Abstract

The Rural Hastings Health Link coordinates care for the 1–5% of the local population whose complexity represents two-thirds of healthcare spending. Gateway Community Health Centre developed a primary care-led model with local partners in primary care and the broader health and social sector built on four interventions: a structure to support integrated system thinking with partners, system navigators embedded in primary care addressing medical and social needs, a digital care-coordination tool and data management supporting accountability. It has altered how providers respond to clients' needs and, as an integrated system of care, created a shared culture of change driven by trust.