How to Find Appropriate Health, Medical and Social System Resources

Knowing where to find the right community, medical and social system supports can be a real dilemma for many of the eight million caregivers in Canada.

In Ontario, a system called Health Links can aid people including older adults with complex health conditions in need of care. It does this by providing a variety of community and medical resources, as well as facilitating communication between the multiple professionals who are involved in one person’s care. Watch the video below to see how it works:


Activity: Watch

Health Links Explained: Can we provide better care for Canadians with complex needs, including seniors? More about Health Links: Some FAQs

What is a Health Link?

A Health Link is a team of providers in a geographic area (primary care, hospital, home, community care, long-term care providers, community support agencies and other community partners) that works together to provide coordinated health care to people with multiple complex conditions, often older adults. Providers work with the older adult and his or her caregiver to design a care plan and to ensure they receive the care they need.

Why Are Health Links Necessary?

We need to close the gaps that often occur as those in our care move from one health care provider to another. Coordinating care is vital to improving the services for care recipients with complex needs.

Some seniors may have mental illnesses and multiple chronic diseases. Many older adults default to the emergency department and are repeatedly re-admitted to hospital when they could (and should) be receiving more appropriate care in their community.

About 75 percent of seniors with complex needs who are discharged from hospital receive care from six or more physicians and 30 percent get their drugs from three or more pharmacies. The result is lower quality care that costs the health care system more.

Health Links put care recipients at the centre of our health care system with family health providers guiding his or her journey through the health system. By bringing local health care providers together as a team, community Health Links give providers the ability to quickly connect patients with specialists, home care services and other community supports. For older adults discharged from hospital, it allows for timely follow-up and helps reduce the readmission to hospital.

Care recipients with the greatest health care needs make up five percent of Ontario’s population but use about two-thirds of Ontario’s health care dollars. Better coordination of care for these people will result in better care and significant health system savings that can be devoted to other areas of health care. This will ultimately improve both patient care and the sustainability of public health.

Health Links are a critical component of Ontario’s Action Plan for Health Care. They will help care recipients receive the right care, at the right place, at the right time.

The Ministry of Health and Long-Term Care
Healthy Change – Community Health Links

Where are the Health Links?

There are currently 82 community Health Links in Ontario. To find out where your local Health Link is, or to see if there is one in your area, call the ServiceOntario INFOline at 1-866-532-3161 from 8:30 a.m. – 5 p.m. ET

Home care and community support services

It’s often possible for older adults with complex medical conditions to stay in their own homes as long as the right supports are in place. In Ontario, Local Health Integration Networks (LIHNs) arrange all government-funded services for older adults who are aging in their place of choice. It is up to the LHIN to decide who receives care, the level of care needed and the duration of care.


Activity: Find Out More

To see if the person in your care qualifies for government-funded at-home care services and community support in Ontario, follow this link: Home and Community Care.


Knowing about the types of in-home services that can be facilitated through your Local Health Integration Network is important. The following information is taken from the website noted above.Health care professionals

If the person in your care requires end-of-life care at home, there are many programs in Ontario that can help. You can request:

  • Nursing and personal care
  • Medical supplies, including low-cost medication for older adults through the Ontario Drug Benefit Plan
  • Tests
  • Hospital and sickroom equipment
  • Transportation to other health services
  • Help to manage pain
  • Home hospice services, including in-home visits and respite care by trained volunteers

Types of services in your community that can be facilitated through the LHIN

Most communities have services for older adults who may need support to continue living independently at home. Some of these programs come at a cost, while others have subsidies and other funding tied to them. In most larger communities, you can find:

  • adult day programs, including social, fitness and other activities
  • transportation services for those who don’t have public transportation nearby or need assistance using it
  • community hospice services, including counselling, support groups, yoga and art classes, and grief support
  • residential hospices where end-of-life care is provided in a home-like environment for those who can no longer stay in their own homes. People in residential hospices receive a wide range of palliative services to keep them comfortable.

Exercise and falls prevention classes

Exercise and falls prevention classes help older adults stay active, healthy and independent. They focus on improving strength and balance to prevent injury and falls. They are led by fitness instructors, trained peer facilitators or support workers. They do not tend to be led by registered physiotherapists. Sometimes these classes are offered in assisted living and long-term care homes.

To find out more about home and community care for older adults in Ontario, see Home and community care.

Caregiver Madeleine learned very quickly that working full time and acting as a caregiver meant she had to be very organized, ask lots of questions and speak up in order to get the services she needed.

My Story: Madeleine and Rose

Madeleine, 56, worked full-time as a government clerk while caring for her 80-year-old mother, Rose. Rose had a series of strokes that caused some paralysis and some dementia. She’s become more forgetful and confused. Madeleine also cared for her father who died a few years ago from prostate cancer.

The stress of working all day and then looking after her mother, with little time for herself, caused Madeleine to take early retirement. Living on two small pensions, Madeleine and Rose are on a tight budget. Madeleine recognizes that she needs to take care of herself as well, and does some volunteer work to get out of the house. However, she also knows that her mother doesn’t like her to leave.

Madeleine quickly learned that no one does anything for you unless you ask. You have to search for information, then ask questions of service providers. Quite often you have to push to get things done the way you want.

When Rose died in 1996, Madeleine had been caring for her for five years.

Madeleine, from an interview for the
National Film Board (NFB) series, “Caregivers”