About the Program
Services for complex and frail seniors. Provided by a Registered Nurse and Community Health Worker in the home.
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.
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: http://www.seochc.on.ca/programs-services/primary-care-outreach-to-frail-seniors-pco/.
Fax completed referral form to Central Intake at 613-739-8196.
For more information please call 1-844-726-5115.