Community Support Services

Helping seniors to live independently and with dignity

In April 2008, the North Shore Tribal Council (NSTC) implemented the Hospital Discharge Planning Services for First Nation seniors as funded by the NE LHIN Aging at Home Strategy. This service is provided by the Nurse Case Manager (NCM), who provides intensive support for seniors with complex needs, through integration of, and collaboration with, hospital and First Nation/Aboriginal community services.

Eligibility Criteria

Must be a seniors and/or long-term care member of one of the seven First Nations of the North Shore Tribal Council, or the urban First Nations, Métis and Aboriginals, residing in the city of Sault Ste. Marie.

How our Nurse Case Managers can help

Upon admission into hospital; by self-identifying yourself as a First Nation, Aboriginal or Métis senior; and by providing your Band Card Number; will initiate the services offered by the North Shore Tribal Council Nurse Case Manager. Upon receipt of the referral, the Nurse Case Manager will conduct a hospital visit to meet with you, and the hospital care team, to address your health care needs and to help to access services necessary to ensure continued care when you return home.

With knowledge of, available health and community resources and inter-professional links with First Nation community support services, primary care, Non-Insured Health Benefits, and Community Care Access Centre and others, the Nurse Case Manager is well-positioned to help seniors and their families navigate through the community and health care system.

DISCHARGE PLANNING

The Nurse Case Manager will work in collaboration with the hospital staff to address your health care needs to ensure continued care when you return home by facilitating client-centered care and service coordination.

SERVICE COORDINATION

The Nurse Case Manager will work with the hospital staff and community health providers to ensure you receive the necessary support services available to you, in order to meet your health care needs while at home (i.e. geriatric (senior) assessment, ensure appropriate referrals, prescriptions for medication, medical supplies, etc.)

FACILITATE CLIENT-CENTERED CARE

The Nurse Case Manager will work with you, your family, and your health providers to ensure that you receive the appropriate services to assist you in living at home with dignity and as independently as possible.

Occupational Therapy

Occupational therapy is a health profession concerned with promoting health and well-being through occupation. Restoring the ability to carry out activities of daily living. Occupation is everything that people do during the course of everyday life.

How Occupational Therapy Can Help

Occupational therapists uses work, self care, and play activities to increase independent function, enhance development, and prevent disability. The OT may include the adaptation of tasks or environments to achieve maximum independence and enhance the person’s quality of life.

Occupational therapists work to restore the client’s ability to carry out activities of daily living like eating, bathing, dressing, returning to work and driving, as well as independent living skills, such as homemaking and money management.

To begin, an occupational therapist will try to find out why you cannot do what you would like or need to do…

Depending on your situation, an occupational therapists may check:

Many occupational therapists use the Canadian Occupational Performance Measure (COPM) which measures change in your ability to perform occupations over a period time. It measures how important the activity is to you and how satisfied you are with your performance in it.

Depending on what the problem is, the occupational therapist can help you to solve it by:

How Physiotherapy can help

Physiotherapy is the primary health care profession that promotes wellness, mobility and independent function. Physiotherapists have advanced understanding of how the body moves, what keeps it from moving well and how to restore mobility.

Physiotherapists manage and prevent many physical problems caused by illness, disability and disease, sport and work related injuries, aging, and long periods of inactivity.

Physiotherapists are skilled in the assessment and hands-on management of a broad range of conditions that affect the musculoskeletal, circulatory, respiratory and nervous systems, including:

Depending on your situation, your physiotherapy treatment may include:

How does physiotherapy work?

Physiotherapists assess and analyze the effect of illness, disability, injury and inactivity and develop specific treatment plans based on their assessment and the individual client’s goals. In order to maximize your health potential and minimize strains and stresses to your body, your physiotherapist will follow these four steps to get you moving as optimally as possible:

1. Assess your level of mobility, strength and endurance.
2. Diagnose your condition and develop a treatment plan to restore movement and reduce limitations, including pain.
3. Prescribe and demonstrate specific therapeutic exercises, monitor your progress over time, and adjust your treatment according to your needs and preferences.
4. Prepare you for independence with advice on how to manage your condition, including education on complications and prevention of a recurring problem.

Physiotherapy Assistant / Occupational Therapy Assistant

The Physiotherapy and Occupational Therapy Assistant (PTA / OTA) is a para-professional who works as a member of our health care team under the clinical supervision of and in collaboration with the Occupational Therapist and the Physiotherapist.

Here’s what they can do:

We understand that it is very important to our clients to maintain their independence for as long as they can. Our service begins with each client being assessed by the Physiotherapist or Occupational Therapist, using standardized valid and reliable tests to measure mobility, balance, risk of falls, strength, flexibility and pain. The assessment is re-administered at regular intervals allowing the therapist to establish a pro-active plan for each client that will keep them physically fit, active, independent and safe in their home.

The PTA / OTA assists in the implementation of the care plans.

Our Service Goals