About Coordinated Care Management - Health Links Model of Care

The Health Links Model of Care is a key commitment of the Ministry of Health and Ministry of Long-Term Care (ministry) and is based on ‘coordinated care management.’ 

The ministry is moving forward with standardizing Coordinated Care Management - Health Links and supporting its scale and spread to a mature state by March 31, 2020. This transitions from identifying ‘Health Links’ as a programmatic approach to the focus on integrating coordinated care management into the delivery of programs and services.  

Provincial Vision: An approach to integrating care for patients living with complex conditions that optimizes sustainable and person-centred care, and serves as a model for sub-regions.

What is Coordinated Care Management - Health Links Model of Care?

Coordinated Care Management - Health Links Model of Care supports individuals living with complex chronic conditions and/or complex needs  to reach personal goals by addressing health and social needs through coordinated care management.

The Model of Care brings health and social service providers together to work collaboratively to seamlessly coordinate care with patients and their families.

Multiple providers, appointments and complex health issues can make it difficult to meet patient needs. A more effective approach to providing care and sharing information can be achieved through formalized coordinated care management.

Key goals:

  • Improve coordinated care management for individuals living with complex chronic conditions  and/or complex needs
  • Broaden the application of the coordinated care management to a wider population cohort that are aligned with sub-region activities
  • Embed coordinated care management as part of the daily work in a more diverse group of service providers
  • Improve real time identification of patients who would benefit from coordinated care management
  • Develop strategies to identify risk factors that would indicate future need of coordinated care management to support early mitigation as a prevention method 
  • Organizations collaborate to develop care plans (on HQO CCP template) that reflect patients’ goals, level of acuity, and need
  • Integrate coordinated care management into organization’s programs, processes, and pathways 
  • Enhance the ability to monitor and report on the impact that Health Links has on patient experience, quality and cost.

Who would benefit from the Health Links Model of Care?

Patients with complex needs and/or multiple chronic conditions would benefit most from this Model of Care.

  • Patients whose high care needs are best supported by a team approach
  • Patients who need coordinated care management support from multiple community, health and social service providers

Additional Information

Health Links in the Hamilton Niagara Haldimand Brant - Carl's Story

 

*In memory of Carl - thank you for sharing your story.