Don’t wait for the government, create your own Health Link


Health Quality Ontario hosted a conference today focused on Health Links, the Ontario Ministry of Health and Long-Term Care program that is intended to provided coordinated care to the 5% of patients who account for 2/3 of all health care costs. Health Links are designed to link the patient, family physician, hospital, long-term care home, and community organizations, in a coordinated effort to improve care.

I followed the conference closely today via social media, as I have followed the program from afar for the past few years. The underpinnings of Health Links make great intuitive sense for these vulnerable patients. Giving patients an individualized and coordinated plan, having care providers who ensure the plan is being followed, ensuring the patients are taking the right medications, and having a care provider they can call who is familiar with their situation. These are all incredibly attainable and important to successful care for these patients. Health Quality Ontario have developed fantastic documents available on their website, and many of their projects have been extremely thorough and well-done.

But here’s my concern. The Health Links program was initially piloted in 2012 in only selected practice areas, and has been described as a success by those involved. Let’s assume the anecdotes are correct and the program does improve outcomes.

Where does that leave the rest of us? Those who haven’t been deemed worthy of access to a Health Link. Those who are restricted from joining a FHO, let alone having access to the allied health professionals in a FHT with NPs, physiotherapy, psychology, social worker, pharmacists, etc. What do the rest of us do? Do we wait for Health Links to find us?

Quite frankly, physicians who aren’t in a Health Link, or a FHT, or one of these privileged groups, can’t wait for the province to find us. We can try to advocate politically for our patients and practices, but in the meantime, we have to make due with what we have.

So let’s create our own Health Links in our offices. We don’t need a rubber stamp from the government to take similar initiatives on our own. I’ll lay out a rough guide here for you to start taking steps to improve the quality and coordination of care for your patients.

This will be in a blog format, but I would recommend taking the aspects of these recommendations that you like, and create a standard custom form that you keep in each patient’s chart to track that they are receiving the necessary interventions.

And away we go…

1) Identify the target patients

The Health Links program identifies the 5% of top users in our system, so do the same for your practice. Identify your 5% of patients who you feel are the highest risk for admission to hospital, highest risk for deterioration, and/or in need of the highest need of resources (either health-related or related to social determinants of health).

2) Identify all relevant family and caregiver contacts for the patient

3) Tell the patient and their caregivers who should be contacted with any health concern

Ensure they have both the physician’s phone number, as well as any relevant home care emergency services. Make sure you are notified upon admission to hospital, discharge from hospital, and any ER visits. Tell them what your availability is for being contacted after hours to prevent ER visits.

4) Make medication reconciliation an ongoing priority

Typically these patients have multiple providers involved in their care, and medications are changing frequently. Medication lists are often out-of-date, leading to potential adverse outcomes. While we tell the majority of patients to bring all medications to all appointments, make it a MUST in your Health Links patients. Once you update their list, provide them a copy by doing a screen capture of your EMR medication list. Tell them that THIS is the list to show to health care providers (the list the pharmacy gives them is often a complete mess). Tell the patient to notify you of any medication change. If they end up in hospital, they are to notify you with any medication change. Document any medication discrepancies and how they came about. Offer compliance packaging whenever appropriate. Review Beer’s criteria. Create a culture where the accuracy of their medication list is seen a top priority, and patients understand its importance.

( is a useful resource for capable patients to track their medications.)

5) Make it clear that you can offer same day appointments whenever needed

6) Be clear whether you offer house calls

7) Insist on follow-up with family physician within 48 hours of hospital visit.

Reconcile medications and review diagnostics and management plan. Ask the following questions: How or why do you think you became too sick to stay in your home? Did you see a doctor before coming to the hospital? If yes, who did you see and when? If not, why? Has anything stopped you from taking your medications? How do you set up and take your medicines every day?

8) Perform a cognitive assessment

Mini-Cog, MOCA, MMSE, whatever your heart fancies…

9) Perform a falls risk assessment

Every office should have a standard falls assessment that you go through with these patients. In brief, do a complete physical exam (including Get up and Go test), optimize vision and hearing, avoid alcohol, remove any offending medications, encourage gait aids/handrails, take regular vitamin D and do home exercises. Remove unsafe conditions in their homes. Offer an OT assessment if the home environment is a concern.

10) Ensure adequate home care is in place, and communicate with case manager regularly

Regularly assess whether specific home care services are needed for patients. When care is deemed no longer necessary, reassure patient that it can be reintroduced if deemed appropriate. Here in my office, a representative from CCAC visits regularly and we “run the list” to make sure everyone’s home care is optimized.

11) Confirm your patient’s health literacy

Ask them to describe their understanding of their ailments to you. As them to describe medication administration to you. The Sixth Vital Sign Program assesses a patient’s health literacy by testing their ability to interpret an ice cream nutrition label. If you learn that their literacy is not adequate, this will certainly change your approach to delivering instructions to them.

12) Set attainable goals in consultation with patient and caregivers

Remember to set SMART goals (Specific, Measurable, Achievable, Realistic and Timely).

13) Review advance care directives on a regular basis

The patient should inform all relevant family and friends about their goals of care. If they wish to be deemed a DNR, offer to complete an official Do Not Resuscitate Form. These can be obtained in bulk by faxing a request to (416) 327-0329. Encourage patients and their families to visit

14) Ensure adequate social and financial resources

15) Plan a full family meeting at least once a year (or more often if needed)

Use this meeting as an opportunity to inform all family members about the relevant info that you have reviewed through your Health Links template. This will serve to make them feel supported, and provide you valuable insight into their concerns about their family member.

16) Provide the patient and their family with a copy of your Health Links template

They should be encouraged to share this with other health care providers.


So there you have it. Try to review the above topics with your “5%” and their families and caregivers on a regular basis, and they will enjoy the majority of the benefits of a Health Link immediately, rather than on the government’s time.


2 thoughts on “Don’t wait for the government, create your own Health Link

  1. Sonya

    Dr Elia…I loved your article about alternative therapy and agree with you 110 percent. I am so sick and tired of my own friends listening to another friend about wacky holistic. .naturopathic bologne rather than my pharmacist backed information. I wish I had the gift of gab that my alternative friend has to be able to defend my view when these debates arise.


  2. Dr. Matt (@DrMattHenschke)

    I’m a bit late to the party on this one but I love this post! I’d love to see a Health Link initiative in Alberta, this is a pretty good framework to start with until something starts up provincially.

    I’ve heard great things about Health Links from colleagues back in Ontario, I’m excited for the data from the pilot projects to come out. Have you heard anything about where and when the data will be published?



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