By Anita Jean
As a primary health care organization, we make special efforts to serve people who have a higher risk of poor health, or people who are having difficulty finding health care because of language, cultural barriers, poverty or isolation. We consider the social, emotional and financial needs of our clients, since these factors affect a person's overall health.
Our inter professional team will work with clients to not only treat the illness or condition but provide information and resources that will allow clients to self-manage their condition. Our multidisciplinary team ensures that clients have access to the most appropriate health care provider.
Our multidisciplinary team includes Community Health Workers who focus on problem solving with clients around determinants of health factors such as income, housing, food security, life skills, and social supports. Community Health Workers assist clients with requests for identification, housing, and applications for financial assistance. Community Health Workers also help build client capacity with group programs designed to enhance life skills, physical health literacy, and mental health wellness.
We are part of Health Links program in Thunder Bay and Greenstone. What is Health Links? Several Community Health Workers are available to facilitate the coordination of care for our clients with chronic disease, or complex and multiple needs. They support our clients by advocating for options and services based on their needs. They assist with client engagement in their care plan. They also support the interdisciplinary team with the development of a coordinated care plan through case conferencing and implementation of coordinated care strategies.
The Health Link program offers clients assistance to better manage their health and well-being. Health Link clients are identified based on their health conditions and are invited to become a part of the Health Links program. The Health Links team will take a holistic view on the client’s health and well –being. The criteria for Health Links consist of four or more chronic or high cost health conditions. Typically this will involve 90% of all palliative care clients, 70% of all frail seniors, and 50% of clients with mental health or addiction issues. An individual with several chronic or high cost conditions may have many needs, many service providers involved, and perhaps unmet needs as well.
What can you expect as a participant Health link? A Community Health Worker will meet with you and work with you to develop a coordinated care plan that will outline your health care goals making sure that you are placed in the center of your care plan. Your coordinated care plan is written in your own words. This is your plan. Your care plan is central to all your care that will come in the future since all care providers will work towards helping you fulfill those goals.
To help develop this plan and personalize the assistance to help you take control of your health and well-being, the Community Health Worker will ask you questions like these:
- Who is involved in your care? If they are from other agencies, can we invite them to a case conference? If family members are your caregivers, would you like them involved?
- What are your health issues? What concerns you most about your health?
- What are your goals for your health? How can we assist you these goals?
The Community Health Worker will help you navigate the health care system. They can accompany you to medical appointments and find ways to be your advocate. Your goals may relate to your health care indirectly. For example, perhaps what you need is transportation assistance, or access to healthy foods. The Community Health Worker will act as your navigator and your health coach to support you in achieving these goals.
To find out more about the Health Links program, contact us at the NorWest Community Health Centres.
Anita Jean is Manager of Health and Social Program at the NorWest Community Health Centres.
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