1. 1 North West Toronto Health Links

2. 2 1.Primary care attachment 2.Coordinated care planning 3.7-Day post-discharge primary care follow-up 4.Reduce avoidable ED visits 5.Reduce admissions to hospitals 6.Reduce primary care to specialist wait times 1. Health Link Program Aims 7.Reduce 30 day readmission to hospital 8.Reduce the time from referral to home care visits 9.Enhance patient experience 10.Reduced ALC 11.Reduce costs

3. 3

4. 4 NWTHL: Year 1 Critical Path February 5, 2015 Partners Council Convened February- March 2015 Advisory Councils & Working Groups Established: -CCP -Primary Care -Patient and Family March 2015- March 2016 - Planning, implementation and evaluation of initiatives and projects completed April 2016 -Spread and Sustainability Strategy developed

5. 5 Partners Council Primary Care Advisory Engagement & Attachment 7 Day Post Discharge Follow Up Transitional Aged Youth, MH Focus Coordinated Care Planning Advisory Acute (Better Care System) Primary Care (ICCT) Seniors Housing, MH Focus (Bracondale) Primary Care (ICCT) Patient/Client Advisory Community Agency Notification (CAN) Long Term Care (ED transfers) Health Human Resources *Patients/Clients/Families are included in Partners Council and Initiative Working Group activities Executive Support Committee Support Project Management Executive Support Committee Support Project Management General Oversight Meets quarterly Partners Council Responsible for planning and initiative portfolio Meets bi-monthly Advisory Councils Meet as needed Responsible for implementing specific initiatives Action Teams

6. 6 Planning for 1-5% populations ID clients (Hospital, Primary Care, Community) Attach to Primary Care (Health Care Connect) Coordinated Care Planning Process (Tool, Principles, Conference) Ongoing Monitoring & Tracking Process and Outcome Measures