Health Links: Improving integrated care for patients with multiple chronic conditions and complex needs.
The North York Central Health Link provides a collaborative, integrated, person-centred approach that focuses on enhancing and coordinating the care of individuals living with multiple chronic conditions and/or complex needs. Care coordinators arrange case conferences with patients and their care team and record the care plan based on patients' goals. The aim of the Health Links approach to care is to create seamless care coordination for this patient population and ensure greater equity for all individuals, so that people with chronic and/or complex care needs are able to reach their highest level of health – or full health potential.
Patient Identification and Referrals
Referral criteria and process
1. Would your patient benefit from intense care coordination and meet one of the following characteristics?
Postal code tool:> input patient postal code at bottom of the page and it will indicate which LHIN the patient resides in.
If yes to question 1, and they live in the Central LHIN, please send a referral to Home and Community Care at the Central Local Health Integration Network:
- Go to the Physicians section of the Home and Community Care website of the Central LHIN (http://healthcareathome.ca/central/en) and click the link Intake and Linking Referral Form, or
- In hospital, use RM&R (Resource Matching and Referral); check Health Links for reason for referral — see image on right.