Cross organizational partnership to support care coordination

As Co-Chair of the Ontario Health Team for East Toronto’s, Community Advisory Council, I would like to sincerely thank the Primary and Community Care Response Teams for their invaluable services. The PCCRT has established a caring environment where our community's most vulnerable individuals receive coordinated care and support from over 20 organizations within their own medical neighbourhood. We are profoundly grateful to the ETHP PCCRT for their innovative and transformative services, which bring hope, healing, and a brighter future to many lives in our community.
Arun Bala, Co-Chair Community Advisory Council, East Toronto Health Partners

In March 2023,  Health Standards Organization (HSO), recognized the Primary Care Response Teams (PCCRT), a program of the East Toronto Health Partners Ontario Health Team (ETHP OHT), as a leading practice in healthcare. The PCCRT was recognized for the capacity to enhance cross-organizational partnerships, leadership commitment and strong governance that supports accountability, planning, co-design, standardized operations, purposeful decision-making, and data collection for evaluation.

The PCCRT project was started in April 2020, at the beginning of the pandemic to offer neighbourhood and team-based health and social services care planning to help vulnerable adults in East Toronto. This project was led by SRCHC in partnership with East Toronto Community Health Centre Network, and was coordinated by Lori Sutton.  Over the last 3 years, over 400 individuals have been referred to the program and over 600 connections have been made to a range of programs and services. To date, there have been over 700 virtual care-planning discussions, where health and social services providers from different organizations and sectors come together to connect clients to primary care, mental health, caregiving, mobility and other services.

As one provider noted, “The PCCRT meetings are a collaborative approach to wrap around care and quality of service for our most vulnerable clients. The experience at the rounds is phenomenal and the responses to problem solving are always pretty quick, reliable, consistent and effective to providing clients with a very valuable service.”

Since its inception, PCCRT has expanded, with 24 organizations now participating in program planning and 74 staff attending rounds to support care coordination. The teams include family physicians, home care coordinators, nurse practitioners, case managers, mental health practitioners, supportive housing workers, and others.  This year, SRCHC worked with all our partners to ensure that this program aligns with systems transformation in home and community care. We conducted a review of the program, clarified the program purpose and developed a shared philosophy. The program has now been transitioned to be housed at VHA Home Healthcare. This will ensure that this program continues to align with other ETHP OHT integrated care initiatives that support a seamless care journey for adults, their caregivers, and the front-line providers supporting them, all while building a culture that supports sharing learning, experience, and resources to support adults, their caregivers, and front-line providers with cultural humility and a trauma-informed approach.