Referral Criteria: Frail older adults with complex health issues, decline in coping and/or managing day to day activities, mobility challenges, recent falls or fear of falling, medication concerns, multiple hospital admissions or Emergency Department visits, mood/memory/thinking changes as part of other health changes, recent unexplained changes in health status, changes in swallowing and/or nutritional status. Appropriate candidates are those with the potential to adequately improve functional loss in avoidance of repeat Emergency Department visits, inpatient admission or admission to long term care.
Patients may come from hospital or the community directly but no longer require nursing care, are able to be managed at home and live close enough to be able to participate in ambulatory services. Patients requiring greater than mild to moderate assistance with toileting or transfers, exhibiting wandering, exit seeking or aggressive behaviours are not appropriate for this service.
Type of Service: Offers inter-professional assessment and intervention for community-dwelling seniors who have experienced a recent functional loss or decline in coping and/or managing day to day activities.
Evidence based care includes the provision of time-limited, inter-professional therapeutic services two times per week for cognitive needs, continence, self-care, mobility, nutrition and swallowing, chronic disease management, driving concerns and secondary prevention (Physician-supported stream). There are two streams – the physician supported and the non-physician supported. Non-physician supported services include, PT, OT, SW and SLP.