Care Coordination

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Determined by the unique needs of each individual our Care Coordinators provide the following supports:

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• Conduct an assessment and develop an initial Care Plan

• Facilitate Advance Care Planning

• Provide ongoing psychosocial support

• Initiate referrals to hospice services

• Facilitate healthcare navigation to link with other support agencies i.e. transportation services

• Provide information and education on end-of-life issues

• Advocate for increased services

• Liaise with Community Palliative Care Physician

• Liaise with the Residential Admissions Coordinator when transition into our Residential Care Program is planned

The Dorothy Ley Hospice Community Support Team