Service Coordination

What Is Service Coordination:

Service Coordination is based on an evidence-based model that supports seniors in accessing services necessary to remain in their homes, whether owned or rented, for as long as possible with dignity and self-determination. Service Coordination also facilitates collaboration between community resources to better address the needs of our seniors, reduce duplication of services and maximize the value of funding sources.

Service Coordinators, working in tandem with appropriate staff, including registered nurses (RN) and Community Health Workers (CHWs), engage and follow senior clients over extended periods of time, conducting the following reoccurring activities that include: 

• assessment of the individual's needs as they age
• participation in the development of a service plan with the senior,
• identification and establishment of relationships with available services in the community
• referral to community-based services 
• providing support in accessing services
• advocating for the client with service providers
• monitoring impact of interventions