What is Integrated Community Care?

We are redesigning home and community services by bringing together primary care providers, mental health and addiction, and community
support and home care services, in partnership with clients and families to co-design a system of care that is easier to access, navigate, and use. Continuing work already underway, and as part of our 2015-2018 Strategic Plan, the Toronto Central LHIN has launched an integrated community care strategy. This strategy drives the design and implementation of a client-centric, coordinated system of care that will simplify access and navigation for providers, caregivers, and clients.

Designing and building a health care system that services the diversity of Central Toronto is a demanding undertaking.

Toronto Central is home to over 1.2 million people, and growing by 7% a year. Our efforts help support over 350,000 clients annually through over 70 community support services and over 50 mental health and addiction support services. With such complex and diverse needs, it is essential to include and work in collaboration with providers, clients, and the community to best meet their needs.

How we are integrating our community

The Integrated Community Care project is a first-of-its-kind, co-creation project that brings together all three service sectors to co-design home and community services. At every step of the process members from primary care providers, mental health and addiction, and community support and home care services have worked in collaboration and partnership with clients and families to reimagine an improved user experience and a more efficient system of care delivery.

A key element of the co-design approach for this project was the ONE COMMUNITY Summit that took place in December 2016.



At the summit, over 200 clients and family members, care providers, community partners, and health leaders explored ideas to enhance our system of care. Summit participants also defined core areas of focus, including improvements to client experience and ways to increase system efficiency.



 >200 Participants


  • Clients & Families
  • Care providers &
    Community Partners
  • Health Leaders

7 Engaging Activities

Collaboratively focus on:

  • Vision feedback
  • Identifying challenges
  • Solutions for an
    integrated system
  • Keys to success

5 Areas of Focus

Critical components of Integrated Community Care:

Simplified and Coordinated Access to Home and Community-Based Services

 Improving Capacity and Client Flow

 Easy Navigation and Care Coordination

Common Service Standards
Common Assessment and Referral Tools



To learn more about each area of focus, click on numbers below:

1. Simplified and Coordinated Access to Home and Community Services

2. Improving Capacity and Client Flow

3. Easy Navigation and Care Coordination

4. Common Service Standards

5. Common Assessment and Referral Tools


Simplified and Coordinated Access to Home and Community Services

Clients told us that they want access to home and community care services close to where they live, so that they can address their care needs.

To improve access to the community services, we are working on three key elements of access:

  • Increasing live voice-call answer rates for existing services
  • Creating partnerships to improve and extend hours so that we can better meet the diverse range of our client’s schedules
  • Collaborating to link and integrate existing services

Improving Capacity and Client Flow

In our conversations, the challenges of waitlists were repeated by citizens and service providers.


To reduce or eliminate waitlists for key services, we are focusing on improving collaboration, sub-region communication, and resource matching.

This includes:

  • Improving communication to reduce wait times
  • Improve the assessment process to provide services more quickly
  • Matching available resources with demand within a sub-region to optimize client flow within the system


Easy Navigation and Care Coordination

Navigating the health system is an important aspect of obtaining the right care when you need it. This is especially true for clients with multiple health needs and concerns.

Essential components to improve case
coordination and navigation include:

  • Mapping resources within the
    system to ensure care providers
    and coordinators can direct
    clients to receive the care they
  • Implementing a consistent
    system-wide approach to care
    coordination for populations that
    need it


Common Service Standards

Across Toronto Central clients and providers should have access to the same services, regardless of the neighbourhood they access their services or reside in.

We are building equitable service
standards by:

  • Assessing which services are
    needed and provided to ensure
    that they are available within all
    local sub-regions
  • Defining a common set of
    service delivery standards and
    information sharing practices
    between care providers



Common Assessment and Referral Tools

To improve the client experience, care providers must have productive and easy communication with each other, working collaboratively to eliminate assessment repetition.


This includes:

  • Identifying the right questions to ask clients at the right times to improve connection to care
  • Implementing referral processes so they can be shared across providers

Building on the work accomplished over the last year, the Integrated Community Care project is now moving towards implementation to achieve the vision of an integrated community care. Each area of focus highlighted above will have action teams comprised of members from across home and community care, and client and family groups. The action teams will bring their objectives to life by working with community partners for on the ground implementation—building a home and community care system that is easier to navigate, access, and use for clients and providers alike.

As a member of our community,your voice is an important part of the Integrated Community Care project.

Let us know what you think, or share an idea with us by contacting