Putting Patients with Complex Needs at the Centre of their Care

Coordinating all the services and supports that a person with multiple health conditions requires. That’s the idea behind the Health Links approach.

The primary care provider, home and community care organizations, specialists and other community partners – as well as the patient and caregivers – work with an identified Health Links care coordinator. Together, they develop one coordinated care plan that focuses on the patient’s goals and what is important to them.

The goal is to improve the quality of care and the health care experience for those who use the health system the most. And the Health Links approach will reduce unnecessary hospital admissions and emergency department visits.

Learn more by watching this video.

Meet Jack

Jack and Debi Beriault

Jack and Debi Beriault

"Health Links is a great model. It is very personal. They really understand what you are going through.” Jack Beriault, client. 

What does this model of care mean for Health Links clients? Read Jack’s story 

Who is eligible?

Target population

People living with four or more complex or chronic conditions

Identified sub-groups

People who are

  • Facing mental health and addictions challenges
  • Palliative
  • Frail

Important considerations

  • Frequent users of health services (e.g. emergency departments, hospital admissions)
  • Economic characteristics (e.g. low income, unemployment)
  • Social determinants (e.g. challenges with housing, social isolation, language)
  • Judgment of clinicians working with patients

Benefits

Patients and families

Primary care providers

  • Care is focused on each patient’s goals and an improved quality of life
  • Patients feel more supported in their health care journey, and are full partners in their own care
  • Fewer visits to hospitals and clinic visits
  • Their providers have a consistent understanding of their conditions and living circumstances affecting their ability to manage their health conditions

 

  • Greater support for care coordination for patients that providers worry about the most
  • A designated lead care coordinator within the patient’s care team to help organize various health care services and supports
  • Reduction in avoidable office and emergency department visits, and in the use of other services that reduce continuity of care, such as walk-in clinics
  • Ability to increase your effectiveness and reach through your practice

Collaborating care team providers

 

Health care system 
  • Broader perspective and understanding about what the patient is experiencing
  • Understanding of roles and responsibilities of each member of the care team, which leads to enhanced knowledge about what each provider is doing to support patient goals
  • Opportunity to work in a team with a range of health and social service providers
  • Potential for partners to become specialized in their roles

 

  • Greater alignment across the LHIN and province with standard processes, tools and communication materials that are recognized and followed by providers to support seamless patient care
  • Stronger linkages with primary care providers for patients with most complex care needs
  • More efficient use of health care resources by reducing unnecessary hospital admissions and emergency department visits

Moving Forward in Champlain

Integrating the Health Links approach to care is a strategic priority of the Champlain LHIN’s Integrated Health Service Plan 2016-19.  

We want the Health Link approach to be the standard of practice – the "new normal" - for patients with the most complex needs.

For general information on the Champlain LHIN's regional approach to Health Links, please contact Karen Patzer, LHIN Senior Integration Specialist (karen.patzer@lhins.on.ca).


How to Access Health Links New!

Anyone – a family doctor, care provider, friend, family, caregiver or even a patient - can identify someone who fits the Health Link criteria.

Health Care Providers

Patients and Families

  • Talk to your family doctor, nurse practitioner or other health care provider to see if the Health Links approach is right for you or your loved one. You can also contact the Health Links manager in your area.

More Information

  • For additional background documents on Health Links, visit the Ministry's website.