Transforming Ontario's Health Care System

Community Health Links in Action - Bernice's Story

Bernice is a senior who lives at home independently.

A personal support worker from the Community Care Access Centre (CCAC) visits once a week and her children are regular visitors.

One day Bernice falls and gashes her arm...

Bernice's Actual Story

professional making home visit

She calls 9-1-1 and is taken to a hospital in ambulance. Bernice is treated in hospital and sent back home.

Her family doctor isn't notified and Bernice receives no follow up care. When the personal support worker comes she's surprised to find out that Bernice was injured.

1 year passes

Bernice falls again and breaks her hip. She is sent to the hospital by ambulance.

She waits three days in the emergency room.

When a space opens up, Bernice is transferred to another hospital for surgery.

Bernice recovers in hospital for the next six months.

She catches Methicillin-resistant Staphylococcus aureus (MRSA), an infection common in hospitals.

As a result of her declining health, Bernice sells her house and moves to a long-term care home.


To care for Bernice over the next five years will cost the health system close to $500,000.


Her Potential Story with Health Links

EMS provide first aid and her primary care provider is notified.

Because Bernice has a number of chronic conditions and health needs, Bernice falls into the category of a "complex patient" and as her primary care provider is part of a Health Link, she is captured through this work. Bernice's primary care provider discussed the creation of a coordinated care plan with her and as part of Bernice's care plan, her doctor makes a geriatric assessment referral. Bernice's children go with her to the appointment and learn how they can improve Bernice's functional ability.

Bernice attends a falls prevention program, where she makes new friends and starts going to bingo.

One day, while leaving bingo, Bernice falls on the ice and breaks her leg. She is taken to her local community hospital.

Hospital staff call the designated referral hospital and Bernice is transferred right away for surgery. Bernice's primary care provider is notified of Bernice's situation.

Following her successful surgery, Bernice is transferred back to the community hospital, where she recovers.

1 week passes

She is discharged to a transitional care program with a complete discharge plan.

1 month passes

Bernice is back at home with ongoing support to help maintain her functional ability.


To care for Bernice in her home, with access to health care in the community, will cost the health care system about $100,000 over the next five years.

Community Health Links put patients and family care providers at the centre of the health care system. By bringing local health care providers together as a team, community Health Links will help family doctors to connect patients more quickly with specialists, home care services and other community supports, including mental health services. For patients like Bernice, who are being discharged from hospital, the Health Link will allow for faster follow-up and referral to services like home care, helping reduce the likelihood of her being readmitted to hospital.

For More Information

Call ServiceOntario, Infoline at:
1-866-532-3161 (Toll-free)
In Toronto, (416) 314-5518
TTY 1-800-387-5559.
In Toronto, TTY 416-327-4282
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