Our Roles
Physician
- Caregiver education and support
- Chronic and acute disease management
- End of life/palliative care
- Medication management
- Ongoing integrated team-based case management
- Refer to specialists and community supports
- Support team members and make joint home visits as needed
- Teaching and training medical residents and students
- Vaccinations and immunization
Social Worker
- Caregiver support, such as education, counselling, support groups and respite care
- Crisis intervention
- Development of care plan with clients and caregivers
- Future care planning
- Linkages to community based services, such as Meals on Wheels and homecare
- Ongoing case management
- System navigation and resource referral
Occupational Therapist
- Assessment and recommendations for activities of daily living, mobility, cognition, home safety, falls prevention and equipment needs
- Prescription of mobility aids and linking to funding sources
- Recommendation of equipment and strategies for pressure sore prevention
- Training caregiver/personal support worker safe transfer techniques
Physiotherapist
- Assessment of clients’ physical abilities, including muscle strength, endurance, balance, mobility, coordination and range of motion
- Collaboration with client, caregivers, and team members to support independence and safety with mobility
- Customized interventions to maintain or improve clients’ functional mobility
- Exercise prescription and progression
- Prescription of walking and transfer aids
Nurse Practitioner
- Partners with team physicians
- Assessment, diagnoses and treatment of acute/chronic health issues
- Provide ongoing primary care, including disease management and medication compliance
- Setting goals to stabilize client medically so clients can participate in activities to promote quality of life
- Support other team members