Ontario Enhancing Care for Complex Patients in Kitchener, Waterloo, Wellesley, Woolwich, and Wilmot

BACKGROUNDER - Ministry of Health and Long-Term Care

May 2, 2014

Ontario’s Health Links program continues to expand into more communities, providing improved care for more seniors and complex care patients. Health Links are part of Ontario’s strategy to put the patient at the centre of the health system so that they receive the right care, at the right time and in the right place.

In Kitchener, Waterloo, Wellesley, Woolwich, and Wilmot, high needs patients will soon benefit from better care co-ordination through the creation of the KW4 Health Link which is being led by the Centre for Family Medicine and currently made up of the following providers:

  • Grand River Hospital
  • St. Mary’s General Hospital
  • New Vision Family Health Team
  • Kitchener Downtown Community Health Centre
  • Woolwich Community Health Centre
  • Waterloo Wellington Community Care Access Centre
  • Schlegel-University of Waterloo Research Institute for Aging
  • The Village of Winston Park
  • Andrew Street Family Health Organization
  • McMaster University KW Family Medicine Residency Program
  • Ontario Neuro-Trauma Foundation
  • University of Waterloo School of Pharmacy
  • Canadian Mental Health Association of Waterloo Wellington Dufferin
  • Community Support Connections (Meals on Wheels and More)
  • Waterloo Wellington Behavioural Supports Ontario Program (St. Joseph’s Health Centre Guelph)
  • Sunnyside Seniors’ Services, Region of Waterloo
  • Alzheimer’s Society of Kitchener-Waterloo
  • 128 family physicians and 3 primary care nurse practitioners of Kitchener, Waterloo, Wellesley, Woolwich, and Wilmot in all models of primary care

What are Health Links?

Health links are teams of local health care providers who co-ordinate treatment and care for complex patients, ensuring care is consistent and effective for an individual’s conditions.

Complex patients are typically seniors and people with multiple chronic conditions or mental illness.

Currently there are 54 Health Links — with at least one operating in every Local Health Integration Network (LHIN), covering half the province.

How do Health Links work?

All Health Links are led by a co-ordinating partner such as a Family Health Team, Community Health Centre, Community Care Access Centre or hospital. They include local health care providers like family care providers, specialists, hospitals, long-term care, home care or other community supports like educational providers, food banks, emergency medical and police services.

With improved co-ordination and information sharing, patients will receive timely access to the most appropriate care in the most appropriate place, and will be supported by a team of health care providers at all levels of the health care system.

By bringing local health care providers together as a team, Health Links help family doctors to connect patients more quickly with specialists, home care services and other community supports, including mental health services. For patients being discharged from hospital, the Health Link enables faster follow-up and referral to services like home care, helping reduce the likelihood of re-admission to hospital.

In order to establish a Health Link, strong representation from local primary care providers and the Community Care Access Centre is required. Joining or establishing a Health Link is voluntary.

How will Health Links benefit patients?

Health Links ensure patients with complex conditions:

  • No longer need to answer the same question from different providers.
  • Have support to ensure they are taking the right medications appropriately.
  • Have a care provider they can call, eliminating unnecessary provider visits.
  • Have an individualized comprehensive plan, developed with the patient and his/her care providers who will ensure the plan is being followed.

Over time, Health Links are expected to result in improvements such as:

  • Reduced unnecessary hospital admissions and re-admissions within 30-days of discharge.
  • Reduced avoidable emergency department visits for patients with conditions best managed elsewhere.
  • Same day/next day access to primary care.
  • Reduced time from a primary care referral to specialist consultation for complex patients.
  • Reduced time from referral to first home care visit.
  • Reduced alternate level of care days in hospital.
  • An enhanced experience with the health care system for patients with the greatest health care needs.

How are the results of each community's Health Link measured?

Health Links share information and measure results while working with their LHIN to achieve short and long-term goals, starting with:

  • Developing co-ordinated care plans for patients with complex conditions.
  • Increasing the number of seniors and other patients with complex conditions with regular and timely access to a primary care provider.

How does the Ministry of Health and Long-Term Care support Health Links?

Each Health Link submits a business plan to the ministry and the LHIN to show how it will achieve short and long-term goals. The ministry and the LHIN provide assistance to develop and implement this plan, along with other key partners like Health Quality Ontario and eHealth Ontario.

The ministry also provides dedicated assistance to each Health Link to work through issues and provide flexibility to break down barriers to providing better care.

Samantha Grant, Minister’s Office, 416-327-4905
David Jensen, Ministry of Health and Long-Term Care,