We envision a community that works together to support seniors, their quality of life and timely access to care. Registered Nurses (RNs) and Community Health Workers (CHWs) work in partnership with seniors’ primary care providers and other service providers in the community to help seniors achieve their goals, to provide care and appropriate supports that empower vulnerable seniors to live at home. RNs role includes: ongoing communication with primary care provider, medication reconciliation, chronic disease management, vital checks, health education, post-discharge follow up and/or other services as needed. CHWs role includes: advocacy, system navigation, education, health promotion & care coordination. An integrated care approach is used for all new clients (this includes completion of coordinated care plans and care conferences). The team offers clients home visits and virtual visits when appropriate. We provide services using a client-centered, strength-based approach that supports client choices.
The client eligibility criteria are: over the age of 65, at risk of hospitalization or LTC admission, inadequate caregiver support, no formal or informal support network, social isolation, low income, and/or other significant barriers, difficulties managing chronic health conditions leading to increase in ED visits, cognitive and/or functional decline.
PCO Catchment Areas Map:
Partners we work with:
To send referral contact:
ShyRose Baloch, Regional Central Intake
PHONE: 1 844 726 5115 (toll free)
South-East Ottawa Community Health Centre (SEOCHC) is a non-profit, community-governed organization that provides a range of multi-disciplinary services to address the social determinants of health.
With enthusiastic employees and volunteers, we are ready to support you no matter any time.
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