Case Management Discussion Table
No individual should navigate complex illness alone, and no organization should manage complex cases in isolation.
Increasingly, individuals living with life-limiting illness are navigating not only complex medical needs, but also mental health concerns, caregiver burnout, housing instability, disability supports, and fragmented systems of care. In response, Hospice Toronto has reimagined its interdisciplinary and interagency Case Management Table to support earlier, more coordinated, and collaborative care, resulting in enhanced system navigation and a greater ability for individuals to choose home as a care setting.
Originally established in 2002 as an internal consultative forum focused primarily on cancer-related care, the table has evolved to reflect today’s broader realities of chronic illness, disability, dementia, caregiver strain, and increasingly complex psychosocial needs. Reactivated in August 2025 in response to growing system complexity and evolving client needs, the renewed model reflects a more integrated and earlier-intervention approach, supporting individuals from the point of diagnosis onward rather than only during later-stage or crisis-driven care.
This monthly collaborative forum brings together Hospice Toronto staff alongside key community and healthcare partners, including Ontario Health at Home, ALS Society of Canada, Alzheimer Society of Ontario, and Shift Collaborative. The table also benefits from the participation of Hospice Toronto volunteers with medical and nursing backgrounds, alongside a bioethics perspective provided by a professor from University of Toronto, whose expertise supports ethical reflection, care planning, and system navigation.
A Collaborative Approach to Complex and Evolving Care
The reactivated model builds on the original foundation while expanding its scope to reflect today’s increasingly complex care landscape. Historically centred primarily on cancer care, the table now supports individuals and families living with a broad range of chronic, progressive, and life-limiting conditions, alongside intersecting social and psychological challenges.
These include chronic illnesses such as diabetes, neurodegenerative conditions such as ALS and dementia, disability-related support needs, caregiver burnout, social isolation, housing instability, and financial precarity — all of which significantly impact care complexity and quality of life.
For example, the roundtable can provide support to a client facing advanced-stage illness, caregiver burnout, housing instability, and mental health issues situations in which no single organization can independently address all these needs. Through coordinated dialogue and the sharing of specialized knowledge, the roundtable facilitates more integrated planning and collaborative problem-solving across different sectors.
An additional strength of the table is its ability to create space not only for coordinated planning, but also for reflective debriefing when particularly challenging cases arise, as well as for identifying emerging trends in care needs across the system.
Impact on Clients, Families, and Care Coordinators
Client Care Coordinators report that the reactivated table has significantly improved coordination, communication, and timely access to supports. Families often feel more supported and less overwhelmed when navigating complex health and community systems.
The table provides clarity in situations where no single organization can meet all needs independently. Through shared decision-making, partners are able to align services, reduce duplication, and strengthen continuity of care. This includes supporting pathways for expedited long-term care placement, connecting clients with disability and community resources, and improving access to financial, psychosocial, and palliative supports.
Importantly, clients with highly complex needs remain connected to Hospice Toronto’s consistent support while benefiting from coordinated, multidisciplinary input across partner organizations. Coordinators also report increased confidence in managing complexity, knowing they are supported by shared expertise and cross-sector collaboration.
The table also creates opportunities to strengthen connections with primary care providers by improving communication, clarifying roles across sectors, and supporting earlier identification of emerging needs. Through coordinated planning and shared understanding of client complexity, primary care teams are better supported to remain connected to patients and caregivers throughout the illness journey. This collaborative approach helps sustain longitudinal relationships while also reducing pressure on physicians and nurse practitioners navigating increasingly complex care environments.
Strengthening System Partnerships
The reactivated Case Management Table has strengthened interagency relationships and improved communication across Ontario Health at Home, ALS Society of Canada, Alzheimer Society of Ontario, and Shift Collaborative.
Partners regularly share knowledge about services, eligibility pathways, and system navigation, improving awareness across sectors and enabling more responsive, coordinated care. This has resulted in faster response times, reduced duplication, and stronger shared accountability in supporting clients and families.
The initiative also demonstrates the important role community-based hospice organizations can play within integrated systems of care — contributing not only direct client support, but also system coordination, cross-sector collaboration, and earlier intervention alongside healthcare and community partners.
Looking Forward
While the re-visioned Case Management Table has already demonstrated significant value, ongoing reflection continues to identify opportunities for growth and enhancement. Expanding partner engagement and participation will further strengthen its impact and support more integrated, coordinated care across sectors.
Most importantly, this initiative reflects a shared belief embedded across all participating organizations: no individual should navigate complex illness alone, and no organization should manage complex cases in isolation. As the table continues to evolve, Hospice Toronto and its partners look forward to deepening collaboration in support of clients and families with compassion, expertise, and shared accountability.