Meeting clients face-to-face in their homes allows us to:

• Overcome communication barriers
• Perform home safety inspections
• Build trust and connection
• Reduce isolation
• Meet caregivers and family members
• Ensure that services are in place and work as intended

First a nurse performs a comprehensive home-based assessment and creates a care plan that prioritizes the client’s values and goals.

The nurse then:

• Provides ongoing face-to-face and telephone follow-up
• Helps to coordinate care
• Communicates with medical providers
• Provides health education for chronic disease self management
• Advocates for clients and caregivers
• Reviews and organizes medications
• Refers and links clients to supportive services
• Navigates the complex system of care
• Offers caregiver support and education
• Facilitates advance care planning

We ultimately aim to increase our clients’ access to needed health and social support. Click here to check eligibility and to access the referral form