Patient Resources



Frequently Asked Questions: Patients and Families


1. What is the Health Links approach?

The Health Links coordinated approach to care provides benefits to patients living with four or more complex chronic conditions.

The Health Links approach to Coordinated Care Planning is about bringing health and social service providers together, as well as other supports you may have or need, to better understand your needs, help you define your goals and support you in a more coordinated way.

Through development of a Coordinated Care Plan, you and your Care Team will be able to better manage your health and well-being. Your Care Team will work with you and your family to identify and help you meet your goals; ensuring that your providers have a consistent understanding of your conditions, and support you to navigate through the health care system. You will feel more supported in your health care journey, have fewer visits to hospitals, and be able to focus on improved quality of life.

The Coordinated Care Plan will support your overall wellness; considering all of your needs – mental, physical, emotional, and spiritual.

Once your Coordinated Care Plan is developed, you will walk closely with your Care Team to identify supports that will help you navigate through the system.

2. What is Coordinated Care Planning?

The Health Links approach to Coordinated Care Planning promotes a shared understanding of what is most important to you through the establishment of a Coordinated Care Plan. Further, it will help clarify roles and responsibilities for each member within your Care Team.

Coordinated care planning allows for a more collaborative and streamlined approach as you transition from one provider to another, allowing you to live well in your community and reduce avoidable healthcare utilization.

3. What are the benefits of the Health Links approach to care for you?

  • Care being focused on your goals
  • Providers having a consistent understanding of your conditions and goals
  • Easier navigation of health care services
  • More coordinated support in your health care journey, having fewer visits to hospitals, and focusing on improved quality of life

4. Who can initiate Coordinated Care Planning?

Anyone – a provider, friend, caregiver, or you. The Coordinated Care Planning process can be initiated at home (including Long Term Care, Retirement Home, Assisted Living, etc.) or in hospital. The Coordinated Care Plan can help support transitions from home to hospital and from hospital to home.

5. Who should be involved in Coordinated Care Planning?

You help to decide; the Coordinated Care Planning Team (Care Team) is a group of professional and non-professional care providers, including you and your caregiver; committed to working better together to support you in achieving your goals. A Care Team will include any individual, program, or organization that you consent to contributing to, and being involved in your Coordinated Care Plan.

Care Team members could include the following:

  • Family, caregivers, and other supports
  • Community and hospital based Health Professionals including:
    • Family Physician/Nurse Practitioner and Specialists
    • Other Health Professional such as:
      • Nurse
      • Social worker
      • Dietitian
      • Physiotherapist
      • Care coordinator/navigator
      • Care Coordinator from Home and Community Care at the North West LHIN
      • Community Pharmacist
      • Someone from Mental Health and Addiction Services (e.g. Counsellor)
      • Someone from Community Support Services (e.g. Homemaker Coordinator)
  • Someone from Social Services (e.g. Ontario Works)
  • Cultural/Community Supports (e.g. Traditional Healer, Translator)
  • Other Community Partners (e.g. French Mental Health & Addiction System Navigator, Spiritual Support)

6. Who decides if Coordinated Care Planning will proceed? You decide.

While anyone from the list above may be asked to participate in the Coordinated Care Planning process, not all need to be involved for the process to proceed. As long as there are two or more providers, and you feel that the process would be valuable, Coordinated Care Planning may proceed.

A copy of the Coordinated Care Plan will be shared with everyone who has been invited to participate in the Coordinated Care Planning process, as determined with the patient.

7. How is a patient’s information protected?

When the Coordinated Care Planning team includes the patient, family, and providers within the “circle of care,” information and discussion occurs as with any other cross-sector collaboration/communication between providers. A patient consent process is leveraged when the care team includes people/organizations that would not be considered within this circle (e.g. Municipal Housing).