Information for Primary Care providersInformation for Primary Care providers_Health Links


The following information applies to primary care providers in Central LHIN who refer to:

  • North York General Hospital (Lead of the North York Central Health Link)  
  • Southlake Regional Health Centre (Lead of the South Simcoe and Northern York Region Health Link)
  • Mackenzie Health  (Lead of the South West York Region Health Link)
  • Black Creek Community Health Centre (Lead of the North York West Health Link)
  • Markham Stouffville Hospital (Lead of the South East York Region Health Link)


How can Health Links benefit me and my patients?

The Care Coordinator will be a direct support to both the patient and his/her providers. This coordinated, intensive case management approach can lead to better outcomes for patients and their providers including avoiding unnecessary hospital admissions and emergency department visits. Health Links provides the structure for teamwork among physicians, nurse practitioners, hospital, community health centre and community health professionals. Central LHIN Health Links patients, identified by specific criteria, are assigned a Care Coordinator who will set up a case conference with you, the patient and his/her care team, and document a Coordinated Care Plan.

How are patients identified for Health Links?

Health Links patients are being identified through a variety of sources, including being identified through an assessment at hospital admission or through a physician who feels that Health Links will benefit their patient. Health Links is using factors such as co-morbidities and previous admissions as initial criteria. Health Links patients can also be referred in by primary care physicians, nurse practitioners or Community Care Providers (EMS, CMHA, LOFT, CHATS).  For information on how to refer, please contact the Health Link in your area.


The common process in identifying Health Links population includes a combination of the following criteria:

  • Patients with four or more chronic/high-needs cost conditions, including a focus on mental health and addictions conditions, palliative patients, and the frail elderly.
  • Economic characteristics (low income, median household income, government transfers as a proportion of income, unemployment).
  • Social determinants (housing, living alone, language, immigration, community and social services, etc.).
  • The target population focuses on adaptation of care planning for vulnerable populations (mental health and addictions, frail/elderly and palliative). 

These criteria are meant to be comprehensive and not limited in scope. If you have a patient that may benefit from intense care coordination, but is not identified by these factors, please contact the Health Link in your area.

How will I find out if my patient is identified as a Health Links patient?

You will receive a faxed letter from the patient’s Care Coordinator that will indicate your patient has been identified for Health Links. 

What should I do if a Care Coordinator reaches out to me?

If contacted by a Care Coordinator, please respond as quickly as possible so that you can assist your patient in receiving the best possible health care to meet his or her complex needs – the success of this initiative depends on the ongoing commitment and cooperation of the entire continuum of care. Your Care Coordinator will be requesting items such as a Cumulative Patient Profile to assist in the creation of a coordinated care plan for your patient.

How can I access my patient’s Coordinated Care Plan?

You will receive a copy of the Coordinated Care Plan from the Care Coordinator that is shared through secure messaging.

Who can I contact if I have a patients I would like to identify for Health Links?

Questions about:

Health Link



South Simcoe & Northern York Region

Ana MacPherson, Clinical Coordinator

905-895-4521 ext. 5326  or

North York Central

Tory Merritt, Manager

416-756-6000 ext. 4182 or

Western York Region

Judy Smith, Interim Lead

905-883-1212 ext. 3882 or

North York West

Heather Buckmire, Project Manager

416-249-8000 or

Eastern York Region

Munira Thayani, Nurse Navigator

905-472-7878 ext. 1886 or

Central Health Integration Network

Charlene Brown, Director

905-895-1334 ext. 7195 or

What billing codes can be used for common Health Links activities?