Coordinated Care for Complex Health Needs

Telemedicine IMPACT Plus (TIP)

150 150 ScopeHub - UHN

TIP is a community-based model of care that addresses complex needs by linking primary care, acute care, and community services.  The TIP nurse works with the patient their family caregiver, and primary care provider to conduct an in-depth comprehensive assessment, which includes determinants of health and patient/family goals.

TIP creates value by:

  • Expediting access to specialty team consults
  • Spanning settings and sectors
  • Utilizing virtual tools
  • Improving the health care experience of patients, families, and providers
  • Reducing inappropriate use of Health Care services
  • Identifying and addressing gaps in the Health Care system
  • Enhancing integration and coordination of care
  • Empowering patients and families

Family Caregivers Flyer
TIP One Pager with Referral Form

Virtual Hub-Mid-East Health Link (St. Michael’s Hospital)

150 150 ScopeHub - UHN

A Health Link network of service provider that includes the TC LHIN Home and Community Care, WoodGreen Community Services, Cota, Fife House, and St. Michael’s Hospital will connect with you and with your consent and your input will help develop your coordinated care plan with your other service providers, identify who will be responsible for organizing your coordinated care plan, including the people you want in your care team, ensure that the plan reflects your health goals.

Coordinated Care Planning

150 150 ScopeHub - UHN

The goal of eCCP is to allow members of the circle of care within different health service providers to collaborate securely and efficiently by creating, updating, sharing, and viewing a client’s coordinated care plan electronically.
To support the implementation of eCCP the Health Partner Gateway (HPG) web-based application, hosted by Health Shared Services Ontario (HSSO) is being utilized which will allow secure exchange of health information between HSPs and their partners, including Toronto Central LHIN Home and Community Care team members. The tool will enable all partners involved in the clients care to collaborate on clients coordinated care plan in real-time.

Better Care Program-North Toronto Health Link (Sunnybrook Health Sciences Centre)

150 150 ScopeHub - UHN

Better Tracking and Triage for Equitable, Reliable Care:  The Better Care Program helps identify patients who can be helped with better care planning.

  • One of the ways you can take part is if you have visited the hospital emergency room several times in the past six months.
  • If you are a patient with multiple chronic health conditions, ask your family doctor if a care plan would be right for you.
  • When you come to an emergency department you might be asked if you want to take part in coordinated care planning.
  • A coordinated care plan that helps meet your goals and needs will be developed just for you.
  • The care planning process help bring your health providers together.
  • As part of this process, you will be enrolled in the Health Links Better Care Program.