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North West CCAC

The Thunder Bay IDN Health Link


Overview of the Thunder Bay IDN Health Link

The top 5% of hospital users account for two thirds of healthcare spending. These high-user patients typically have multiple complex conditions and access many areas of the health care system. A recent study found that 75% of seniors with complex conditions who are discharged from hospital receive care from six or more physicians and 30% get their medications from three or more pharmacies. This uncoordinated care from several different providers can result in both gaps and duplication in the care provided.

The Thunder Bay IDN Health Link has identified these high-users and has an innovative plan to work with them to improve their health and well-being, lessen their reliance on ER visits, and reduce system costs at the same time.

Below are two videos showing Jaun-Paul's journey.  The first video takes place shortly after entering the Thunder Bay Health Link Program.  The second video was done one year after becoming a Health Link Particpant. 

Jaun-Paul's Journey to Improved Health and Well-being.

Video #1                                   Video #2



The North West Community Care Access Centre (NWCCAC), as the lead organization for the City of Thunder Bay IDN Health Link, has partnered with the Enhanced Care Team Clinic. The Enhanced Care Team Clinic was designed to address the highest health needs for Northwestern Ontario's most vulnerable clients. The Enhanced Care Team Clinic serves individuals with co-morbidities, who are high users of the Thunder Bay Regional Health Sciences Centre (TBRHSC) emergency department, and are at increased risk of readmission, given the complexity of their conditions. This intensive collaborative practice clinic concentrates on the stabilization of an identified population of medically complex patients, the coordination and management of their care, and the transitioning of their care to an appropriate primary care provider in Thunder Bay. Within this collaborative team, the client leads the direction for services needed and care goals.

The Thunder Bay IDN Health Link invites these patients to join the Enhanced Care Team Clinic and places them with a NWCCAC Integration Bridge Coordinator who will work with them and their family over the course of two hours or more to develop a Coordinated Care Plan that will:

  • identify their health care goals.
  • put them at the centre of their health care plan.
  • connect them with service agencies that will help provide the care and assistance they may require.
  • ensure communication between healthcare providers.
  • decrease their visits to Emergency Rooms and hospital admissions.

These Coordinated Care Plans become the central document in the patient's care and all members of the coordinated care team base their care upon the goals the patient has set for themselves. This document is so completely patient-centred that it is written in the first person; in their voice. This is their plan, not the primary care provider's, not the coordinator's.This is shown in the following excerpt from the Coordinated Care Plan:


Coordinated Care Plan  






It is up to the patient to set their healthcare priorities and the Health Link team will work with them to achieve those goals and to bring the appropriate health care partners to the table to assist the patient.

Health Link patients are often placed with a NWCCAC Health Coach if the patient's goals dictate it would prove beneficial. These coaches assist them to better navigate the health care system and to help them with any other issues, concerns or questions they may have regarding their healthcare or healthy living in general. This personalized assistance will help empower the patient and enable ownership and implementation of their coordinated care plan.

The care provided by the Health Link is often broader than that offered by primary care providers since it offers patients enhanced care that includes addressing not only the medical needs of the patient, but the psychosocial as well. The biopsychosocial model states that biological, psychological and social factors all play a significant role in determining a person's health and well-being. The social determinants of health are a key focus of the Health Link.

The Thunder Bay IDN Health Link is about coordinated care and services that are wrapped around the patient based on their goals. Through the Health Link, everyone in the patient's personalized care network — including doctors, nurse practitioners, coordinators, health coaches, therapists, dieticians, social workers, mental health workers, pharmacists, housing agencies and other community organizations — shares information about the patient's health in order to meet the patient's goals and to improve their journey through the health care system.

This marks a philosophical change in the delivery of health care, not a new program. The Health Link and the collaborating partners believe in the importance of system change, but the patients are leading the direction of that change.

The Health Link is change at the grassroots level with a team approach to care.

To summarize the Thunder Bay IDN Health Link:

  • The Health Link is dedicated to improving the health care experience of the high-user patient by creating a Coordinated Care Plan suited to their health care goals.
  • These Plans, and the work of the care team, will keep the patient from unneeded Emergency Room visits or admissions to hospital.
  • The Health Link will assist the patient to make positive changes in their lives through the assistance of the members of the personalized care network.
  • By helping these people avoid unneeded healthcare visits, service will improve for all Ontarians.


 After six months in the Thunder Bay Health Link, Jeremy's health and well-being have improved dramatically.