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Sub Region Planning / Health Link

Only 5% of patients account for two-thirds of health care costs in Ontario.  Why?  Because these patients face complex medical, social and emotional challenges and sometimes fall through the cracks.  The best way to help them is for the whole health system – hospitals, family doctors, agencies, community organizations and other partners – to work together to understand and meet their needs. This is the Health Links approach.

Please see below for more info, or call 519-653-1470 and press “5”

Sub-Region Planning

Cambridge and North Dumfries Health Link Steering Committee has been leading Health Link initiatives since 2013. Eighteen member organizations identified priorities for collaborative system planning and formed working groups to implement the change activities, including:

  • Mental Health and Addiction Services Integration with Primary Care *
  • Discharge Planning – with a focus on Congestive Heart Failure (led now by Cambridge Memorial Hospital) *
  • Primary Care Collaboration

*Two working groups with Collaborative Quality Improvement Plans, engaging 13 different organizations across the two plans.

What is new?  The Health Link Steering Committee has shifted to have a broader Sub-Region Planning role and is now the ‘Sub-Region Leadership Table’.

In Home Team

Four in-home care teams have been created to support the Health Links approach in Waterloo-Wellington.  These interprofessional teams provide holistic care based on each patient’s situation and expressed goals.  Each team has a Home and Community Care Coordinator and providers such as Nurse Practitioner, Registered Nurses, Social Worker, Pharmacist and Outreach Worker.  For patients not needing services in-home, a System Navigator/ Social Worker will work with patients to coordinate services and care.

What does the In Home Team and System Navigation do?

Teams ensure that people with complex conditions:

  • Have individualized, coordinated care plans based on their personal goals.
  • Have care providers who check in to ensure the plan is helping and make changes to the plan when needed.
  • Have support to ensure they are taking the right medications.
  • Have a care provider they can call who knows them, is familiar with their situation, and can help.
Who would benefit from a referral?

Did you know that our referrals are sent by primary care, health and social service organizations?

Clients to refer are those with complex needs and:

  • Have complex chronic conditions such as heart failure, chronic obstructive pulmonary disease, diabetes or dementia.
  • Are very frail or have frequent falls.
  • Are not managing well, even with frequent doctor visits or repeated calls for assistance.
  • Are visiting the emergency department or being hospitalized frequently.
  • Cannot get to regular office appointments, for whatever reason.
  • Are not getting the care and support they need.
Patient Referral Form

Please click here for the Health Link Referral Form


Cambridge and North Dumfries is the lead organization for Connectivity, often referred to as Situation Tables across the province. Connectivity meets Tuesday mornings to review situations of elevated risk and provide a quick and collaborative response to individuals and families in our community.

Please click here for the 2017 Connectivity Evaluation Report.