Seniors with complex medical issues can be referred to the Senior Services team by their CWC PCN family physician. This interdisciplinary team provides specialized primary care with the goal of supporting seniors to remain at home in their community for as long as possible. Team members help patients access medical and community services, assist with personal needs and identify and address gaps in care.
The team can assess for a range of medical, social and psychological concerns, including:
- Safety (hazards, medications)
- Function and mobility (falls, transportation)
- Health and nutrition (diet, pain control, chronic disease management)
- Mental health (cognitive function, depression)
- Psychosocial issues (family support, abuse/neglect)
- Environmental assessments (home visits)