Pathways is an online resource that allows clinicians and their office staff to quickly access current and accurate referral information, including wait times and areas of expertise, for specialists and specialty clinics. In addition, Pathways makes available hundreds of patient and physician resources that are categorized and searchable. This information enables clinicians to identify the […]

• Home care (nursing and/or personal support)
• Hospital-based acute medical, surgical or rehabilitation care
• Nursing home/residential long term care
• Palliative care at home or in hospice
• Primary care
• Social services (eg. transportation, food banks/food preparation, employment services)
• Specialized ambulatory/community medical clinics

Target Population

No specified target population

La gestion de cas (GC) est l’un des modèles de soins intégrés les plus étudiés pour les personnes ayant des besoins complexes. Après des essais prometteurs à petite échelle, il est maintenant nécessaire d’étudier sa mise en œuvre à plus grande échelle dans différents contextes de santé. Cette étude vise à étendre la GC en […]

Progress Place Clubhouse is a community based mental health initiative supporting adults living with serious mental illness through a recovery-oriented, integrated care approach. The initiative operates as a collaborative community where individuals, referred to as members, work alongside staff to run the organization. Through shared, meaningful activities that sustain daily operations, members build skills, social […]

• Community-based group or day care
• Social services (eg. transportation, food banks/food preparation, employment services)
• Supportive housing

Target Population

Adults (40-64) Individuals with long term (chronic) conditions other than mental health (e.g. pediatric conditions,diabetes, stroke, Parkinson’s) Individuals with mental health conditions other than cognitive decline Individuals with social determinants of health needs (homelessness, poverty, marginalized) Older Adults (65+) Young Adults (18 – 40)

Reconnect has developed partnerships with five large urban hospitals in Toronto to ensure patients/clients who are transitioning between the two settings experience a smooth, seamless transfer of care. The keys to the success of this process are building open, communicative relationships between the staff dedicated to the partnership at both organizations, actively looking for challenges […]

• Hospital-based acute medical, surgical or rehabilitation care

Target Population

Adults (40-64) Individuals (e.g. older adults) with frailty Individuals with BOTH complex health and social determinants needs Individuals with mental health conditions other than cognitive decline Older Adults (65+) Young Adults (18 – 40)

Renfrew County’s Homelessness and Addiction Recovery Treatment (HART) Hub is a barrier-free, integrated initiative supporting individuals experiencing homelessness, addiction, and complex health and social needs. Built on the collaborative Mesa model, the Hub unites health care, housing, mental health, addictions, and community partners to deliver coordinated, compassionate care. Its goal is to provide timely access […]

• Community-based group or day care
• Financial supports
• Other
• Social services (eg. transportation, food banks/food preparation, employment services)
• Supportive housing

Target Population

Adults (40-64) Children (< 18) Individuals with BOTH complex health and social determinants needs Individuals with social determinants of health needs (homelessness, poverty, marginalized) Older Adults (65+) Young Adults (18 – 40)

SCOPE is a primary care integration program that launched in 2012 to rapidly connect primary care providers (PCPs) to hospital and community services through a single point of access. Built upon co-design with primary care, SCOPE is the scaffold connecting >4300 PCPs in 22 sites across Ontario. Local PCPs identify gaps in care to initiate […]

• Home care (nursing and/or personal support)
• Hospital-based acute medical, surgical or rehabilitation care
• Nursing home/residential long term care
• Primary care
• Social services (eg. transportation, food banks/food preparation, employment services)

Target Population

Adults (40-64) Caregivers / Carers Children (< 18) Individuals with BOTH complex health and social determinants needs Individuals with cognitive decline (e.g. dementia, Alzheimer’s) Individuals with long term (chronic) conditions other than mental health (e.g. pediatric conditions,diabetes, stroke, Parkinson’s) Individuals with mental health conditions other than cognitive decline Individuals with social determinants of health needs (homelessness, poverty, marginalized) No specified target population Older Adults (65+) Palliative or end of life care Young Adults (18 – 40)

Southlake@home Plus is an innovative ALC reduction program delivering comprehensive post-acute care directly in patients’ homes. Its primary goal is to minimize hospital stays by optimizing discharge planning, enhancing behavioral health supports, and fostering multidisciplinary stakeholder collaboration—ultimately improving patient outcomes, reducing system pressures, and promoting sustainable, family-centered care transitions for Ontario’s healthcare network.

• Financial supports
• Home care (nursing and/or personal support)
• Hospital-based acute medical, surgical or rehabilitation care
• Primary care
• Social services (eg. transportation, food banks/food preparation, employment services)
• Specialized ambulatory/community medical clinics

Target Population

Adults (40-64) Caregivers / Carers Individuals (e.g. older adults) with frailty Individuals with BOTH complex health and social determinants needs Individuals with cognitive decline (e.g. dementia, Alzheimer’s) Individuals with mental health conditions other than cognitive decline Older Adults (65+)

Southlake@home Plus is an integrated home- and community-based care initiative designed to facilitate safe, timely discharge for medically ready patients, with a strong emphasis on behavioural health support. The program delivers coordinated rehabilitation, specialized behavioural supports (including crisis intervention, de-escalation strategies, and trauma-informed care), and caregiver education to ensure a smooth transition from hospital to […]

• Home care (nursing and/or personal support)
• Hospital-based acute medical, surgical or rehabilitation care
• Primary care
• Supportive housing

Target Population

Adults (40-64) Caregivers / Carers Individuals (e.g. older adults) with frailty Individuals with BOTH complex health and social determinants needs Individuals with cognitive decline (e.g. dementia, Alzheimer’s) Individuals with long term (chronic) conditions other than mental health (e.g. pediatric conditions,diabetes, stroke, Parkinson’s) Older Adults (65+)

The initiative is a collaborative of 14 partners working together to serve a range of functions including service planning/delivery, care navigation, and governance. The goal is to support the wellbeing of residents living in Creditvale Mills social housing properties, and the surrounding area, including 616 units in a dense service area. Programs are available in […]

• Primary care
• Social services (eg. transportation, food banks/food preparation, employment services)
• Supportive housing

Target Population

Adults (40-64) Caregivers / Carers Children (< 18) Individuals (e.g. older adults) with frailty Individuals with BOTH complex health and social determinants needs Individuals with cognitive decline (e.g. dementia, Alzheimer’s) Individuals with long term (chronic) conditions other than mental health (e.g. pediatric conditions,diabetes, stroke, Parkinson’s) Individuals with mental health conditions other than cognitive decline Individuals with social determinants of health needs (homelessness, poverty, marginalized) Older Adults (65+) Young Adults (18 – 40)

TAPMI is a comprehensive, interdisciplinary academic pain program and regional hub for chronic pain care in Toronto. Hosted at Women’s College Hospital, TAPMI brings together five academic pain centres to coordinate access to specialized chronic pain services through centralized referral, intake, assessment and triage. Patients are matched to the most appropriate program or service across […]

• Specialized ambulatory/community medical clinics

Target Population

Adults (40-64) Individuals (e.g. older adults) with frailty Individuals with BOTH complex health and social determinants needs Individuals with long term (chronic) conditions other than mental health (e.g. pediatric conditions,diabetes, stroke, Parkinson’s) Individuals with mental health conditions other than cognitive decline Individuals with social determinants of health needs (homelessness, poverty, marginalized) Older Adults (65+) Young Adults (18 – 40)