PROGRAM INFORMATION:
Referral for the Health Access Program operated under Parkdale Queen West Community Health Centre. This program is open to patients being discharged, or having been recently discharged, from the hospital into community who require increased access to health services and community support.
DESCRIPTION:
The Health Access Program is a time-limited case management focused on system navigation and care coordination program that supports newly discharged clients to transition back into the community and reduce hospital readmissions. Successful referrals will receive timely access to community support, care coordination between new and existing services, and discharge planning once service integration has been secured. Referrals are accepted by Hospitals, Primary Care, Home Care and Community Agencies. Intake workers will verify that referral criteria are met, including hospital admission and discharge.
ELIGIBILITY CRITERIA:
Clients Must be:
- One recent/current acute hospital admission
- A minimum of 3 admissions in one year for a chronic health issue
- Be in need of services, support or resources to live safely in the community.
- Be a resident of South Parkdale
Services Offered:
- Short-term case management (approximately 3 months)
- Conducts thorough client assessments of current circle of care to determine if adequate supports are in place.
- Referral and connection to a suite of holistic and clinical services to address client needs and prevent hospital admissions.
- Facilitate the development or integration of a comprehensive care team.
- Oversee care planning and care coordination.
- Accompaniments and home visits with/to clients to appointments related.
- Discharge planning into sustained wrap-around care
Health Access Navigation Services (HANS) Program
