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Care Planning

What is a coordinated care plan??



The biggest benefit is that it has helped my patient having that feeling the he has been heard and it has helped and reassured his family that we are listening to his concerns .The impression that I’ve gotten is that planning process has been a really big help to the patient. I think he feels heard…I think that it has helped his family see that there’s something happening, that there’s a plan being developed, that people are not ignoring him, that people are working on a plan that will be good for him…It made them feel more reassured because they’re just listening to his side of the story… It is absolutely important to have the patient participate in the care planning process… Having everybody involved decreased everybody’s frustrations…I wish I would have done it sooner.

-          Dr. Joyce Zazulak, McMaster Family Practice


What is Health Links “Care Planning”?

The Ministry of Health and Long-Term Care has formed Health Links in order to improve the coordination of health services for those who use them most. Clinicians are all familiar with planning care for patients. Most encounters result in a plan of care, either small (e.g. come see me again next week) or large (e.g. carrying out assessment of competency to assist in transition to long-term care).


So what is different about Health Links care planning?

Health Links care planning is a special kind of conversation that just makes sense, but is not yet part of everyone’s approach. Health Links care planning is;

  • Not only patient-centred, but patient-driven.
  • Integrated - in that it involves the entire circle of care (including anyone identified by the patient as in the circle: health and social service professionals, family, and others).
  • Unique - developed for the very particular needs of one individual.
  • Comprehensive - dealing with all facets of a person’s life that might have an impact on their health services use.
  • Alive - a work in progress, never finished, always being updated, and certainly being accessed by all who the patient identifies as needing access.


How Does It Happen?



  1. Patient Identified: Hospital, CCAC, family physician or social service agency identifies a person who is using, or at risk of using, high levels of health services. If this is not the family physician, the family physician is informed (without need for consent as they are already in the circle of care).
  2. Care conversation begins: Family physician or CCAC care coordinator approach the patient and begin to understand their situation: what matters most to them, what are their medical and social issues, what is their social context, and who is in their circle of care. Home Visit Template
  3. Circle of Care convened: Bringing together, in person or virtually, as many in the circle of care as possible, is extremely useful. This meeting generally takes up to 90 minutes. All relevant issues are discussed, a plan of action is made, and how the patient and each member in the circle of care is accountable to the care plan is described. This will be facilitated by the most appropriate member in the circle of care (person who knows patient best, who has skills in care planning or other). In some cases, patient express consent (written rather than implied) for an agency or person to be involved in care planning may be required. Consent to Release Personal Health Information
  4. Care plan distributed: The patient decides who in the circle of care should have a copy of the care plan. It is updated when needed and as the situations changes. 

Ministry Care Plan Template

Patient tool template

Patient tool instructions


This is not easy…

This is a new way of thinking – We are in the first phase of a new way of doing business…inventing this will take time, and we have to learn along the way how to do better.

It takes time—this takes a lot of time and scheduling is difficult. But we have noticed that most patients involved in this care planning have required a high investment of time for all players, without a great deal of progress. This is an opportunity to spend time more effectively.

The landscape is always changing – A patient’s journey is in motion – situations, conditions and outlooks change rapidly. Keeping the care plan current and relevant is important.


…But the Investment up front pays off down the road!