South Simcoe and
Northern York Region
Healthy Change Happen
The South Simcoe Northern York Region HealthLink is participating in the roll-out of an electronic Coordinated Care Plan tool (CCT) that provides opportunities for Health Services Providers (HSPs) in our Health Link to enhance collaboration and communication among the Health Link Care Team.
Roles and responsibilities for the Lead Care Coordinator and Health Link Care Team members have been developed.
TheLead Care Coordinator (LCC)has a unique role in the Health Links client’s journey. They ensure care continuity by:
- Obtaining Client Consent for HealthLinks enrollment
- Conducting Client Interviews
- Conducting requiredAssessments (if required)
- Organizingand facilitating the Care Team Case Conference,inviting Care Team Participants
- Building relationships with Health Link Team members
- Acknowledging existing members
- Initiating Care TeamReferrals, if required
- Initiating the Care Plan(if not already started in the Hospital).
- Supporting theClient/Patient in the Health Links CareJourney
HealthLink Team members act as the eyes and ears for the Lead Care Coordinator and the Primary Care Provider often learning of a worsening condition before it is too late. As a member of an inter-professional care team, the team member has responsibilities to:
- Identify clients who would benefit the most from an collaborative care plan
- Participate in Coordinated Care Conference
- Provide past medical history if available
- Add Client Services to the Care Plan
- Update Client Services on the Care Plan
- Support the Client in the Health Links Care Plan
- Advice Care Team members of any concerns or issues with Health Link Clients.
Changes to an individual’s care plan – e.g. care goals, health status, treatment plan, medications, service providers, etc. are communicated to all team members electronically, ensuring that everyone has consistent information and knows their role. Health Service Providers are encouraged to stay connected in the provision of services and supports by following their clients/patients in the CCT.