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Our partners include health and community organizations and primary care providers from across our Link, as well as local hospitals and the Toronto Central CCAC. To support their efforts to better coordinate care for their patients and clients, we provide the following links to helpful resources.

  • Seniors Mental Health


    What it does

    Contact information

    Psychogeriatric Resource Consultant for Primary Care

    Based in Mt. Sinai Hospital, the PRC for Primary Care provides services and supports to assist primary care physicians in caring for their patients and their caregivers, with a focus on dementia and responsive behaviours.

    416-586-4800, ext. 5251

    PRC Dementia Resources for Primary Care

    Baycrest Seniors Counselling and Referral Service

    Provides counselling, referrals and health system navigation support to anyone with a question about seniors care. Referrals can be made to programs at Baycrest or anywhere else in the community.

    416-785-2500, ext. 2223

    Baycrest Centre for Mental Health

    A multi-component treatment program for people dealing with late-life mental health problems. The service provides psychiatric assessment and treatment for seniors within the community who are experiencing health problems such as depression, anxiety, and changes in memory, behaviour, or personality. Programs are also offered that address caregiver stress

    416-785-2500, ext. 2730

    Alzheimer Society of Toronto First Link

    A referral program designed to help people newly diagnosed with dementia. After referral a social worker will contact the patient directly.

    Contact: George Torys
    Website (with online referral form)

    Seniors Crisis Access Line

    SCAL provides access to local services and supports for seniors in crisis experiencing issues such as mental health and addictions concerns, age-related cognitive problems, memory loss or wandering, self-neglect, elder abuse concerns, and life adjustment problems. They can provide immediate referrals and linkages to community mobile-crisis units, supports for family and caregivers, and translation support for 110 languages. SCAL service covers seniors living between the 401 and Lake Ontario, and Warden to Islington.


    Monday to Friday
    10 a.m. to 9:30 p.m.
    Saturday and Sunday
    10 a.m. to 6 p.m.

    Toronto Dementia Network

    The Toronto Dementia Network is a website with an extensive collection of information about dementia-related services and events in Toronto.


    Behavioural Support for Seniors

    The Behavioural Support for Seniors Program (BSSP) enhances quality of care and life for people struggling with, and demonstrating, difficult behaviours as a result of mental health, dementia, neurological conditions and brain injuries.This program is for seniors, their families and caregivers, who are living at home or in long-term care homes.

    The BSSP is made up of specialized behavioural programs including:

    • community outreach teams,
    • a transitional behavioural unit,
    • long-term care teams,
    • crisis mobile services and
    • an education and training consortium.


    The Access Point

    Coordinated access to mental health, addictions and supportive housing providers within Toronto. Open to anyone 16 years of age or older, with mental health and/or addictions problems that are seriously affecting their lives, and live in or plan to live in the Access Point boundaries, which are Port Union Road to Highway 427, and Steeles Ave. to the lake.



  • Driving Assessment & Transportation Services


    What it does

    Contact Information

    DriveABLE in Toronto (also called Saint Elizabeth Health Care – Driver Assessment and Training Services)

    Following the assessment, the outcome and recommendations will be discussed with the patient and summarized in a clear, concise written report, which is sent to the patient referring physician and, if required, the Ministry of Transportation Driver Improvement Office.

    Address: 100 Tempo Ave, Suite 330, Toronto, M2H 2N8

    Fax: 416-398-3206

    Major Intersection: Victoria Park Ave – Finch Ave Catchment: Toronto Central Cost: $495 (not covered by OHIP)

    St. Joseph’s Health Centre – Elderly Community Health Services

    Provides evidence-based help, identify, assess and support medically at-risk drivers. A geriatrician will assess the patient’s physical ability, cognitive skills, and perceptual cues in relation to driving. On-road/in-vehicle evaluation is not included.

