Identified Sub-Groups Client/ Patient Identification for Health Links in the Central LHIN What is Health Links? Health Links is an integrated model of care that brings a team of care providers together in partnership with patients with complex needs, to provide coordinated, efficient and effective care. Purpose of the Guide? To assist clinicians to identify eligible patients using the new Health Links target population definition and be invited to participate in the program. Does your Client/ Patient meet one or more of the following characteristics? Target population Patients with 4+ co-morbidities Identified Sub-Groups Mental health and addictions Palliative Frail elderly Considerations Economic characteristics (e.g. low income, unemployment ) Social determinants (e.g. housing, living alone, language) Clinical judgement Patient would benefit from integrated coordination Lives in catchment area SSNYR Health Link (Newmarket, Aurora, Georgina, East Gwillimbury, Bradford West Gwillimbury, Alliston, New Tecumseth) or or or and Still uncertain if your client/patient would be appropriate for Health Links? Consider: if your client/patient . . . Has had 2 or more ED visits in the past six months Has had 2 or more hospital admissions in the past six months Is at high risk of readmission post-discharge Has had 5 or more visits to primary care in the past 12 months Is socially isolated Lacks adequate care-giver support Has multiple health care providers Is a high user of health care services Is a frequent user of community services Has multiple medications (7 plus) Lacks primary care, secondary care * All referral sources welcome DRAFT v2: Oct ‘16

Identifying Patients for a Health Link in the South Simcoe Northern York Regional Health Link South Simcoe and Northern York Region Health Link Ana MacPherson Clinical Coordinator 905.895.4521 x5326 healthlink@southlakeregional.org Amanda Hearn Administrative Assistant 905-895-4521 x6327 AHearn@southlakeregional.org South Simcoe and Northern York Region - Health Link Referral Process For clients/patients requiring predominantly Medical Assistance Refer to RM&R (in hospital) or CCAC referral form http://healthcareathome.ca/central/en/partner/Documents/Intake%20and%20Linking%20Referral%20Form%20Central%20CCAC.pdf For client/patients requiring predominantly Mental Health/Addiction and Social Health Assistance Refer to Community Partners in the Health Link Region Community Services that are eligible for government funding support require a referral from a Community Care Access Centre (CCAC). For Persons caring for clients/patients requiring predominantly Dementia Care Refer to Alzheimer’s Society of York Region For a list of Health Service Partners in Ontario go to : https://www.ontario.ca/locations/health/ DRAFT v1: Nov 16