What is Health Links?
Five per cent of patients account for two-thirds of health care costs. These are most often patients with multiple, complex conditions. When the hospital, the family doctor, the long-term care home, community organizations and others work as a team, the individual receives better, more coordinated care.
Working together, providers design individualized Care Plans with individuals living with multiple chronic conditions and their families to ensure they are supported to reach their goals and receive the care they need. For this person it means:
- Care being focused on the individual’s goals
- Providers having a consistent understanding of their patient’s conditions
- Easier navigation of health care services
- Feeling more supported in their health care journey, having fewer visits to hospitals, and focusing on improved quality of life.
Ontario’s experience with implementing the Health Links approach has demonstrated many aspects about how to better organize services and providers around the needs of these individuals that are living with multiple chronic conditions and/or complex needs.
Health Links Approach to Care
The Coordinated Care Plan will help the providers supporting these individuals to better manage their health and well-being.
The Health Links approach to coordinated care planning promotes a shared understanding of what is most important to the patient through the establishment of a Coordinated Care Plan, inclusive of clear roles and responsibilities for each member of the patient’s Care Team.
Coordinated care planning is meant to support a patient’s overall wellness. It considers the “whole person” needs – mentally, physically, emotionally and spiritually. Think about cultural or community support people that patients would want included on their Care Team to support this “whole person” approach (e.g. spiritual support, traditional healer, naturopath, neighbour, friends, etc).
- 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, as well as the utilization of other services that reduce continuity of care such as, walk-in clinics
The patients’ journey through the health care system will be improved through more effective communication with their Health Care Providers and more involvement in decision making.
By having a Coordinated Care Plan, patients with complex health care needs will benefit by not having to continuously repeat their health story or answer the same questions every time they require care.
MICs Health Link is being led by numerous partners:
- Cochrane Family Health Team
- District of Cochrane Social Services Administration Board, Housing and Paramedic Programs
- Ininew Friendship Centre
- Iroquois Falls Family Health Team
- MICs Group of Health Services
- Minto Counselling Centre
- Misiway Milopemahtesewin Community Health Centre
- North East LHIN Home and Community Care
- Red Cross
- South Cochrane Addiction Services
- Wahgoshig First Nation