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Programs & Services

Health Links

Through the Geraldton District Hospital, a program called Health Links is offered that looks to care for patients who have high health care needs and may have trouble navigating the health care system. Our Health Links Care Coordinator based out of Geraldton supports patients by helping them organize and understand their health care needs.

Overview of the Greenstone Health Links

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 Greenstone Health Links 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 emergency room visits, and reduce system costs at the same time.

At the Provincial level, the Ministry of Health and Long-Term Care first launched regional care networks called Health Links in 2012, with the goal of increasing communications between all members of a patient’s health care team. The program has proven to be very successful and has been rolled out province-wide. There are currently 82 approved Health Links across 14 Local Health Integration Networks.

For more information on Health Links:

Please visit the Ministry Of Health and Long-Term Care’s website:

Health Links Patient Map 

Partners in the Greenstone Health Links

The following organizations are working together to ensure that Health Links patients receive the best possible care:

  • Geraldton District Hospital
  • NorWest Community Health Centres
  • Greenstone Family Health Team

What can a patient expect as a participant of Health Links?

One of the most important aspects of Health Links is that it is completely patient-centred. This means that a Health Links Care Coordinator will work with the patient to develop a Health Care Plan that will outline their health care goals as well as strategies on how to achieve those goals.

  • The Care Plan will do the following for the patient:
  • identify their health care goals.
  • develop a plan on how to achieve those 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:

Goals Chart


This personalized assistance will help empower the patient and enable ownership and implementation of their coordinated care plan. The care provided by the Health Links 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 Links.

The Greenstone Health Links is about coordinated care and services that are wrapped around the patient based on their goals. Through the Health Links, everyone in the patient's personalized care network 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 Links and the collaborating partners believe in the importance of system change, but the patients are leading the direction of that change. The Health Links is change at the grassroots level with a team approach to care.