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Primary Care Outreach To Seniors






In Person

Contact Information:




About the Program

Services for complex and frail seniors. Provided by a Registered Nurse and Community Health Worker in the home.

Additional Details

Services are provided to help seniors maintain their health and independence. All referrals are screened through a central intake to ensure criteria are met. See the criteria below.

Services offered:

  • Help with medication review

  • Chronic illness monitoring

  • Provide accompaniments to medical appointments as appropriate

  • Assist with documentation completion

  • Administer cognitive screenings

  • Help get a Primary Care Provider

  • Support with health care system navigation

  • Refer to supportive community programs

Criteria for referral:

  • 65 years old or above

  • Lives alone or isolated

  • Lacks support network (friends/family)

  • Living in poverty

  • Suffers from chronic illness and/or pain

  • Recent visits to Emergency Department

  • Recent change in memory/cognition

  • Falls in the last 3 months

  • Recent changes in mood/ behaviour

  • New medical diagnosis within the last 3 months

  • Weight loss +10 lbs in less than 2 months

  • “No Shows” for medical appointments

  • Concerns of general safety/abuse

How to Refer a Client:

Referral forms are available at:

Fax completed referral form to Central Intake at 613-739-8196.

For more information please call 1-844-726-5115.

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