Integrated, patient-centred care

When care providers work together as a team for seamless patient transitions, information sharing and care coordinating, the patient can receive better care, and the system can operate more efficiently.

Patients with the greatest health care needs make up 5% of Ontario’s population, but use approximately 65% of provincial health care costs.

These are most often patients with multiple, complex conditions who rely on a substantial number of providers for support – perhaps a family doctor, a specialist such as a cardiologist or respirologist, hospital/emergency department visits, home care services, and other health or social services.

Health Links Approach to Care

The provincial Health Links website identifies that 75% of seniors with complex needs discharged from hospital receive care from six or more physicians, and 30% get their drugs from three or more pharmacies, which contributes to lower quality care that costs the health care system more.

The Health Links approach to care is meant to help patients with complex health care needs to improve their experience and outcomes.

The patient's primary care provider, specialists, home care supports, and other community partners – as well as the patient and caregivers – work with a Health Links Care Coordinator. Together, they develop one Coordinated Care Plan (CCP) to focus on what is important to that patient.

This approach to care of benefits the entire health care system by delivering:

  • Appropriate care and care settings – complex patients get the care they need.
  • Increased patient satisfaction through better coordinated care.
  • More efficient use of resources - fewer repeated tests.
  • Shorter wait times with more appropriate use of the hospital emergency room (ER) – people in the ER who actually require emergency medical attention get it faster, because complex patients receive the care they require, at the right time and in the right place.
  • Fewer readmissions to hospital – complex patients receive appropriate follow-up care in the community, so they aren't coming back to the hospital due to gaps in their care plan.

Improving Patient Experience

Patients benefit in the following ways:

  • Have an individualized, coordinated plan.
  • Smoother transitions when you visit different providers, and not have to re-tell your health care story.
  • Support to help you navigate the health care system.
  • Receive integrated, high quality care.
  • Through the patient consent process, health information is kept confidential and only shared with providers in the patient’s “circle of care”.

Improving Provider Experience

By collaborating in the Health Links Coordinated Care Plans, provider benefits include:

  • A Health Links Care Coordinator is a direct support to the patient and his/her providers.
  • This Care Coordinator brings the full care team together – including providers from across the spectrum of care, to develop a care plan based on the person's unique needs and goals.
  • The Coordinated Care Plan enables consistent understanding of the patient’s conditions and needs, and enhances cross-sector coordination/communication.
  • Through coordinated, intensive case management, patients and providers can realize better outcomes – including avoiding unnecessary utilization (e.g. primary care, walk-in clinic and emergency department visits and hospital admissions).
  • To enroll, contact

Targeted Population

Identifying patients who may benefit from a Health Links CCP approach to care includes consideration of criteria such as

Target Population People living with 4 or more complex or chronic conditions
Care Needs May Include Those with mental health addiction  Palliative population  People who are frail 
Other Considerations
  • Economic characteristics (e.g. low income, unemployment)
  • Social determinants (e.g. challenges with housing, social isolation, language)
  • High users of Hospital Emergency Departments and/or Primary Care visits
  • Clinical judgment
  • Note: this criteria is comprehensive, but not limited.

Referring Patients

Anyone – primary care physicians, nurse practitioner, community service agency, a caregiver or friend, or the patient – can initiate a request for assessment for a Health Links Coordinated Care Plan. Patients can be residing anywhere: at home, in assisted living, retirement home or long-term care home, or be in hospital.

To initiate a request:

  1. Fax your completed referral form to 416-222-6517 or 905-952-2404 
  2. Telephone Information and Referral for Home and Community Care Support Services Central at 1-888-470-2222 (8:30 am-8:30 pm)

Health Care Providers are invited to contact to register your patients, and gain secure access to the Coordinated Care Plan in the Health Partner Gateway.

Additional Information