Improving care for patients with complex conditions

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For Anthony Bontje, a 86-years old Richmond Hill,ON resident who has a number of health challenges, including vascular disease, arthritis, lumbar stenosis and high blood pressure, being a Southwest York Region Health Link patient means that all of his care providers know his medical history and work together to achieve his health goals.

Anthony is one of the first patients to use the Health Link service in Southwest York Region. His care is now organized and tracked by a patient coordinator who met with him and his family, developed a comprehensive plan and shared it with all of Anthony’s health providers. His daughter Kris, who is also his primary caregiver, is impressed with how the process has been going so far.

And Anthony is not the only patient to have this experience. Twenty-three other patients are already enrolled, and many other seniors and people with complex medical needs in Ontario’s Vaughan, Richmond Hill, Thornhill and King City may soon find accessing their healthcare easier with the launch of the Southwest York Region Health Link.

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Health Links is a new model of care that makes it easier for people who rely on our system the most to access health care in Ontario. By bringing together the hospital, physicians, specialists, home care, long-term care and community services, the Southwest York Region Health Link works work with healthcare providers, patients and families to better coordinate care for those with complex medical issues.

With the support of a committed team of healthcare providers in the hospital and in the community, patients identified in the Southwest York Region Health Link will experience more seamless and more responsive care which addresses their specific needs. This means reduced Emergency Department visits and re-admissions, reduced wait times to see a specialist and an improved patient and family experience.

The goal of Health Links is to improve the patient experience and help healthcare providers stay connected each and every time a patient accesses healthcare. Working together with identified patients, providers develop personalized coordinated care plans with clear goals, ensuring the right services and actions are matched to the patients’ needs.

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Over time, Health Links will make a difference by:

  • Improving access to family health care for seniors and patients with complex conditions;
  • Reducing avoidable Emergency Department visits;
  • Reducing the need to go back to the hospital shortly after discharge;
  • Reducing the time it takes to see a specialist once referred by the family doctor or nurse practitioner;
  • Improving the patient’s care and experience.

The Southwest York Region Health Link received formal approval from the provincial government on January 23, 2015.

As the lead organization for the Southwest York Region Health Link, Mackenzie Health has helped to foster the development of the Health Link and its collaboration with 20 community partners across the continuum of care to help make it easier for people who rely on the system the most, such as seniors and people with complex conditions, to access healthcare in the region.

The Southwest York Region Health Link has also partnered with York University advance an academic study with a focus on quality improvement and self-management for patients with complex conditions.

Patients, families or caregivers who wish to know more about the program and how to become part of it are encouraged to contact Carla Rodriguez, Director of the Southwest York Region Health Link at 905-883-1212, extension 7847, or email SWYRhealthlink@mackenziehealth.ca.

The Southwest York Region Health Link Project Office is located at 9401 Jane Street, Suite 101, Office #1019, Vaughan, ON, L6A 4H7.