Primary and Community Care Response Teams share 2021/22 Annual Evaluation highlighting success of improving care for vulnerable adults in East Toronto


East Toronto Health Partners’ (ETHP) Primary and Community Care (PCC) Response Teams have published their 2021/22 Annual Evaluation Report (Download PDF), which highlights the successes of this integrated care planning program for the period of April 2021 to March 2022.

The report demonstrates the impact of the collaborative program, which involves healthcare and social services providers and community health ambassadors from more than 24 agencies in East Toronto working together to create coordinated care plans for vulnerable adults living in East Toronto.

From April 2021 to March 2022, our PCC Response Teams:

  • Developed customized care plans for 126 clients, including adults with complex needs and individuals who are homebound and do not have a family doctor.
  • Facilitated 426 care discussions between clients’ existing care and referral teams and our PCC Response Teams.
  • Connected clients to 198 services, including primary care (i.e. family doctors and nurse practitioners) and supports related to mental health, housekeeping, caregivers and other areas.

These service connections help improve the health of vulnerable adults, especially during the COVID-19 pandemic when some health and social services have been restricted.

Other highlights from the PCC Response Teams’ 2021/22 Annual Evaluation Report include:

  • Expanded participating partners to include five new organizations: Baycrest Centre, which provides behaviour support to the PCC Response Teams; Eastview Neighbourhood Community Centre; Houses Opening Today Toronto (HOTT); and Mustard Seed/Fontbonne Ministries.
  • Created Senior Mental Health Collaborative to support clients with mental health, cognitive or behaviour factors that affect their well-being.
  • 96% of surveyed partners agree that the PCC Response Teams have improved clients’ access to care.
  • 92% of surveyed partners are satisfied with their experience with the PCC Response Teams.

The 2021/22 Annual Evaluation Report also highlights the quality improvement and learning health systems approach used within the program. It specifically identifies key drivers for success and opportunities for improvement.

Read the PCC Response Team’s full 2021/22 Annual Evaluation, and all future reports, at

How to refer someone to ETHP’s PCC Response Teams

For providers in East Toronto:

  • Refer through If you are a healthcare or social services worker in East Toronto and have a client who you think would benefit from our PCC Response Teams, we encourage you to learn more about the program and refer a client by visiting
  • (NEW) Refer through Ocean: If you are an Ocean user, you can 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 the website/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.

For people who live and/or get care in East Toronto:

  • If you live in East Toronto, have health challenges and think you would benefit from the PCC Response Teams, please read the eligibility criteria.
  • If you are eligible, ask a member of your care team to refer you to the Response Teams by visiting

We thank all of our partners for their collaboration and support since the launch of the PCC Response Teams program in 2019. We look forward to continuing our integrated care planning together!

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