    Address: 30 The Queensway, BMO Financial Group Ambulatory Care Centre, Ground Floor – Glendale Wing, Toronto, M6R 1B5

    Fax: 416-530-6585

    Major Intersection: Roncesvalles Ave – The Queensway Catchment: Toronto Central 

    Toronto Ride

    A partnership of 13 community services that provide door-to-door transportation to seniors 55+. Available from M-F, 8am-5pm. A small fee is charged, based on distance travelled. Subsidies are available.

    Toronto Ride 
    140 Merton Street, Second Floor
    Toronto, ON M4S 1A1 

    Fax: 416-481-2930

  • Resources for Healthcare Providers Caring for Patients with Complex Needs


    What it does

    Contact information

    Solo Practitioners in Need (SPIN)

    SPIN is a direct referral program that allows family physicians to connect complex patients to services available within a network of local Community Health Centres as an extension of their primary care. The service does not affect your roster. You can refer any complex patient in your practice through one referral form and one central intake.

    Services provided include counselling, dietician, diabetes education, foot care, physio, dental care, HIV testing, smoking cessation, asthma education, settlement services, employment services, LTBTTQI services, housing support, legal and income services, ESL programs, sexual health, addiction services and traditional health for the Aboriginal community.

    Participating CHCs include Access Alliance, the Anne Johnston Health Station, Parkdale Community Health Centre, Anishnawbe Health Toronto, Davenport-Perth Neighbourhood and Community Health Centre, Central Toronto Community Health Centres, Planned Parenthood Toronto and the Centre francophone de Toronto.


    Toronto Central CCAC Dedicated Phone Line for Primary Care

    One number access to all community information to:

    • Ask about a patient currently on CCAC caseload
    • Refer patients with chronic and complex needs
    • Connect with your Care Coordinator
    • Find out about all community services


    The Integrated Community Care Team (ICCT), Baycrest

    ICCT provides integrated, inter-professional care for seniors, focusing on existing neighbourhood resources that can improve the quality of care to ensure that primary care providers are supported in caring for their homebound older adult patients with complex needs. There are three streams of service:

    • Shared Care: ICCT shares the primary care with a medically complex patients’ family physician
    • Primary Care: ICCT assumes primary care for homebound people who do not have a family doctor
    • Consultation: ICCT conducts a comprehensive assessment for medically complex patients and provide recommendations to the referring provider.

    Referrals are made by contacting the ICCT secretary.

    Fax: 416-785-2409

    Telemedicine IMPACT Plus (TiP)

    TiP offers one-time inter-professional consultations to complex patients and their family physician to coordinate care planning and derive new solutions for addressing the patient’s chronic conditions. Across the TC LHIN, each TiP consulting team has a core membership (as required) of a:

    • Psychiatrist
    • Internist
    • Pharmacist
    • Social Worker
    • CCAC Coordinator
    • Dietician
    TiP Information and Referral Form

    Community Navigation and Access Program (CNAP_

    CNAP is an alliance of over 30 non-profit Toronto-based agencies working together to provide Toronto seniors with the care they need to reduce isolation and improve their quality of life.

    Social workers can connect seniors and their caregivers to programs and services offered by a non-profit agency in their local community.

    1-877-540-6565 Website

    Resources for Coordinated Care Planning

    For more information call Sarah Doherty, Project Manager for NWTHL
    416-785-2500, ext. 6510

  • Resources for Seniors & Caregivers


    What it does

    Contact Information

    Baycrest Seniors Support Program

    The Seniors Support Program provides support to seniors and family caregivers living in the community by consistently staying in touch with them.

    Through a scheduled weekly telephone call or e-mail, each volunteer will patiently listen to their client, offer encouragement or provide helpful information as required. If individuals need more support a social worker is available.

    These services are free and can usually be offered in the following languages: English, Russian, Hebrew, Yiddish, French, Italian, Spanish, German, Hungarian, Portugeuse and Turkish.

