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Health Links General Information


Hamilton Niagara Haldimand Brant LHIN Overview of the Health Links Program

Video: Health Links Explained

Video: What is care planning?

Care Planning and Care Coordination Research Evidence and Reports


The King's Fund- Coordinated Care for People with Complex Chronic Conditions

"This report presents the findings from a two-year research project funded by Aetna and the Aetna Foundation, which aimed to understand the key components of effective strategies employed by studying five UK-based programmes to deliver co-ordinated care for people with long-term and complex needs. It elicits some key lessons and markers for success to help identify how care coordination might be transferred from the UK to the US context."


The King’s fund - Providing integrated care for older people with complex needs
This report synthesises evidence from seven case studies covering Australia, Canada, the Netherlands, New Zealand, Sweden, the United Kingdom and the United States. It considers similarities and differences of programmes that are successfully delivering integrated care, and identifies lessons for policy-makers and service providers to help them address the challenges ahead.

HSPRN - Caring for people with multiple chronic conditions: A necessary intervention in Ontario

This paper outlines the need for and evidence supporting improved disease management programs for multiple chronic conditions based in ontario.


Robert Wood Johnson Foundation - Care management of patients with complex health care needs

“This report explores how patients' complexity of healthcare needs, vulnerability, and age affect the cost and quality of their health care. In addition, it examines the potential for care management to improve quality of care and reduce costs, elements of success, and challenges.”


Journal of the American Medical Association - Effect of a Postdischarge Virtual Ward on Readmission or Death for High-Risk Patients - A Randomized Clinical Trial


IHI- Care Coordination Model: Better Care at Lower Cost for People with Multiple Health and Social Needs

"This IHI white paper outlines methods and opportunities to better coordinate care for people with multiple health and social needs, and reviews ways that organizations have allocated resources to better meet the range of needs in this population. There is special emphasis on the experience of care coordination with populations of people experiencing homelessness."


Resources and tools from the Persons with Complex Health Needs (PCHN) workshop

These resources were designed to accompany the Hamilton Central Health Links workshop on "Coordinating Care for People with Complex Healthcare Needs (PCHN)". However, they can also be read independently to supplement healthcare provider knowledge on care planning as well as the broader literature on PCHN management.

All resources and tools can be found at this link. Contents of the folder include the

Workshop Guide : Summarizes the first portion of the workshop focused on providing a high level overview of who PCHNs are, what models of care exist for the population, and how the Hamilton Central Health Links program adapted care planning to meet the needs of the population

Care planning guide: This is a modified version of the template used by the Hamilton Central Health Links when organizing PCHN  medical and social history when developing a care plan.

Hamilton Niagara Haldimand Brant LHIN Health Links Model of Care Process and Key Requirements: This document further summarizes the care planning process and how it has been adapted within our local LHIN.


Other readings pertinent to the workshop


OMA - Key Elements to Include in a Coordinated Care Plan

This is an OMA report providing an overview of what makes a good care plan and the steps physicians can take while interviewing patients. Following this workshop, please use this guide as a reference during the care planning process or email our course support volunteers at the email listed at the top of this document.


Grant, Richard W., Jeffrey M. Ashburner, Clemens S. Hong, Clemens C. Hong, Yuchiao Chang, Michael J. Barry, and Steve J. Atlas. “Defining Patient Complexity from the Primary Care Physician’s Perspective: A Cohort Study.” Annals of Internal Medicine 155, no. 12 (December 20, 2011): 797–804. doi:10.7326/0003-4819-155-12-201112200-00001.

To compliment the definitions of complexity discussed in the above resource as well as the workshop, this paper provides insight into the process other physicians have used when defining complexity among their own patient populations


Ministry of Health and Long-Term Care - “Patients First: Proposal to Strengthen Patient-Centred Health Care in Ontario

Patients first is the recent discussion paper released by the Ministry of Health and Long Term Care proposing the expansion of the patient centered medical home model in Ontario. If implemented, Ontario will see an increase in PCMH based care planning for complex patients as well as further health provider integration.


Bodenheimer T, Berry-Millett R. Care management of patients with complex health care needs. Policy. 2009 Dec;1:6.

This review provides an overview of what models exist to provide care for complex patients as well as the characteristics of successful models




Please see the videos located at the top of the resources page.


The workshop resources will be updated over the next several months. We would like to thank everyone from the Hamilton Central Health Links Team who helped make this workshop possible. If you would like further information on the availability of the workshop or clarification on its content, please contact Dr. Dale Guenter ( and Aditya Nidumolu (


Patient Centred Care Research Evidence and Reports

NHS England- How Can We Transform How Care Looks and Feels for Patients?

This series of articles explores how the patient experience can be transformed by integrated care that promotes dialogue and shared decision making between patients and healthcare providers.

The Change Foundation- Loud and Clear- Seniors and Caregivers on Navigating Ontario's Healthcare System

"Loud and Clear reflects what the Change Foundation heard late in 2011 during province-wide consultations with seniors with chronic conditions, and their informal caregivers. The report captures their voices, views, and experiences of navigating healthcare transitions and offers new data and unique insights into the big and little things that would improve their health, quality of life — and the quality and sustainability of our system."

OMA- Patient-Centred Care

"In this paper, patient-centred care research is reviewed from both the system standpoint and the practitioner standpoint, including research and experience in other jurisdictions, and challenges to providing patient-centred care."

The King's Fund- Joined-up Care- Sam's Story

"This short animation aims to bring integrated care to life for anyone involved in improving patient care. If those working towards integrated care can share this vision with others in their local health and care system, then there is a real chance they can make integrated care happen."

The Change Foundation- PANORAMA Panel

"The PANORAMA panel is a way for the Change Foundation to learn about people's interactions with the healthcare system on a first-hand, regular basis. We take what we have learned from the panel to inform recommendations to advance a patient-centred healthcare system."


Advance Care Planning

United States

Death Over Dinner

"How we want to die – represents the most important and costly conversation America isn’t having. We have gathered dozens of medical and wellness leaders to cast an unflinching eye at end of life, and we have created an uplifting interactive adventure that transforms this seemingly difficult conversation into one of deep engagement, insight and empowerment."


Speak Up- Advance Care Planning

Quality Improvement

Health Quality Ontario- bestPATH

"As a support to Health Links, bestPATH offers a suite of tools and expertise to help identify and address gaps in the quality of care and delivery of services to individuals with complex chronic illnesses. Specifically, bestPATH is designed to facilitate the achievement of Health Links objectives by providing leadership and support in: measurement, evidence-informed change ideas, and building sustainable capacity for change and improvement."

Information Technology

South West LHIN- Spire

"An easy to understand video explaining the SPIRE/HRM project which enables physicians to receive patients' hospital records directly into their Electronic Medical Record solution."

ClinicalConnect Quick Tour (about 6-7 minutes)

ClinicalConnect Website


The Change Foundation- Health System Navigators: Band-Aid or Cure?

For Physicians

OMA- Health Links

The Ontario Medical Association has a wealth of resources targeted to physicians, including the impact of physician leadership and stories of turning Health Links aims into reality from across the province

Physician Billing Codes

HNHB LHIN letter to Physicians

Release re:Health Links from OCFP

Other Interesting Links

Where you live may decide how soon you die - Canada, Health - Macleans

Hotspots Video RE: Camden New Jersey

Housing as Health Care- New York's Boundary Crossing Experiment

EMS Stars: Emergency Medical Services "Superuser" Transport Associations: An Adult Retrospective Study