Health Links – a New Health Care Initiative Underway

What are 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 patient receives better, more coordinated care. Providers will design a care plan for each patient and work together with patients and their families to ensure they receive the care they need. For the patient it means they will:

  • Have an individualized, coordinated plan
  • Have care providers who ensure the plan is being followed
  • Have support to ensure they are taking the right medications
  • Have a care provider they can call who knows them, is familiar with their situation and can help.

14 NE LHIN Health Links in Various Stages (as of summer 2016)

  • Timmins Health Link (Timmins Family Health Team is lead agency), has been active since 2013 and has developed care coordination plans for more than 60 patients.  
  • Temiskaming Health Link (Blanche River Health Partners is lead agency), has been active since 2013 and has created more than 50 care coordination plans for patients.
  • North Cochrane Health Link (Centre de sante communautaire du Kapuskasing and Nord-Aski Family Health Team are co-lead agencies) has begun to pilot patients through their coordinated care planning process and includes the communities of Hearst, Kapuskasing, Smooth Rock Falls and Iroquois Falls.
  • Sault Ste Marie Health Link (Group Health Centre is lead) has begun to pilot patients through their coordinated care planning process.  
  • Nipissing-East Parry Sound Health Link (West Nipissing General Hospital is lead) includes West Nipissing, Mattawa, North Bay, and Powassan, with a number of smaller communities in the East Parry Sound area. It has begun to pilot patients through their coordinated care planning process.
  • Greater Sudbury Health Link (CMHA Sudbury-Manitoulin is lead) has begun to pilot patients through their coordinated care planning process. The Greater Sudbury Health Link will have a large focus on patients with mental health and addictions conditions, as well as patients with a dual diagnosis.
  • New Health Links for 2016-17 under development/to be developed:
    • East Algoma Health Link 
    • Parry Sound Health Link 
    • Espanola/Sudbury West Health Link
    • Algoma North Health Link
    • Manitoulin Island Health Link 
    • Cochrane/MICs Group Health Link
    • James and Hudson Bay Coasts Health Link
    • Chapleau Health Link

Health Links Emerging Best Practices

  • In the Timmins Health Link, “Patient Discovery Interviews” are being created to better serve the needs of those accessing care.
  • In the Temiskaming Health Link, work has begun on implementing Collaborative Governance with the aim of bringing together the Board of Directors of the participating partner agencies to work on the Health Link level.
  • In the Sault Ste. Marie Health Link, work has begun using a Guided Care Nurse model, to ensure patients have one person to contact with questions at any time.

Background on Health Links

Resources for Establishing a Health Link in NE LHIN

Health Links & Health Quality Ontario

Health Quality Ontario (HQO) allows Health Link programs to succeed by offering expert leadership and the tools to help Health Link communities identify, address, and deliver key services to individuals with complex chronic illnesses.

HQO lends support to Health Links by providing evidence-informed change ideas, assisting in patient engagement and helps to build sustainable capacities for change and improvement.

  • Click here to access more information on HQO’s Improvement Packages
  • Click here to access more information on HQO’s Quality Improvement Framework
  • Click here to visit HQO’s Health Link page for more information.