    416-785-2500, ext. 2223

    Alzheimer Society of Toronto

    Information, resources, education, counselling services and support groups

    Fax: 416-322-6566 

    Community Legal Education Ontario (CLEO)

    Financial and legal rights information

    Fax: 416-408-4424

    Advocacy Centre for the Elderly (ACE)

    A community-based legal clinic for low-income seniors.

    Fax: 416-598-7924 

    CARERS Program

    Based in the Reitman Centre at Mt Sinai Hospital, CAREERS is a problem solving technique based program that supports and teaches coping skills to caregivers through group therapy and simulation practice. A concurrent group for the care recipient is also offered.

    416-586-4800, ext. 5192 
    Fax: 416-586-3231 

    St. Clair West Services for Seniors (SCWSS)

    SCWSS provides a variety of support services to older adults and/or adults with disabilities who wish to maintain their quality of life living in their homes. Services include:

    • Adult Day Centre
    • Case Management
    • Community Programs
    • Meals on Wheels
    • Supportive Housing
    • Transportation Services
    • Home Help and Respite Care
    416-787-2114 Website

    Lumacare provides a variety of programs both in the home and the community. Services include:

    • Congregate Dining
    • Assisted Living Services
    • Overnight Respite Program
    • Day Programs
    • Diners Club
    • Care Coordination
    • Home Support
    • Meals on Wheels
    • Transportation
    416-398-5511 Website
    SPRINT Senior Care

    A non-for-profit community support service agency that offers a wide range of low-cost services to seniors and their caregivers. Services include:

    • Counselling and Support
    • Day Programs
    • Caregiver Relief and Support Services
    • Foot Care
    • Home Care
    • House Calls
    • Meals and Nutrition
    • Supportive Housing
    • Transportation
    416-481-6411 Website
    Circle of Care: Senior Home Service

    As part of the Sinai Health System, Circle of Care provides services for seniors and their caregivers which include:

    • Assisted Living
    • Personal Support and Respite Care
    • Meals and Nutrition
    • Transportation
    • Supporting Holocaust Survivors
    • Counselling and Support
    • Supportive Housing
    • Supporting Caregivers
    • End-of-life care
  • Palliative Services


    What it does

    Contact Information

    Temmy Latner Centre for Palliative Care, Mt Sinai Hosptial

    The Temmy Latner Centre for Palliative Care is a Mount Sinai Hospital-based palliative care department that can provide end-of-life care to those dying from a life-threatening illness either in the patient’s home or in hospital.

    416-586-4800, ext. 7884

    Shirley and Philip Granovsky Palliative Care Unit, Baycrest Health Sciences

    The Palliative Care Unit provides 24-hour pain and symptom control combined with emotional and spiritual support to patients with late or end-stage malignant and non-malignant disease in need of palliative care. Long- and short-term palliative stays are available.

    Contact: Intake Social Worker, Baycrest Centre
    416-785-2500, ext. 2256.

    Directory of Palliative Care Services, including home-based, inpatient and hospice-based services.



  • Respite Services


    What it does

    Contact Information

    Community Care Access Centre (CCAC)

    Provides: case management and coordination, Personal Support Workers (PSWs), Home Help, links to Long Term Care short stay facilities, links to all other services.

    Toronto Central CCAC: 
    Fax: 416-506-0374

    Outside of Toronto call 416-310-2222


    Community Navigation Access Program (CNAP)

    Provides links to agencies that provide PSW, care-giving services, group activities, short-term stay, day and night programs, friendly visiting, transportation, home help, etc.


    Respite at the Terraces of Baycrest Retirement Residence

    Generally a 30-day stay (at $110/day) to recuperate from illness and recover from surgery for those who cannot cope at home alone.


    Baycrest Respite Care for Palliative Patients

    Shirley and Philip Granovsky Palliative Care Unit – Respite Stays of up to two weeks. Respite patients receive pain and symptom control in a supportive environment.

    416-785-2500, ext. 2256.

    LumaCare Overnight Respite Program

    This program provides short and long term overnight stays for individuals who require 24-hour support. Costs range from $40-$119 per night.