In the City of Thunder Bay sub-region, there is a need to improve health system integration for vulnerable and at-risk patients. In particular, communication and coordination could be improved between the North West LHIN and Most Responsible Providers (MRPs) for complex and palliative care patients. This IDEAS team's project aim was that by October 2018, 80% of MRPs with patients who are considered complex will receive initial and ongoing communication from the LHIN describing their home care services and supports.