (ethp.ca/pccresponseteams). A member of your care team can include your family doctor, personal support worker, case manager, supportive housing worker, volunteer community health ambassador or anyone else who works in health or social services in East Toronto. After they refer you, we will be in touch with this person to share next steps.

Our Response Teams assist health care and social services workers in East Toronto by helping them think through and develop a strategy for supporting their vulnerable adult clients with complex needs. These adults may require a wide range of supports and services, including healthcare, food security, financial services, housing, and mental health and wellness. We help the client’s care and referral team access and coordinate delivery of services in a timely, integrated and culturally competent manner, helping to keep vulnerable adults safety at home and out of hospitals.

In addition, our Response Teams strengthen collaboration among healthcare and social services professionals in East Toronto by creating a space for them to pool their knowledge, resources and expertise to develop coordinated care plans. This gives health care and social service workers the opportunity to participate in a localized, integrated healthcare system that improves the way East Toronto residents access and receive care.

We encourage referrals from a wide range of healthcare and social services workers in East Toronto, including family physicians, outreach workers, supportive housing workers, community health ambassadors and others. We look forward to working with you and supporting the care you provide to improve the health of our East Toronto communities.

If you are a healthcare or social services worker in East Toronto and have a client who you think would benefit from ETHP’s PCC Response Teams, please click here to complete an online referral form. A member of our Response Teams will contact you within two to five business days with next steps.

As part of these steps, you will be invited to a care planning discussion. You may also be asked to forward this invitation to other members of your client’s care and referral team and to prepare a presentation that outlines your client’s care needs.

Urgent referrals will be accommodated whenever possible. If you have questions about the PCC Response Teams or referral process, please email LSutton@srchc.com. 

(NEW) Refer through Ocean: If you are an Ocean user, you can also use our listing in the Ocean Health Map (a map-based directory of health services in Ontario).

• Within the listing, you will find the link to this webpage and our referral form, an overview of the program and contact information for the program lead.
• Find our listing by searching “PCCRT” or using this link.
• Then use the “Add to Favourites” function to add the listing to the main page of the Ocean Health Map, making it easier to access anytime you use the directory.