RECREATIONWe provide services in: clients' homes, community centres, schools, seniors' residences, day programs, charitable organizations, faith communities, libraries, recreation centres. Services are delivered where most convenient and appropriate for clients, reducing barriers. Each location asse
ACTIVITIESWe obtain consent for info sharing, communicate via secure methods, participate in care coordination meetings, and ensure smooth transitions by documenting all coordination activities. At SJHCG, care coordination uses Caseworks, Oscar Pro, and Care Dove platforms to share information with
MEANINGFULClient and family input shapes our investigation process by including their perspective on what occurred, the impact on the client, and their concerns or questions. We interview clients and families early in the investigation, incorporate their observations into our analysis, and share fin
SOCIALWe maintain an updated resource directory with: community health programs, specialized services, mental health, home care, rehabilitation, social services, cultural/language-specific services, crisis services. Each listing includes contact info, eligibility, services, referral process.
PHYSICALWe use the PIECES model (Physical, Intellectual, Emotional, Capabilities, Environmental, Social) and standardized assessments (e. , RAI-MDS) to capture a holistic view of the client's health. Documentation is maintained in the client health record/chart.
COGNITIVEA comprehensive assessment includes: reason for referral, medical/surgical history, current health status, functional abilities (ADLs/IADLs), cognitive status, mood and behaviour, social determinants of health, family/caregiver support, and client goals. Review assessment templates in your
PREFERENCESWe wanted to develop a diabetes management program. We held focus groups with clients to understand needs/preferences. They told us timing and transportation were barriers.
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
CALENDARLTC information is in LTC-100-1 Long-Term Care Program Policy on The Pulse. Resources include Resident Bill of Rights posted on units, care planning templates, activity calendars, dietary preference forms, family communication guides, and team meeting schedules. Unit managers, RN care coor
OUTCOMESWe evaluate effectiveness through client outcomes data, community health indicators, partner feedback, program utilization rates, and quality improvement initiatives.
