Table 1 Description of the Senior Care Program and Health Links

Description

An interdisciplinary primary health service delivery program offered through 10 Community Health Centres (CHCs) in Ontario

An approach to coordinating care that links patients, their health care providers, and their caregivers together through a coordinated care plan that documents the roles, responsibilities and contact information for each individual

Mandate Structure

A program that reports to the Regional Authority, is directed by the Lead Site, and is composed of various satellite sites

A province-wide initiative mandated by the Ministry

Objective

Provide community-based services to frail seniors (and their caregivers) to enable them to stay healthy, live more independently, and avoid unnecessary use of costly emergency rooms in hospitals

Improve the quality of care and the health care experience for those who use the health system the most, and coordinate care for the top 5% of health care system users

Target Population

Frail seniors (aged 65+)

Patients of any age with complex conditions

Objective of the integration