Information for patients 

Information for patients_health links

Enrollment as a Health Links patient: A step-by-step guide

  • Step 1: The patient is identified as a Health Links patient by his or her primary care physician, nurse practitioner, community health care provider, a hospital, the community health centre or by themselves or their primary caregiver.

  • Step 2: The patient is enrolled in a Health Link close to their home by their primary care provider.

  • Step 3: A coordinator is assigned to the Health Links patient (through the Local Health Integration Network or community resource).   

  • Step 4: A home visit is completed by the Care Coordinator to understand the patient’s needs and begin discussing his/her individual goals.

  • Step 5: A case conference is held with the patient and caregiver, Care Coordinator and health care providers to determine a plan to best respond to the complex care needs of the patient in a coordinated way.

  • Step 6: A coordinated care plan is developed.  A coordinated care plan is a regularly updated action plan that contains important patient information, care providers who the patient sees and the patient’s plan of care with clear goals that are set by the patient and supported by the care team.

  • Step 7: The patient is linked to the right services and supports, such as community, primary care and/or mental health supports. 

  • Step 8: Once the patient and the team agrees that the patient's  goals are met and they are able to self-manage their care and their symptoms, the patient may be transitioned to other less intensive services with continued use of the established coordinated care plan. If the need arises, the patient can initiate more active engagement with the Health Link in order to increase the intensity of support provided during more challenging times in his/her journey.