Collaboration enhancing diabetes care in Central East LHIN

The Scarborough Hospital, Scarborough Centre for Healthy Communities and Central East LHIN ensuring people with diabetes
receive care at most appropriate points

Since partnering with the Scarborough Centre for Healthy Communities (SCHC) in January 2014, patients with diabetes who come to The Scarborough Hospital (TSH) have seen greater efficiencies in having the right care provided at the right place in a timely manner, say key stakeholders.

Thanks to this collaboration, patients with diabetes who come to TSH are assessed and then either admitted to the hospital based diabetes program or referred to the SCHC’s Community Diabetes Education Program, depending on their care needs.

When patients with diabetes are referred to SCHC, an initial needs assessment is performed by a nurse and a social worker who provides care and connects them with community resources, some of which can be offered on site.

Aside from medical resources, people with diabetes who are referred to SCHC can also access food banks, furniture banks and social services, among other resources.

Since April 1st, 2013, the Community Diabetes Education Program has been reporting to the Central East Local Health Integration Network (LHIN). Prior to that, the program was accountable to the Ministry of Health and Long-Term Care.

The Central East LHIN identified that people living with diabetes don’t always want to receive diabetes education in acute care hospitals — sometimes they want to receive education in the community-based settings.

Scarborough has the highest rate of diabetes in the Central East LHIN’s catchment area. Because of the high number of people living with diabetes, there was a need to develop a process to determine who could best meet the needs of different patient groups.

Ethel Doyle, Patient Care Director at The Scarborough Hospital (TSH), says the many community-based services provided by SCHC made the centre an ideal partner.

“When we looked at the needs of these particular patients, what we recognized is that at the Scarborough Centre for Healthy Communities there is an education centre as well as a number of community resources and programs that are really focused on wellness, which is something that we don’t always have here at The Scarborough Hospital,” Doyle says.

“So we recognized the opportunity to formally partner with Scarborough Centre for Health Communities as a means of enhancing the care continuum for diabetes patients in Scarborough. We will be extending this partnership to other diabetes education community based programs that report to our LHIN such as TAIBU Community Health Centre’s community diabetes education program.”

"Patients who are admitted to the hospital after their initial triage may later be referred to our community partners once they’ve learned to control their condition to the point that they safely receive care in the community. If their diabetes becomes too challenging to control, patients are able to quickly come back to TSH."

“It’s leveraging the system to enable patients to access services seamlessly and in a navigated way through the system, from hospital to community and from community back to hospital,” Doyle says.

Andrea Falcone, manager of the Community Diabetes Education Program, says since the program began reporting to the Central East LHIN there has been better awareness of the diabetes resources available in Scarborough — and more seamless transitions that ensure patients are referred to the best possible services.

“Since the LHIN (has become involved) there has been a greater clarity of roles and more collaboration,” Falcone adds. “I find that the LHIN has been doing a really good job at aligning the clients to where they can best be seen.”

The Central East LHIN is currently implementing its third Integrated Health Service Plan (IHSP), setting out a shared goal for the local health care system to help Central East LHIN residents spend more time in their homes and their communities.

Vascular health is a concern across Canada. Together with hospitals and community agencies from across Scarborough, Durham Region and the North East cluster, the LHIN is actively working on the “Community First – Vascular Aim”.

To learn more about Diabetes Resources in the Central East LHIN – including the location of all the Diabetes Education Centres in Scarborough, Durham and the North East Cluster, please click on “Get Connected with Care – Diabetes Resources.” 

To learn more about the LHIN’s Chronic Kidney Disease Initiatives, please click on “Get Connected with Care – Chronic Kidney Disease Initiatives.

The LHIN is also working with its local health service providers – physicians, nurses, administrative leadership – on an Integrated Stroke Strategy. 

If you have any questions or require additional information, please contact Karen O’Brien, Public Affairs at or 905-427-5497 ext. 212.

Submitted by Deron Hamel, Axiom News.  To contact Deron, please email