What is Health Link?

Health Link is a new model of care that focuses on providing intensive care coordination for those patients who need it the most. It is intended to target the top 5% of the most complex patients in the province of Ontario.

Who is a typical Health Link patient?

A Health Link patient could be someone who is experiencing mental health and/or complex medical issues such as congestive heart failure, chronic obstructive pulmonary disease or diabetes. Along with their complex medical history, these patients frequently have a complex social history and may have limited family or caregiver supports to assist with coordinating their needs.

Sometimes Health Link patients may frequent the Emergency Department or may be utilizing multiple community resources. Often these patients have had lengthy in-patient hospital stays, and may be receiving homecare services as well.

Health Link patients may show up in their family physician’s office repeatedly or their family physician may be receiving many calls from other providers regarding complexities around their care.

Why refer someone to the Oakville Health Link?

The primary care provider may have done all the “right” things to address the patient’s medical and social needs, but the patient is still not “under control” and the patient is struggling to cope. By referring a patient to Health Link, the patient and primary care provider will benefit from intensive care coordination in the community that may help the patient access and use the services available to them.

When a patient is enrolled with Health Link, the assigned Health Link care coordinator will work with the primary care provider, the patient, the caregivers and others within the circle of care to develop an individualized coordinated care plan that outlines steps towards achieving the patient’s health goals.

What are the key benefits to my patients being enrolled in Health Link?

  • More intensive personalized care coordinated by a Health Link care coordinator
  • A personalized care plan developed with the patient, the primary care provider, the Health Link care coordinator and others within the circle of care
  • Ongoing support and monitoring by the patient’s care team to review and discuss the personalized care plan
  • An improved journey through the health care system due to more effective communication among the patient’s health care providers and more involvement in decision making
  • Supports to ensure that they are taking the right medications