Integrated Care for Patients with Complex Health Conditions

Coordinating all the services and supports that a person with multiple health conditions requires. That’s the idea behind the Health Links approach.

The patient's primary care provider, home and community care organizations, specialists and other community partners – as well as the patient and caregivers – work with a care coordinator. Together, they develop one coordinated care plan that focuses on the patient’s goals and what is important to them.

The goal is to improve the quality of care and the health care experience for those who use the health system the most - and the Integrated Coordinated Care Management approach reduces unnecessary hospital admissions and emergency department visits.

Coordinated Care Management Framework

Documents created for coordinated care management can be used by any individual or organization participating in coordinated care planning. Employees are equipped with tools, templates, and resources necessary to support the creation and maintenance of coordinated care plans within an interdisciplinary care team. Access the entire compilation of resources contained in the Coordinated Care Management Toolkit or click on each step below for more information and resources. 

Model of Care

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1. Invite and Identify

Identify and invite potential patients to participate in coordinated care planning

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3. Care Conference

Conference between care team and patient to review progress and goals

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5. Transition

Warm hand off to new integrated care lead as required

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2. Interview

Care team is established to help patient achieve identified goal(s)

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4. Implementation of Actions

Care team members are responsible for the timeline and implementati...

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6. Ongoing Management

Care lead maintains contact with patient to identify changes in condition, and goal achievements