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Improving Care for High-Needs Patients

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Improving Care for High-Needs Patients

McGuinty Government Linking Health Providers, Offering Patients More Co-ordinated Care

Ministry of Health

Ontario is improving co-ordination of care for high-needs patients such as seniors and people with complex conditions through the creation of 19 Health Links across the province.

Health Links will encourage greater collaboration and co-ordination between a patient's different health care providers as well as the development of personalized care plans.  This will help improve patient transitions within the system and help ensure patients receive more responsive care that addresses their specific needs with the support of a tightly knit team of providers.

Each Health Link will measure results and develop plans to:

  • Improve access to family care for seniors and patients with complex conditions.
  • Reduce avoidable emergency room visits.
  • Reduce unnecessary re-admission to hospitals shortly after discharge.
  • Reduce time for referral from primary care doctor to specialist appointment.
  • Improve the patient's experience during their journey through the health care system.

Health Links are part of the McGuinty government's Action Plan for Health Care, by delivering faster access and a stronger link to family health care, and providing the right care, at the right time, in the right place.

Quick Facts

  • 19 early-adopter communities have been chosen to launch the first Health Links and will submit plans to the Ministry of Health and Long-Term within the next 60 days. Over time, Health Links will be expanded across the province.
  • A Health Link may include family doctors, specialists, hospitals, home care, long-term care and community support agencies. Each Health Link will have one of its providers play a co-ordinating role.
  • Each Health Link will work with its LHIN to develop personalized care plans for seniors and other patients with complex conditions, and to increase the number of those patients with a primary care provider.
  • Patients with complex conditions include seniors, those with multiple chronic diseases, and those with mental illness and addictions
  • A recent study found that 75 per cent of seniors with complex conditions who are discharged from hospital receive care from six or more physicians and 30 per cent get their drugs from three or more pharmacies.
  • Complex patients represent up to five per cent of Ontario’s population, but use two-thirds of the health care budget.

Additional Resources


“Health Links will break down barriers for Ontarians, making access to health care easier and less complicated. By encouraging local health providers to work together to co-ordinate care for individual patients, we’re ensuring our most vulnerable patients – seniors and those with complex conditions – get the care they need and don’t fall between the cracks.”

Deb Matthews

Minister of Health and Long Term Care

Media Contacts



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