Transcript Patient Identification for Health Links in the Central LHIN What is

Client/ Patient Identification for
Health Links in the Central LHIN
What is Health Links?
Health Links is an integrated model of care that brings a team of care providers
together in partnership with patients with complex needs, to provide coordinated,
efficient and effective care.
Purpose of the Guide? To assist clinicians to identify eligible patients using the new
Health Links target population definition and be invited to participate in the program.
Does your Client/ Patient meet one or more of the following characteristics?
Target population
or
Identified Sub-Groups
or
or
and

Patients with 4+ co-morbidities

Mental health
and addictions

Economic characteristics (e.g. low income,
unemployment )
Social determinants (e.g. housing, living alone,
language)

Palliative

Frail elderly
Considerations

Clinical judgement

Patient would benefit from integrated coordination

SSNYR Health Link (Newmarket, Aurora, Georgina,
East Gwillimbury, Bradford West Gwillimbury, Alliston,
New Tecumseth)
Lives in
catchment area
Still uncertain if your client/patient would be appropriate for Health Links? Consider:
if your client/patient . . .
• Has had 2 or more ED visits in the past
six months
• Has had 2 or more hospital admissions
in the past six months
• Is at high risk of readmission postdischarge
• Has had 5 or more visits to primary
care in the past 12 months
* All referral sources welcome
•
•
•
•
•
Is socially isolated
Lacks adequate care-giver support
Has multiple health care providers
Is a high user of health care services
Is a frequent user of community
services
• Has multiple medications (7 plus)
• Lacks primary care, secondary care
DRAFT v2: Oct ‘16
Identifying Patients for a Health Link
in the South Simcoe Northern York
Regional Health Link
South Simcoe and Northern York
Region Health Link
Ana MacPherson
Clinical Coordinator
905.895.4521 x5326
[email protected]
Amanda Hearn
Administrative Assistant
905-895-4521 x6327
[email protected]
South Simcoe and Northern York
Region - Health Link
Referral Process
For clients/patients requiring
predominantly Medical
Assistance
Refer to RM&R (in hospital) or CCAC referral form
http://healthcareathome.ca/central/en/partner/Doc
uments/Intake%20and%20Linking%20Referral%20Fo
rm%20Central%20CCAC.pdf
For client/patients requiring
predominantly Mental
Health/Addiction and Social
Health Assistance
Refer to Community Partners in the Health Link
Region
For Persons caring for
clients/patients requiring
predominantly Dementia Care
Refer to Alzheimer’s Society of York
Region
Community Services that are eligible for government
funding support require a referral from a Community
Care Access Centre (CCAC).
For a list of Health Service Partners in Ontario go to :
https://www.ontario.ca/locations/health/
DRAFT v1: Nov 16