The Individual, Family, or Caregiver

Support in identifying and accessing key resources and care assistance

Collaboration with alternative care partners, nurse practitioner, physician, or other service provider

Support in scheduling, coordinating appointments and services

Accompaniment and Advocacy on appointments

Support in care conferences

A person-centered, in depth assessment and evaluation of the individual(s) including all areas of concern e.g. medication regimes, physical and mental health well being

Support in setting goals and creating individualized plans of care

Advice and support on placement options that best suit individualized needs

Accompanied tours of potential LTCH’s and, or Retirement Homes

Collaboration with staff of the home and other external care providers

Review and interpretation of MOLTC reports of LTC homes

Support and assistance with admission into alternate level of care (LTC home, Retirement home)

Advocacy and support in discharge from hospital

Individualized needs assessment and care planning

Family support in the collaboration and education of staff