Implementing cross-agency care coordination case management solutions

Canada’s Connected Care for Canadians Act (Bill S5) reinforces expectations for interoperability and vendor alignment, but success will be in the operational details: standardized definitions and consent models people can follow, role-based access that is defensible under privacy law, data stewardship across organizations, and governance that can survive turnover.

VitalHub is working with three organizations in the Waterloo/Wellington region to develop a Mental Health and Addictions Information Exchange (MHAIE) providing timely, personal health information to enable safe quality care.

As noted by Anna Tersigni, director, Quality & Risk and chief privacy officer, CMHA Waterloo Wellington, a core principle is solution-agnostic exchange across case management platforms to support regional network growth.

When a client is enrolled in two or more organizations, they are matched in the MHAIE, unless the client has explicitly applied a lock box directive. In the event of the “Harm to Self or Others” scenario, the lock box can be over-ridden as per Ontario Privacy laws.

Work is proceeding in three phases:

• a shared client and consent record across partners (in pilot);
• sharing selected service records such as enrollments, documents, and events;
• expansion into referrals, reporting, and additional interfaces.

In phase one, partners established a joint governance body overseeing hosting, a memorandum of understanding clarifying ownership and accountability, shared incident and breach procedures, coordinated communications and public disclosure, and shared auditing and monitoring, including Privacy Impact and Threat Risk assessments.

Beyond enabling staff in the three organizations to view shared client information, the pilot is accelerating alignment on privacy and security practices, reducing ambiguity and creating a consistent experience for clients.

Tersigni emphasized that a major hurdle to enabling effective shared models is a common interpretation of PHIPA legislation and roll out of an implied consent model. What we need are solutions that support Privacy and Security by Design, and trust that detailed audit trails exist and are being monitored, she said.

Dual-context work – regional solutions alongside agency systems: With the advent of Ontario treatment networks, some staff are required to document in a service-specific regional case-management solution (e.g., youth outreach programs) while also providing home agency services to the same client.

This dual-system reality fragments client information and care plans, affecting timeliness and continuity for clients while adding administrative burden for staff and organizations.

While it may not be possible for teams to use a single system, selective and governed exchange of key information should be enabled with clear attribution for things such as care team member identification, notes, goals, risk flags, and referral status.

Outsourced services – third-party delivery and partner access: When agencies contract out services (e.g., housing supports), coordination and effective client care depends on the right information, in the right place, at the right time.

Too often, partners rely on paper or limited digital tools, so information is shared verbally or by fax/email, resulting in delays, lost context, and extra follow-up work, while clients experience slower handoffs and less continuity.

A sustainable model pairs partner-friendly access with explicit governance. Partnership portals enable configurable access controls, with workflow patterns for structured requests, status updates, and task handoffs, removing reliance on fax/email while avoiding unnecessary access beyond what partners require.

The Children’s Treatment Network (CTN) provides coordinated intake, service navigation, and specialized services to children and youth with disabilities and developmental needs across the York and Simcoe regions. In 2025, CTN went live with one of VitalHub’s case management solutions, involving staff across 20+ organizations and 1,200+ schools.

While CTN is in post-go-live stabilization, the design illustrates multi-partner and data stewardship complexity yet showcases how coordinated workflows enable collaboration across service teams. Lewis Park, director, information systems and technology at CTN, recognized that the complexity of the network model, cross-team coordination, and the challenge of standardizing processes became clearer after the requirements gathering phase. Active partner engagement helped surface readiness and risk early – but also highlighted that each onboarding decision affects the entire network, reinforcing the need for stronger central coordination.

Despite challenges, Lewis emphasized that the strong partnership between CTN, Network Partners and VitalHub has been crucial in working through implementation challenges.

To make cross-agency coordination reliable at scale, partners need more than connectivity: shared definitions, practical consent and access models, strong security and auditability to build trust, and day-to-day processes that reduce rework. VitalHub is committed to partnering with organizations, other vendors, and government to create streamlined, efficient, and effective cross-boundary solutions.

Ruby Lederman is Vice President, EHR & Care Coordination Products and Solutions, VitalHub Corp. To learn how VitalHub can help your organization support cross-agency care coordination, reach out to info@vitalhub.com.