We are committed to working together with partners across Ontario's health care system – physicians, specialists, nurse practitioners, contracted service providers as well as community support services agencies and others – to deliver high quality care for people in local communities.
If you have a patient with an acute or chronic condition whose needs are not able to be met through current treatment and supports, we can provide a variety of home and community-based services to help.
Our team of professionals includes Nurses, Occupational Therapists, Physiotherapists, Dietitians, Speech Language Pathologists, Social Workers and Personal Support Workers.
When you refer a patient to our services, a Care Coordinator will work with you and your patient. Our Care Coordinators will:
- complete a comprehensive psycho-social, functional and health assessment
- develop, or work with you to develop, a care plan to support transitions from hospital to home and to safely remain in the community
- link the patient to appropriate health system and community resources (e.g. Meals on Wheels, transportation, day programs, etc.)
- arrange a more supportive living environment, either at home or in the community, for patients with health care needs that cannot continue to be met in their current situation.
To refer a patient, please see our Physician Referrals Forms page >>
Ontario Health Teams
As outlined in The People's Health Care Act, 2019, the Ontario government is building a connected health care system centred around patients, families and caregivers. Across Ontario, Ontario Health Teams (OHTs) are being introduced to provide a new way of organizing and delivering care that is more connected to patients in their local communities.
To learn more about OHTs, please visit the Ontario Ministry of Health website.
To support health care providers preparing to work together as an OHT, you are welcome to review the following resources that outline key information about our local population and Home and Community Care Support Services Central:
- Home and Community Care
- Palliative Care
- Long-Term Care