Hospital discharge & care transitions
When a return home raises questions about support, Elder Caring can help you understand care needs and coordinate the next steps with the people involved.
Care management in Toronto
Care Management
You don’t have to manage it all yourself.
Understand your options, bring the right support together and move forward with an experienced care manager beside you.
How we can help
Make sense of the choices.
Put support in place.
Care management connects the practical details with the person at the centre of them.
Guidance from Registered Social Workers, Registered Occupational Therapists and other allied health professionals.
- 01
Understand the needs
Assess the living situation, preferences and support already in place.
- 02
Explore the options
Make sense of care at home, community resources and assisted living.
- 03
Coordinate the next steps
Get help with care plans, transitions, family conversations and ongoing monitoring.
Looking for a senior residence? Explore our dedicated Residence Search & Selection service.
Get help choosing a residence ↗A focused first step
Start with a conversation.
Leave with more clarity.
Our Introductory Wellness Consultation gives you time with an elder care expert from Elder Caring to talk through your situation and explore the support available.
After purchase, Elder Caring contacts you by email to arrange a time.
The depth behind the guidance
What our care managers do.
Explore the assessment, coordination and ongoing support available through Elder Caring.
Assessment & a plan that fitsUnderstand the person, their preferences and the support they need.
- Registered Social Workers, Registered Occupational Therapists and other allied health professionals with many years of experience supporting older adults, families and caregivers in the community.
- Able to coordinate care and support based on the result of their assessment. The assessment may be formal (using a variety of assessment tools) or it may be informal, based on our own observations and interactions with the client and their family. We also connect with various teams and other people that may work with the person already, so that we see the whole picture, and avoid duplicating efforts.
- Able to look at the entire person ─ holistically ─ including understanding their environment, physical abilities, functional abilities, cognitive abilities, emotional challenges, and impact on caregiving within the family and or community system.
- Flexible, creative and innovative, and always try to look at the strengths and abilities of those we work with, not only their limits, in order to bring dignity and quality to their lives. Furthermore, we try to always try to keep people’s values and goals at the forefront of our work, and to keep up with and implement evolving best practices when it comes to the care of those we work with and their particular needs.
- There to plan ahead and think about future challenges that may arise, and to see the “whole picture” while being able to be focused on the details of the here and now. In today’s Covid-related world, thinking outside of the proverbial ‘box’ and being innovative in our approach to care is paramount. We work to find the best solutions for you – our client.
Coordination, resources & advocacyBring the right people together and navigate changes in care.
- Our client’s quarterback, and we provide the professional guidance to ensure everyone is on the same page as we all collaboratively develop and adjust the plan of care.
- Advocates and bridge builders in a health care system that sometimes operates in silos and only when things come to a crisis point. We try to be proactive and prevent crisis; we are also excellent at working through crisis situations.
- Knowledgeable about community resources, including how to access specialists, care at home, services from the public sector, and services from the private sector. We liaise, coordinate, and navigate between these services, taking into account the whole person and including nursing, Personal Support Workers (PSW), companionship, recreation support, music therapy, physiotherapy, and many others!
- Independent and different from the case managers working at the provincial local health authority or in a hospital. These public sector case managers and discharge planners can only do so much, as their services are quite limited by large caseloads and time restrictions imposed by government budgets. Care managers at ECI carry a considerably smaller number of clients and are all supervised by our clinical social worker supervisor. We fill many gaps in our current public system, but also work collaboratively with it.
- Different from many home health care companies’ care management roles. We see their role as being quite different than ours. Home health care companies sell personal support worker hours; many families believe that the hiring of a personal support worker is the answer to everything that is needed. Bringing in a PSW may be only part of the solution. We examine all aspects of living well at home which often includes additional supports/services than the hiring of a PSW. We always recommend using a reputable home care company when hiring a PSW.
Support for families & individualsGet guidance when you are managing care on your own or alongside others.
- Able to be there in a variety of ways for those without families and caregivers, or to support those who need extra support.
- Can act as “coaches” and do provide short-term counselling and mental health interventions as needed but refer out to psychotherapists and counsellors when longer term treatment is required.
- Recommended by satisfied clients, the public sector including Home Care, the Public Guardian and Trustee, hospital discharge planners, community-based programs and family doctors, as well as the private sector including lawyers, trust and estate financial advisors, employee assistance providers and businesses.
Benefits coverage & medical expenses
Many extended health plans cover the services of a Registered Social Workers/Occupational Therapist.
Registered Social Workers are authorized as ‘medical practitioners‘ under the Income Tax Act for the purpose of claiming medical expenses on income tax returns.
Coverage and eligibility depend on your circumstances. Check with your benefits provider or tax advisor.
As your needs change
Support beyond the first conversation.
Putting assessment recommendations into practice
Following a Functional Living Assessment, discuss a separate care-management engagement to help implement the recommendations.
Community integration & everyday connection
Elder-care assistant support can include accompaniment, engagement and time in the community. Discuss the activities, availability and scope appropriate to the person.
Dementia & specialist support
Care managers can discuss specialist input for changing needs, including dementia-related concerns. Ask about the appropriate professional, current availability and scope of support, including nurse practitioner involvement where relevant.
Advocacy & family conversations
Bring the person’s preferences and needs into care discussions, make sense of available resources and coordinate with family and professionals.
Related support
Find the support that fits.
Let’s take the next step
Tell us how
we can help.
Share a little about your situation and how we can reach you.
What happens next?
We’ll discuss your needs and help identify the right support. Any paid service is agreed with you before it begins.
Prefer to speak with us?
416-658-8887Or toll-free 1-866-473-8887