Health Service Providers

The Ministry of Health and Long Term Care (MOHLTC) has identified a Target Population Approach to identify clients who would benefit from a Coordinated Care Plan (CCP).  This will provide a consistent, standardized way to define and describe the complex/high needs patients across LHINs and Health Links, and over time allows the province a way to describe the characteristics of complex/high needs patients.

Who would benefit from a Coordinated Care Plan?

Those individuals who require coordinated service from multiple health and social providers; those with high care needs who would be best supported with a team approach:

  • Who are living with 4 or more co-morbidities (including mental health and addictions, palliative care, and frail elderly populations)

AND who may be impacted by the following:

  • Economic characteristics (e.g., low income, unemployment)
  • Social determinants (e.g., challenges with housing, social isolation, language)

Did you know that 5% of Ontarians use over 66% of total health care resources? The South West LHIN has also determined that people with the following health system utilization might benefit from a CCP:

  • 4+ Emergency Department Visits AND 3+ Hospital Admissions in the past year OR
  • 5+ Emergency Department Visits in the past year (excluding pregnancy and infancy)

For more information about Health Links or Coordinated Care Planning, please contact the London Middlesex Health Link via email at [email protected] or by phone at 519-473-0530, x452.

To Make a Referral

A referral can be made to CCAC directly to begin the Coordinated Care Planning process. Please use this referral form located on the CCAC website.

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