Scarborough Partnership Delivers Provincial-First Solution to Fragmented Palliative Care  

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June 18, 2025

Reprinted with permission from SHN.

Scarborough Health Network (SHN) and Scarborough Centre for Healthy Communities (SCHC), along with their partners in Scarborough Palliative Care (SPC), have developed a unique, innovative solution to delivering more integrated services for the hundreds of patients across the community who receive palliative care. By connecting the SPC partners through SHN’s Epic clinical information system for documentation and managing digital health records, the organizations are now able to make more expedited referrals, communicate more collaboratively, and care for and transfer patients between each other more seamlessly.  

Sharing one health record helps to avoid preventable Emergency Department visits, support patients to die in their location of preference, and improve the overall patient/family experience. In fact, this marks the first time in Ontario that a hospital network has fully integrated a community organization into its Epic system to improve the delivery of palliative care. 

“This is a great example of how we can use digital solutions to improve patient care and what’s possible in local health system integration,” said Michele James, Executive Vice President, People and Transformation, SHN. “I am so proud of the collaborative effort put forward by all our partners, which truly benefits our patients and families who need palliative care services in Scarborough.” 

Connecting the dots for better patient care  

SHN, SCHC, and their partners Yee Hong Peter K. Kwok Hospice, Scarborough Academic Family Health Team, Ontario Health at Home, and Shepherd Village – who are all affiliated with the Scarborough Ontario Health Team (SOHT) – have a long history of working together to provide palliative care services in the Scarborough area. This reflects the nature of a palliative diagnosis, which often necessitates the patient moving between different care settings and resources provided by different organizations.  

However, because the partners worked from different IT systems and processes that did not ‘talk’ to one another, transferring patients between organizations often meant added delays and redundancies in their healthcare journey. For example, patients may have been required to provide all their information repeated times, which could lead to missed information or inaccuracies.  

“As partner organizations, we wanted to be more in sync to better support these transitions, which was the drive behind launching SPC. Our aim was to address the fragmentation of patient records that can disrupt continuity of care and find a new way to offer the best possible healthcare experience. Our solution was to come together within the same health information system to enable more cohesive palliative services,” said Sari Greenwood, Director, Mental Health & Addictions, Oncology & Palliative Care.  

Through SPC, each partner has been connected to SHN’s Epic clinical information system. This allows them to view and work from the same record, no matter what services patients are receiving. This kind of collaboration helps reduce preventable Emergency Department visits, supports patients to die in their location of preference, and improves the overall experience for patients and their families. 

Going a step further to be the province’s first  

In addition to bringing all six organizations together to view records, there was also the opportunity for a full integration between SHN and SCHC within Epic. SHN’s Rowntree Palliative Care Centre has a particularly close, interconnected relationship with SCHC which includes a number of joint initiatives, sharing physicians across both organizations, and providing complementary services that see a lot of the same patients. This tight connection opened the possibility of exploring uncharted territory – which truly captures SPC’s pioneering vision. 

“I’m incredibly proud of my team’s role and the collaborative spirit displayed by all our partners,” remarked Jeanie Argiropoulos, CEO of SCHC. “This initiative is not just about improving patient care today; it’s about creating a blueprint for the future of healthcare that other regions and sectors can look to as an example. We are setting a new standard for collaboration and care delivery by coming together to improve how we share patient information. We hope that this can serve as an inspiration for others to embrace technology and connectivity to serve patients better.” 

“By coming together to improve the way we share patient information, we are setting a new standard for collaboration and care delivery. Our hope is that this can serve as an inspiration for others to embrace technology and connectivity to better serve patients.” 

After the feasibility assessment came months of highly-technical programming work by the SHN team, and followed by many hours of training by SCHC staff. The result is a first for Ontario – a community partner organization plugged directly into a health network’s Epic clinical information system.  

“SCHC is now able to see health records for patients receiving palliative services during a stay in an SHN hospital – and conversely, when a patient arrives to the hospital, the team there has instant access to everything that has happened in the community,” said Dr. Raymond Berry, SHN Division Head for Palliative Care. “This means we are providing coordinated care that removes the problems inherent in having disparate systems that don’t ‘talk’ to each other.” 

A game-changer for patient information sharing

One of the benefits of the new solution is that it allows for better data collection and analysis, which can help identify gaps, trends, and opportunities for improvement in palliative care. For example, the partners can track how long it takes for patients to receive palliative care services after a referral, how often patients are transferred between settings, and more. The partners can then use this data to inform their planning, decision-making, and quality improvement initiatives. 

The integration also supports the use of mobile tools, like tablets and smartphones, enabling healthcare providers to bring health records with them to patients who need to receive treatment in their homes. The providers can then make updates right there on-the-spot instead of taking notes that must be transcribed into the system later. 

The feedback from these cross-organization care interactions has been very positive, with a clear sense that use over time will open up further enhancements – as SPC and palliative services in Scarborough continue to lead and innovate.   

Accessing care

Patients may be referred by a primary care provider to palliative care services in Scarborough through the SPC Common Referral Form. For patients who want to learn more, the SPC partners are here to have a conversation. Please call 437-290-8063 for general inquiries or help with initiating a referral.