Downtown East Toronto
Coordinated Care Planning Resources
Ontario is improving care for people with complex conditions through coordinated care planning. This innovative approach brings together health and other social service providers to better and more quickly coordinate care for high-needs patients.
What does coordinated care planning do for patients?
- A shared understanding of patients goals, conditions and medications
- Smoother transitions between contexts such as hospital to community
- Greater patient involvement in shaping care
- Ongoing relationships between providers
- An evolving care plan as needs change
- More accessible services
- A reduction in avoidable hospital utilization
Patients living with complex health issues have multiple providers across numerous sectors, and benefit from highly integrated and coordinated care. Poorly coordinated care has been identified as a significant cause of adverse health outcomes and rising health care costs. Coordinated care reduces gaps in the care of patient/clients with multiple chronic conditions.
What is unique about coordinated care planning?
- Places the patient’s goals at the centre of care planning
- Determines a provider responsible for taking the lead in coordinating care
- Supports providers to work with each other and with the patient to develop an individualized Coordinated Care Plan (CCP)
- Facilitates access and attachment to primary care
- Enable ongoing communication and collaboration within the circle of care
Coordinated care planning materials for providers and patients
- Care Conference billing codes for physicians (pdf file)
- Health Link provider pamphlet (pdf file)
- Health Link patient pamphlet (pdf file)
- Coordinated care plan template (Word file)
- Coordinated care user guide (pdf file)
- How to develop Coordinated Care Plans: modules 1, 2 & 3
- Care conference facilitator quick guide
- Client centered questions for CCP development
- eCCP registration form
- eCCP consent form
- eCCP Website – tip sheets, forms, FAQ and training materials
For more information
Contact Dorothy Wedel, Mid-East Toronto project manager
Dorothy.wedel@unityhealth.to
416-867-7460 ext. 48303
