Ontario Enhancing Care for Complex Patients in Cambridge, North Dumfries and Surrounding Area

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 Cambridge, North Dumfries and the surrounding area, high needs patients will soon benefit from better care co-ordination through the creation of the Cambridge and North Dumfries Health Link which is being led by the Langs Community Health Centre and currently made up of the following providers:

  • Alzheimer Society of Cambridge
  • Cambridge Cardiac Care Centre
  • Cambridge Family Physicians: Dr. Anil Maheshwari, Dr. Russ Springate, Dr. Elaine Parker and Dr. Russ Ashton
  • Cambridge Memorial Hospital (CMH)
  • City of Cambridge
  • Community Living Cambridge
  • CMHA of Waterloo Wellington Dufferin
  • Community support Connections
  • Doctor Recruitment Committee
  • Fairview Mennonite Home
  • Grand River Hospital
  • Grandview FHT
  • Lutherwood
  • Mosaic Counselling and Family Services
  • Preston Medical Pharmacy
  • St. Mary’s Counselling Service
  • Social Planning Council of Cambridge and North Dumfries
  • Traverse Independence
  • Two Rivers FHT
  • University of Waterloo, Low Vision Clinic
  • Waterloo Region CCAC
  • Waterloo Regional Homes for Mental Health
  • Waterloo Region NPLC
  • Waterloo Regional Police Services
  • Waterloo Region Public Health Department
  • Waterloo Sexual Assault/Domestic Violence at CMH and SMGH

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,