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.


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

Sidebar Sidebar
Current News
6th Annual Bake for Hospice
Please come to the Harbourview Clinic on Thursday March 29th to see, smell and buy our fresh baked pies, just in time for Easter Weekend. Doors Read more...
Thursday, March 15
It's Dietitian Day!
It’s Dietitians Day! Dietitians believe in the potential of food to enhance lives and improve health. Find out more about Nutrition Month at  Read more...
Wednesday, March 14
Mindfulness Meditation for Chronic Pain
Our Spring course offering for Mindfulness Based Meditation for Chronic Pain starts March 21st in Picton. Call Kerry at 613-476-0400 ext. 214 or Read more...
Thursday, March 8