About the North Toronto Health Link
What we do
The mandate of each Health Link is to identify individuals within our community who have complex chronic health needs and support them and their care providers on a single coordinated care plan. We do this work with the cooperation of local care providers, including health, community service, housing and emergency services, as well as with the input of our patient and family advisory council.
How does the program work?
Individuals who enroll with the Health Link work with their entire care team, including family and friends, to design a care plan based on their needs and goals. This type of coordination ensures that everyone in a patient’s circle of care (i.e. those who are providing or assisting in the provision of health care for a particular patient, such as health professionals, hospitals, pharmacies, community support organizations, etc.) knows about and is in contact with one another, and can collaborate on a single integrated care plan for that person. The Health Link’s role is to provide health-care providers with the resources and training necessary to help them participate in this process.
Participation in the Health Link is entirely voluntary. Even after enrolling, a patient has the right to defer their participation or opt out altogether. Read more about your privacy rights.
Who can participate?
People who have complex needs are identified either through one of our health/social service provider partners in the community or at Sunnybrook Health Sciences Centre through a real-time flagging and notification system called Better Care (Better Tracking and Triage for Equitable, Reliable Care). Better Care flags patients who come to Sunnybrook frequently enough that their health needs may be considered complex, and notifies a special care team who will offer participation in the Health Link program to the patient.
Complex needs can come in a variety of forms, but they are more common in those who are:
- Frail and elderly;
- Experiencing mental illness and/or have addictions concerns;
- In need of palliative care;
- Living with multiple chronic conditions;
- Working with multiple health care providers.
People with complex needs may have difficulty keeping track of all their medical appointments and following all their providers’ instructions, and as a result may be coming to hospital more than is necessary.
If you believe you would benefit from improved care coordination, please speak to your health care provider or call the Health Link Project Manager at 416-480-6100 ext. 87594.
For more information
For more information on the Health Link or the coordinated care planning process, please contact the Health Link Project Manager at 416-480-6100 ext. 87594.
For coordinated care planning resources such as health-care provider and patient-friendly descriptions of the coordinated care planning process, a copy of the care planning tool, and other helpful documents, please see our resources page.