Health Links

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Health Links: Improving integrated care for patients with multiple chronic conditions and complex needs.

The North York Central Health Link provides a collaborative, integrated, person-centred approach that focuses on enhancing and coordinating the care of individuals living with multiple chronic conditions and/or complex needs. Care coordinators arrange case conferences with patients and their care team and record the care plan based on patients' goals. The aim of the Health Links approach to care is to create seamless care coordination for this patient population and ensure greater equity for all individuals, so that people with chronic and/or complex care needs are able to reach their highest level of health – or full health potential.

Health Links model

Patient Identification and Referrals

Physicians, hospitals, home and community care, community support services and mental health and addiction agencies are able to identify and/or refer patients to Health Links. 

Referral criteria and process 

1. Would your patient benefit from intense care coordination and meet one of the following characteristics?
 
Health Links referral criteria
 
2. Does you patient live in the Central LHIN?  Map of Central LHIN

Postal code tool:> input patient postal code at bottom of the page and it will indicate which LHIN the patient resides in.

If yes to question 1, and they live in the Central LHIN, please send a referral to Home and Community Care at the Central Local Health Integration Network:

  • Go to the Physicians section of the Home and Community Care website of the Central LHIN (http://healthcareathome.ca/central/en) and click the link Intake and Linking Referral Form, or
  • In hospital, use RM&R (Resource Matching and Referral); check Health Links for reason for referral — see image on right.
If your patient does not live in the Central LHIN, you can contact healthlinks@nygh.on.ca and indicate where your patient resides to receive additional information on how to connect your patient to the appropriate Health Link.

Resources and updates

Additional resources
Health Links patient brochure

How to access my patient's Coordinated Care Plan (CCP)?

CCPs are managed by the care coordinator. The care coordinator will share the care plan with the care team and patient via fax or mail. Should you want a copy, please reach out to your patient's care coordinator.

Billing codes for common Health Links patients

Coordinated Care Plan

Updates: Quarterly newsletter

Contact us

Do you have questions about the North York Central Health Link?
Contact Tory Merritt, Manager, North York Central Health Link

Tel: 416-756-6000 ext. 4182
Email: healthlinks@nygh.on.ca