Abstract
Background: Chronic diseases pose significant burdens on individuals, caregivers, and healthcare systems, often intensified by fragmented care between hospitals and community providers. In Ontario, Canada, COPD, CHF, diabetes (with a focus on lower limb preservation), and stroke have been prioritized due to their impact on quality of life and healthcare resources. To address these challenges, the Ontario government has provided seed funding to 12 Ontario Health Teams, including East Toronto Health Partners (ETHP), to implement integrated care pathways aimed at transforming chronic disease management.
Approach: Supported by individuals with lived experience, caregivers, community and champions across disciplines including specialists, primary care, home care, and digital health experts- a ETHP task force built and implemented a chronic disease management prototype pathway. Beginning with COPD and guided by Canadian Thoracic Society standards and treatable traits framework, the pathway emphasizes patient-centered care, self-management, health equity, and alignment with health quality standards.
The model addresses key community-identified needs, integrating remote care monitoring post-hospital discharge and targeting 5-, 7-, and 30-day readmission rates to reduce hospital utilization and improve patient support at home. Two new roles were created: Clinical Care Facilitator (CCF), who conducts comprehensive assessments addressing clinical, social, mental health, and co-morbidities; and Access Administrator (AA), who facilitates connections to and, reduces barriers to accessing chronic disease management services. An innovative shared care planning platform enables individualized care plans, streamlines provider communication, and enhances team-based coordination.
Components of the pathway include: 1) Patient exacerbation self-management plans for flare-ups, 2) Case and care management by our CCF ensuring coordinated support, with regular progress reports shared with primary care and the patient, 3) Medication management offering structured support to optimize treatment, 4) Regular follow-ups assess care continuity, self- efficacy and intervention effectiveness. 5) Care team rounds facilitating collaborative support across a multidisciplinary team of health, social, and community providers, 6) Patient education drawn from resources like Living Well with COPD, ensure accessibility and clarity in patient-facing materials.
To promote continuous quality improvement, ETHP launched an initial cohort of 10 patients to refine processes, tools, and workflows through rapid-cycle improvement, driving ongoing adaptations to meet patient needs effectively.
Results: Through comprehensive engagement with providers, partners, community members, and patients, ETHP launched East Toronto Care Network (EastTCaN- https://ethp.ca/our-work/east-toronto-care-network/), a scalable, multisector, patient-centered, integrated care model that empowers individuals to "manage their chronic disease instead of the chronic disease managing them."
The first COPD pathway for hospital admissions has ~60% acceptance rate. Strong implementation support including evaluation scientists have driven performance measurement and rapid-cycle improvements, with patient journey mapping highlighting experience measures and program gaps.
Implications: Equipped with provider and patient tools and digital enablers that support team-based care planning and service integration, EastTCaN aims to enhance the quality of life for chronic disease patients. Grounded in evidence-based pathways, ETHP is now positioned to expand to CHF, with diabetes and lower limb preservation pathways set to follow, strengthening East Toronto's capacity for integrated, comprehensive chronic disease management.