Since 2015, when Cota became involved in Coordinated Care Plans (CCP), we have facilitated over 100 individuals living with complex health challenges across the city of Toronto. The Health Links identified that

individuals living with complex health issues could benefit from better integrated coordinated care to provide the best health care possible. They saw that the top 5% of patients consume about two-thirds of health care dollars, and yet, these individuals with complex health conditions often receive the most poorly-integrated care.

Supporting Coordinated Care Planning

Cota allocated two mental health case managers to act as Transitional Care Coordinators (TCC’s) in the sub-LHIN region (Mid-East and East). The TCC’s lead the development of a Coordinated Care Plan that involves the client, their existing service providers, and informal supports (family, friends, neighbours etc.). All four come together to coordinate efficient and effective care. TCCs provide services for approximately three month, during which a long-term lead is then identified.

In addition, the majority of our staff in our Integrated Service teams (ISTs) have been trained in Coordinated Care Planning and when needed, initiate care planning with their clients. Our Home, Health and Community Program as well as Cota’s Streets to Homes team are also trained to lead CCPs.

Facilitating the coordination of care requires all health care providers to be involved in a client’s care and to:

  • Understand what is most important to the client and caregiver in achieving their health and social care goals
  • Have timely and easy access to each client’s relevant health/social information
  • Participate in team discussions with clients about how to best achieve their health and social care goals. Communicate on an ongoing basis to monitor and update the client’s coordinated care plan.

*Jane's Story: 

Before Receiving a Coordinated Care Plan

It is always rewarding to hear back from individuals who receveid services from our Cota Transitional Care Coordinators.

One such story involves a former client, *Jane. *Jane required multiple supports for her complex needs. After consenting to a Coordinated Care Plan, her situation was brought to the table. Jane's portfolio indicated that she was living with serious physical health issues, mental health and addictions issues, she had no income, and had recently ended a long-term relationship (which resulted in *Jane becoming homeless).

In a period of three months, agencies and individuals at the CCP table, led by Cota’s Transitional Care Coordinator, had linked Jane to a multi-disciplinary healthcare team who helped her with physical and mental health supports.

*Jane was assisted in contacting family members and met her parents for the first time in more than 20 years. Jane was also moved to transitional housing and received income support from ODSP.

She was further linked to other community supports to help her with mental health and addictions issues.  

*This is not the client's real name, but she has given us permission to share her story.

After working with a Transitional Care Coordinator: 

*Jane wrote to us and said:

[Before,] I felt hopeless and alone. I felt scared, confused, and I did not know how to start my life over. With the support of my care team, I have been given freedom to live a new life; one free from alcohol, abuse, and dependency on others. My life is not perfect but I can breathe again.

– *Jane, previous client