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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 about TC LHIN Electronic Coordinated Care Plan and resources, please use link

For more information

For more information about TC LHIN Electronic Coordinated Care Plan and resources, visit torontocentrallhin.on.ca or contact Mary Eastwood, Mid-East Toronto sub-region manager
mary.eastwood@unityhealth.to
416-867-7460 ext. 48303