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South West Primary Care Alliance

Health Links - Coordinated Care Planning




Information for Primary Care Providers


The Health Links Approach to Coordinated Care Planning

Multiple providers, appointments and complex care issues can make it difficult to met a patient's unique meeds. A more collaborative approach to care can be achieved through Coordinated Care Planning. Bringing together multiple providers, the patient and his or her informal supports enables the development of a care plan that best supports the patient goals and need.

Primary Care can lead or participate in this collaborative approach to care, which seeks to:

  • Further the optimal model of primary care that is based on a continuous patient-provider relationship, coordinated services across the health system, and a high-level of access and equity in the delivery of services
  • Provide greater care coordination for patients that providers worry about the most
  • Strengthen linkages and relationships among care providers to support the delivery of primary care that is truly person-driven
  • Ensure that patients with complex needs receive integrated and coordinated care
  • Designate a lead coordinator within the patient’s care team to help organize various healthcare services and supports
  • Document a shared care plan focused on patient's goals
  • Reduce avoidable office visits, ED visits and hospital admissions



For support to lead Coordinated Care Planning, connect with local in-person resources:
 
To discuss Coordinated Care Planning for individuals across the South West LHIN:
 
  • Call 1-855-371-6337

For individuals who need Home and Community Care Services through the SW LHIN and Coordinated Care Planning, please complete a referral form:
 
For more information, documents and tools, go to: http://swhealthlinks.southwesthealthline.ca/