FAMILYFall risk is communicated through care plan documentation, visual cues (e. , color codes), huddles, and transfer of accountability reports. Changes in risk are communicated to the team and family immediately.
COMMUNICATIONClear, timely exchange of information between team, residents, families. Includes handoffs, conferences, documentation. Barriers addressed, effectiveness evaluated. Essential for coordination and safety.
PARTICIPATIONWe collaborate through: joint planning and program development, shared service delivery, information sharing and referrals, participation in community health initiatives, coordinated response to public health issues (outbreaks, immunizations), shared training/education, regular communicati
CONFERENCEWe maintain communication among teams serving different locations, use shared documentation systems, hold regular case conferences, and standardize protocols to ensure seamless handoffs. At SJHCG, care coordination uses Caseworks, Oscar Pro, and Care Dove platforms to share information wit
CONCERNSWe use prioritization criteria to triage based on urgency/acuity, safety concerns, and risk of functional decline. High priority clients are served first; others are waitlisted with regular updates.
PARTNERSHIPKey indicators include: number of community members served, health status improvements, wait times, readmission/ED visit rates, falls prevention, client satisfaction, community awareness, partnership engagement. Also track population-specific indicators like chronic disease management, imm
UPDATESWe use prioritization criteria to triage based on urgency/acuity, safety concerns, and risk of functional decline. High priority clients are served first; others are waitlisted with regular updates.
INVOLVEMENTWhere a participant is not able to complete these forms independently, they will be provided to an identified SDM for completion. This process is documented in organizational policies available on the intranet, and specific examples can be found in department procedure manuals.
SUPPORTWe received a referral for a client with complex needs requiring daily visits and specialized equipment. We reviewed our caseload and identified we had geographic capacity but lacked specialized training. We arranged consultation support and accepted with a training plan.
COLLABORATIONIf a participant or SDM does not have a credit card, or access to a chequing account, or are reluctant to share banking information, alternative arrangements will be made in collaboration with the Business Office Clerk.
