DETERMINANTSA 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
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.
HOUSINGOur network includes primary care, home care, mental health/addiction services, social services, housing support, transportation, and specialized community support agencies.
INCOMEIncome 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.
EDUCATIONOngoing training for staff, residents, families. Methods include orientation, annual updates, competency verification. Documentation includes attendance, content, evaluation. Required for accreditation.
FOODClients can access our community resource directory/binder, handouts, our website, or by speaking with the social worker or care coordinator who can help navigate these resources.
SCREENINGClient 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.
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.
RESOURCESService delivery is client-centered: comprehensive needs assessment, individualized service plans, flexible scheduling, regular progress monitoring, and coordination with healthcare providers and community resources.
ADVOCACYResources for resident rights include: the Residents' Bill of Rights (posted and in admission packages), advocacy services contact information, family council information, and policies on The Pulse. The social worker can also provide guidance on resident rights issues.
