Community care resources are used to help individuals who need care and support to live independently in the community and to avoid social isolation. The main aim of providing community care services is to enable the individuals we serve to remain in their own homes and to retain as much independence as possible. Continuity and effective communication across various resources are essential to ensure that the best services are utilized. Care Coordination supports an integrated system-wide approach to care for people with chronic and complex care needs – this is accomplished by working across the interface between acute and community-based services. It aims to achieve consistency of care through clear communication, linkages and collaborative integrated care planning. This care may involve planning, logistical coordination, and advocacy, identification of personal goals and motivators, as well as education. Our coordinators are trained to advocate for and liaise between the target population and a variety of health, human, and social services organizations. They passionately support individuals by:
- Providing information on health and community resources
- Coordinating transportation
- Making appointments
- Delivering appointment reminders when needed
- Addressing barriers to engagement, ensuring a sustainable ongoing care plan for the client is established
- Supporting both client self-management and the family
Beatrice Loving Heart supports the individuals we serve with moving from a healthcare setting to the community. Follow-up and effective communication are essential to promote a successful transition and avoid a preventable health problem or re-institutionalization. Following the transition, our team will follow-up with the individual to determine how things are going. Medication management, self-care ability, compliance with follow-up appointments, satisfaction with home health or outpatient therapies are some of the areas that are prioritized. Our Team supports people who are being discharged from the hospital or any institution to connect with the supports they need to stay safe in the community. Working with community partners, our team helps clients to transition to the community, providing immediate support to prevent a visit to the emergency department; Develop a wellness plan; Find housing; Get support for mental health and substance use issues; and Access Peer Support. Our Community Transitions Team works in partnership with local hospitals, emergency shelters, and other agencies. Our Transition Coordinators work with a myriad of community services to find resources, make connections and ensure a safe changeover to independent living. We believe that with the right support, an individual can make their own decisions about where and with whom to live.