1. Identified Sub-Groups
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
Patients with 4+ co-morbidities
Identified Sub-Groups
Mental health and addictions
Palliative
Frail elderly
Considerations
Economic characteristics (e.g. low income, unemployment )
Social determinants (e.g. housing, living alone, language)
Clinical judgement
Patient would benefit from integrated coordination
Lives in
catchment area
SSNYR Health Link (Newmarket, Aurora, Georgina, East Gwillimbury, Bradford West Gwillimbury, Alliston, New Tecumseth) or or or
and
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 post-discharge
Has had 5 or more visits to primary care in the past 12 months
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
* All referral sources welcome
DRAFT v2: Oct ‘16

2. 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
x5326
Amanda Hearn
Administrative Assistant
x6327
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
For client/patients requiring predominantly Mental Health/Addiction and Social Health Assistance
Refer to Community Partners in the Health Link Region or Streamlined Access:
Community Services that are eligible for government funding support require a referral from a Community Care Access Centre (CCAC).
For Persons caring for clients/patients requiring predominantly Dementia Care
Refer to Alzheimer’s Society of York Region
Tel: Toll-free:
For a list of Health Service Partners in Ontario go to :
DRAFT v2: Jan 2017