The Thousand Islands Health Link is a program that works with patients that have a range of complex conditions that often require many health care and social support professionals.  Individualized coordinated care plans are designed by care providers and their patients in an effort to increase communication and promote collaboration within all member of a patient’s care team.  The Health Links programs assist to close any gaps when a patient moves from one provider to another, allows for faster follow-up and helps reduce the likelihood of readmission to hospital.

 

Goals for the Coordinated Care Plan:

• It is developed to meet the patient’s goals and support their holistic care across a variety of healthcare programs

• It is  used as a communication tool for the patient, family/caregivers, and others involved in the patient’s care  

• It reflects  the patient’s stated values, beliefs, goals, needs, and preferences  

• It is  developed through collaboration between the patient, caregivers, providers, and substitute decision-makers where appropriate 

• It is written in clear language, using the patient’s own words where possible

• The patient is given a copy of the Care Plan to keep and take with them to all medical appointments.