What Is Haldimand Health Link?
In our community, five percent of the patients account for nearly two-thirds of the health care usage. There can be many reasons for this; complex medical and social issues, or mental health challenges. Sometimes, these patients simply cannot coordinate everything that is going on in their lives. Health Links is a model of care that can help.
The best way to support these patients is for all the organizations that touch their lives to work together with primary care providers (family doctor) to give them the coordinated care they need.
Haldimand Health Link will see that people who need care and support:
- Have individual, coordinated care plans.
- Have caregivers who frequently check in to adjust and evaluate care.
- Have access to care in their community.
Health Links: Community and Primary Care Working Together
When the hospital, the primary care provider, the long-term care home, community organizations and others work as a team, the patient experiences more coordinated care, leading to improved outcomes.
Staying Healthy at Home
Improving at home support is a vital step to improving the lives of patients with complex needs. By working with primary care physicians, this level of support can help patients avoid hospitalization and emergency room visits. Health care providers will complete coordinated care plans at home for patients who:
- Have multiple chronic conditions such as heart failure and COPD.
- Are frail and experience falls at home.
- Frequently visit the hospital and the emergency room.
- Live with mental and psychosocial challenges such as depression, anxiety, social isolation or substance abuse and need help.
Who Would Benefit from This Model of Care?
People with multiple complex needs who:
- Frequently visit the emergency department.
- Frequently are admitted and readmitted to hospital.
- Need additional support to get the care they need for complex issues.
When you make a referral, the team works with primary care providers and the patient to develop and implement a care plan. You will have a health care provider who is your Integrated Care Lead (ICL) who will keep your team up to date about the your progress and activity.
Participation is confidential and voluntary; patients may withdraw at any time.
Team members will develop a connection between primary care, the home, and other appropriate services. Together we will deliver coordinated care to improve health outcomes.
HHL Referral Form
For Information and Referrals, Contact Haldimand Health Links at:
Wendy Renault: System Integrator