Detailed Overview

Provides care management to frail older adults with complex, acute and chronic conditions and/or adults with ongoing functional impairment in their home, community setting and/or via telephone; establishes and maintains ongoing collaborative partnerships with clients, families, Primary Care Practitioners, Home Health professionals and other community partners to optimize client capabilities and community engagement. As a member of a multidisciplinary team, provides clinical assessments, coaching, interventions, services and follow up to enable clients and their families to live confidently and safely at home; emphasizes the promotion, maintenance and restoration of health including the treatment of diseases through teaching, counselling and direct client care; facilitates and manages client transitions across the health care continuum to optimize recovery from or adapting to changes in the client's condition to minimize re-admission to residential...