Transitional Care Coordination

Mid-East Toronto Health Link Partnership

In 2017 Fife House partnered with Mid-East Toronto Health Link to provide urgent care coordination by a transitional care coordinator. Fife House provides a transitional care coordinator for people living with HIV/AIDS in the regions that meet specific criteria. Providers in hospitals, primary care and community care organizations identify and refer people to the Health Link Virtual Hub. Partners include Toronto Central Local Health Integration Network (TC LHIN), WoodGreen and Cota. All transitional care coordinators have an expertise in:

  • Mental health and addictions
  • Elderly with psychological complexity
  • Medically complex people
  • HIV/AIDS

The role of a transitional care coordinator is to provide hospitals, shelters, primary care practices and others unable to lead a coordinated care plan with a single channel referral process for clients who need better coordination of care in the community. This work bridges gaps between health care sectors, and advances the concept of a network of providers working together to improve coordination of care and patient experience.

Fife House’s transitional care coordinator is also partnered with coordinated access to HIV/AIDS Housing & Supports Initiative Program. A referral will be made to the transitional care coordinator when a client meets the Health Links definition of a complex client and is wait-listed for case management services.

In 2017 our transitional care coordinator provided transitional care coordination to over 30 complex needs clients. Twenty percent of those clients are referred from the Toronto Health Link Virtual Hub and 80% from the coordinated access to HIV/AIDS Housing & Supports Initiative Program.