You are here: Home / What We Do / Patient Engagement

Patient Engagement

"What Matters to Me Should Matter to You"

A key Health Links principle and aim is to actively involve the person in their care and to improve patient experience. This section includes information collected from surveying patients about their experience accessing healthcare in Hamilton, highlights tips for clinicians and describes how Health Links tools can assist. The last component is a video which highlights the lived experiences of 3 Hamilton residents and encourages clinicians to hear what matters to the person, and imagine what is possible!


What We Know

Individuals representing 3 different patient populations were surveyed about their experiences using a survey adapted from the Change Foundation;

Health Links – Individuals in Hamilton who had at minimum 3 hospitalizations and 5 emergency room visits in a year

GIM – Patients admitted at the General Internal Medicine unit at Hamilton Health Sciences

HNHB LHIN Discharge Bundle – Individuals with Chronic Obstructive Pulmonary Disease (COPD) who had access to a range of services at Hamilton Health Sciences

A full summary of the interview findings can be accessed by clicking on the following link. Navigating the Healthcare System in Hamilton.

The survey found that individuals accessing Healthcare in Hamilton differ in their experiences. Differences were seen through responses to the survey questions:

Responses to Survey Questions



What Can We Do About It?

This section draws largely from, “It’s all about me”: The Personalization of Health Systems.

The paper outlines 10 tips towards the personalization of the health care system, representing a shift towards individual health and wellness, rather than disease.  Here, we summarize tips 1-3, which are particularly relevant to clinicians. For more information, click on each tip below!



tip1pic tip2pic tip3pictip1 tip2 tip3


How can Health Links help?

One aspect of Health Links’ work is the creation of coordinated care plans.

Why a coordinated care plan?

"the needs that individuals have are not complex — they are remarkably simple, but often numerous. Typical needs may include transportation to appointments, a refrigerator for storing medications, a telephone to communicate with care providers, nourishing food, and a place to call home. Specialty care for people with diabetes, cancer, or asthma, methadone treatment, mental health treatment, and issues with food security and housing stability are not in and of themselves complex challenges; the complexity arises when the tasks of making connections among multiple care providers and linking each intervention to the individual’s overall care plan fall in the lap of the individual alone without effective partnering or support".

- Institute for Healthcare Improvement White Paper, Care Coordination Model Better Care at Lower Cost for People with Multiple Health and Social Needs

What is different about Health Links care planning?

      • Not only patient-centred, but patient-driven.
      • Integrated - in that it involves anyone in the formal and informal circle of care (including anyone identified by the patient as in the circle: health and social service professionals, family, and others). Care should make sense from a patient perspective, and any plan should be communicated across the circle of care.  This moves away from isolated episodes of care to a care journey. Providers are tasked with ensuring care they give align with the broader journey (See Privacy for more details, including the required consent forms)
      • 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 person identifies as needing access


Health Links Care Planning


While Health Links’ initial focus is on individuals who frequently visit emergency room and who are frequently admitted to hospital, these principles can apply to any service user.

The Health Link visit template provides suggested conversation starters to get to the root of what matters to the individual.

The Health Links coordinated care plan clearly includes sections which focus on detailing the “What Matters to Me”, Likes and Dislikes, and Individual care needs. If you are a lead for care planning, take the time to work with the individual to ensure this is specified in a concise manner. If you encounter someone with a coordinated care plan, take a moment to review this document with the individual to set the stage for your conversation.

For examples of what matters most to 3 individuals in Hamilton, watch the video below!





The Change Foundation (2012). Loud and Clear: Seniors and caregivers speak out about navigating Ontario’s Healthcare system.

Patient-centred care  -,2010.pdf

Craig C, Eby D, Whittington J. Care Coordination Model: Better Care at Lower Cost for People with Multiple Health and Social Needs. IHI Innovation Series White Paper. Cambridge, Massachusetts: Institute for Health Improvement; 2011

Snowdon, A., Schnarr, K., Alessi, C. It's all about me: the Personalization of Health Care Systems. London, Ontario: Ivey International Centre for Health Innovation. .