Mid-East Toronto Sub Region - Health Link
Virtual Hub
Download Virtual Hub referral form (Word file)
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
