North Renfrew County Health Links
What is the Health Links approach?
Health Links is an approach to care coordination for people requiring support from multiple health and social service providers.
The Health Links approach is not for everybody. At present, the target population focuses on people living with four or more complex or chronic conditions. Identified sub-groups include:
- Those with mental health and addictions challenges
- Palliative population
- People who are frail
Other considerations include:
- Economic characteristics (low income, unemployment etc.)
- Social determinants (challenges with housing, social isolation, etc.)
- High users of health services (such as emergency departments or primary care visits)
- Clinical judgment
This patient-centred approach ensures that a person has a coordinated care plan that focuses on their goals, and a designated care coordinator within their care team.
Today, the Health Links approach focuses on a few. In time, the approach will benefit many more patients, caregivers and providers.
Who is involved?
The Health Links approach is a good example of how Ontario is working to bring together providers and health organizations to work as a team with patients and their families.
When the family doctor or nurse practitioner, community organizations, specialists, the hospital, the long-term care home and others works as a team, patients with multiple, complex conditions receive better, more coordinated care. Working together, providers design individualized Care Plans with patients and their families to ensure they are supported to reach their goals and receive the care they need.
What does the Health Links approach aim to achieve?
The goal of the Health Links approach to care is to create seamless care coordination for patients with complex needs, by ensuring each patient has a Coordinated Care Plan (CCP) and ongoing care coordination.
The Health Links approach to care encourages health and social service providers to work together more closely in order to coordinate care with patients and their families.
What are the benefits to patients?
The Health Links approach to care provides many benefits for patients living with complex chronic conditions including:
- Care being focused on the patient's goals.
- Providers having a consistent understanding of their patients' conditions.
- Easier navigation of health care services.
- Patients feeling more supported in their health care journey, having fewer visits to hospitals, and focusing on improved quality of life.
What are the benefits for providers?
Benefits for providers include:
- Greater support for care coordination for patients that providers worry about the most.
- Having a designated lead care coordinator within the patient's care team to help organize various health care services and supports.
- Health Links aims to reduce avoidable office and ED visits.
- More effective use of services.
What can friends and family of patients expect?
The Health Links approach to coordinated care planning would help to ensure your family member/friend is getting the personalized, coordinated care they need in the right place, at the right time.
- You and your family member/friend, health and social service providers, and other supports are part of the full care team and will be included in the care coordination process.
- Coordinated care planning will ensure you have the support you need to help your family member/friend with their care needs.
- Sharing the care plan will reduce the need to repeat information to different providers.