The Coordinated Care Program

For Who:

Mostly for the frail elders with multiple co-morbidities living at home and in need of support to access all services that can support their health. Other patients facing complex health and social issues can also be involved in this program.

The Goal:

The main goal is to conduct a comprehensive assessment of the patient, usually in their home, to include the bio-psycho- social aspect of their health. We can then identify their needs and help navigating the system to provide them with services.

How:

Often a nurse practitioner will be involved to do the assessment and to collaborate with the primary care provider. All of the Family Health Team programs work in coordination to support the health of the patient and may be involve in the collaborative care program. One of the key is to identify the patient goals with their health and to work with them to achieve them. We work in collaboration with other community agencies to integrate and coordinate care.

Marie-Elaine Delvin, Nurse Practitioner with the Prince Edward Family Health Team at County FM 99.3 studio recorded July 12, 2016


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