COORDINATIONService delivery is client-centered: comprehensive needs assessment, individualized service plans, flexible scheduling, regular progress monitoring, and coordination with healthcare providers and community resources.
INTEGRATIONIntegration in community health services involves systematic assessment, planning, implementation, evaluation. Staff trained on standards, procedures documented, outcomes monitored. Quality improvement when gaps identified. Aligns with accreditation requirements.
CONTINUITYClient learns their care coordinator at intake/within first visit/initial assessment. This happens early so client knows from the start who to contact with questions. Coordinator is assigned based on geography, caseload, expertise, or continuity principles.
TRANSITIONSWe 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
COMMUNICATIONClear, timely exchange of information between team, residents, families. Includes handoffs, conferences, documentation. Barriers addressed, effectiveness evaluated. Essential for coordination and safety.
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.
AGENCIESWe 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
PLANNINGService delivery information is in CSS-100-1 Community Services Program Policy on The Pulse. Resources include service planning templates, assessment tools, safety protocols for home visits, emergency contact procedures, documentation guides, and community resource directories. Managers an
FOLLOWClient self-referrals are triaged using our initial screening tool. Referrals from organizations include clinical info and may have different priority pathways. Both are logged, acknowledged within 2 business days, and followed up with intake assessment.
SEAMLESSWe 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
