Health Link Sault Ste. Marie
Health Link is a program that helps bring patients with multiple, complex conditions together with a healthcare team that works directly with them to make sure they are getting better, more coordinated care. Health Link Sault Ste. Marie adopted the John Hopkins Guided Care Model, which involves team-based chronic care management to provide comprehensive, coordinated, continuing care.
The Guided Care Model and Health Link utilizes a Guided Care Nurse (GCN) as a primary point of contact for patients and their caregiver(s). The GCN will work in partnership with the Primary Care Provider (PCP), the patient, the patient’s caregiver(s) and other health care professionals and community agencies. The GCN will facilitate and support ongoing care planning, health teaching, integration of assessments and service plan development to respond to the changing needs of patients and caregivers.
The GCN will write an individualized Coordinated Care Plan (CCP), which based on the patient’s goals. The CCP is intended to:
- Help individuals manage their health and health care on a daily basis
- Guide care, regardless of where the person’s care is taking place
- Take the individual’s medical history into account, including information from their PCP, hospital records, specialist consultations, medications and other health-related and support services