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Mid-East Toronto Sub Region - Health Link

Virtual Hub

Identification

  • Patient or client eligible for Health Links is identified in a setting where there is no one to lead a coordinated care plan
  • Patient or client is engaged by identifier
  • Identifier refers patient/client to the Virtual Hub team

Transitional Care Coordinator Virtual Hub team

  • Virtual Hub Team receives referrals
  • Team determines which Transitional Care Coordinator (TCC) team member will manage referral
  • Selected TCC team member assesses patient needs and surfaces existing circle of care

Facilitation of Coordinated Care Plan (CCP)

  • TCC or lead from existing circle of care facilitates CCP on urgent basis
  • Where there is an existing lead the TCC supports and coaches as needed to build care planning ability
  • The TCC provides support for up to three months – in this time finds a long-term lead to hand off to if needed

Download Virtual Hub referral form (Word file)

For more information

Contact Lara McLachlan, Health Link Project Manager, Mid-East Toronto Sub-Region
McLachlanL@smh.ca
416-867-7460 ext. 48373