- ALC or potential for Alternate Level of Care (ALC) in acute care who requires complex care needs upon discharge in the community; preferably those with active Long Term Care (LTC) placement application or waiting for crisis placement
- Generally frail with multiple comorbidities
- Patient needing behavioral support; must have a geriatric assessment
- All of Central West LHIN area
Model of Care
- Planned collaboration between Home & Community Care and service provider to ensure a comprehensive yet streamlined approach to providing care for complex or at-risk patients.
- Provide wrap around care in the community by providing various services including nursing, PT, OT, SLP, and PSW to provide continuous in-home support
Complete a coordinated care plan
Virtual house calls when appropriate
Geriatric assessment is required
Personal Care and Care Coordination:
The service provider care coordinator will assist you with your transportation needs. Some transportation services are free and some require a fee. A care coordinator from the assigned service provider will assist you with your health care needs, including system navigation. You will receive personal support services that are based upon your assessed care needs, as discussed during the assessment. Additional allied health support e.g. nursing, OT, PT, SLP, etc., will also be provided as required.
Homemaking and Activities of Daily Living:
Personal support workers will assist you with meal preparation, laundry and light housekeeping as required.
Mobility Aids and other Equipment:
The service provider care coordinator will coordinate with the hospital transition care coordinators to assess what type of equipment (e.g. hospital bed, mechanical lift, walker, wheelchair, etc.) you might need once you are in your home. The client/family members will work with the Home and Community Care Coordinators with regards to renting, loaning or purchasing the equipment.
The service provider care coordinator will assist you with your transportation needs. Some transportation services are free and some require a fee.
PSWs can assist you with your medication management by reminding you to take your medications on time, or by assisting you in taking your medication. The care coordinator can also help you to coordinate with your pharmacist or primary care physician as required.
You are responsible for providing your own personal supplies including toiletries and incontinent products as necessary.
Virtual care is available through the service provider. The care coordinator will assist you to connect with your primary care physician, other specialist or with your love ones virtually.
You or your family member, in collaboration with the hospital or your family physician, will arrange the Oxygen coverage and delivery.
Emergency Call System:
The Service Provider may provide you with a mobile phone with installed speed dialling system to connect with service provider staff anytime you require immediate assistance.
Family members, including children are always welcome to visit, provided that they wear proper Personal Protective Equipment.
Personal Protective Equipment (PPE):
The service provider will provide the Care Providers with the appropriate PPE that they should use when providing the services. They will also observe the infection prevention protocols to prevent the spread of infection.
All communication regarding the program or the clients’ needs should be directed to the service provider, CANES/ESS/PSL. This includes compliments or complaints that are related to or regarding the care services.