We are committed to working together with partners across the 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 the South West.
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. We can also 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.
A team approach
When you refer a patient to our services, a Care Coordinator will work with you and your patient to ensure continuation of the best possible care. The Care Coordinator 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.)