Beyond Hospital Walls: Improving care coordination

TORONTO – Canada’s emergency departments are under significant pressure. In 2024–25, there were 16.1 million ED visits, with 1.2 million patients leaving before being seen. One in ten admitted patients waited more than 48 hours for an inpatient bed.

But ED pressure does not begin or end in the ED.

Patients move between primary care, hospitals, home care, long-term care, and community services. Each transition creates another point where information, decisions, and responsibility need to connect. When they don’t, the impact can show up as delayed referrals, repeated follow-up, unclear ownership, and additional work for already stretched teams.

So what does it take to make integrated care work when the patient needs the next step to happen?

On November 4, Hypercare will bring together perspectives from primary care, frontline navigation, and Ontario Health Team transformation to examine what happens at the point of contact, where care moves between organizations that may not share the same employer, budget, or reporting structure.

The discussion will explore:

• Where coordination breaks down and what that means for the teams responsible for keeping care moving.
• How ownership and decision-making affect execution when responsibility crosses organizational boundaries.
• What makes cross-organizational workflows work in practice, beyond having a pathway on paper.
• What organizations can realistically measure in the first year to understand whether coordination is improving.

Join the conversation to gain a clearer view of the operational conditions, governance, and measures that can help make integrated care work across organizational boundaries.

Register for the November 4 webinar: https://hypercare.zoom.us/webinar/register/3917912996153/WN_VnLeUIrDTGKEAC0i-Hhhbg

Speakers

Dr Rahima Alani
Family Physician and Primary Care Clinical Lead, SCOPE·Michael Garron Hospital – Toronto East Health Network
Dr. Rahima Alani is a family physician practicing at Planned Parenthood Toronto and the Canadian Centre for Refugee and Immigrant Health Care. She is a Clinician Teacher in the Department of Family and Community Medicine at the University of Toronto and the Primary Care Lead for SCOPE in East Toronto.

Emmi Perkins
Director of Transformation for the Guelph Wellington Ontario Health Team·Guelph Wellington Ontario Health Team
Emmi Perkins (MHSc, BScPT, Reg. PT, CHE) is the Director of Transformation for the Guelph Wellington Ontario Health Team, leading system?level change in collaborative governance, integrated care, and improved population health outcomes. A regulated physical therapist with front?line experience across multiple sectors, she brings a grounded, interdisciplinary perspective to her leadership work as an outcome?driven, patient? and provider?focused change agent committed to equitable health outcomes.

Sufyan Khatri
SCOPE Nurse Navigator, EasT-FPN / Michael Garron Hospital·Michael Garron Hospital
Sufyan Khatri is a registered nurse and the SCOPE Nurse Navigator at Michael Garron Hospital. SCOPE supports family physicians and nurse practitioners in the community with resource finding and creating connections in the community and at MGH. Sufyan has been with SCOPE since its inception in 2019.

Dr Joseph Choi
Emergency Physician, COO/CMO, co-founder of Hypercare
Joseph is Hypercare’s founding COO and CMO, leading efforts to improve clinical communication and coordination through technology. He is a practicing emergency physician in downtown Toronto and is active in quality improvement and hospital administration. He also serves as an associate professor in the Department of Medicine at the University of Toronto, contributing to medical education and research.