Community Support Services

Our Community Support Services program is committed to providing the highest quality of care for the elderly and for people living with a disability.

Our team is staffed with a Manager, Physiotherapists, Occupational Therapists, Rehabilitation Assistants, First Nation/Aboriginal System Navigators who provide Discharge Planning Services, Assisted Living Services Coordinators, and an Advanced Clinician Practitioner in Arthritis Care (ACPAC) Therapist

Coordination services include the development of community and regional program infrastructure, management of a loan cupboard, advocacy, training and program planning. The provision of outreach community based physiotherapy, occupational therapy, and hospital discharge planning services are also available.

The Occupational Therapists continue to work with clients to restore their ability to carry out activities of daily living by helping to regain lost function or adapting activities and environments to the person’s abilities, to maximize independence and enhance their quality of life.

Our Physiotherapists continue to manage and prevent physical problems caused by illness, disability and disease, work related injuries, and aging.

Rehabilitation Assistants work closely with the Physiotherapists and Occupational Therapists to help clients reach their full potential while maintaining as much independence as possible.  PTA/OTA services can include therapeutic taping, caregiver back care, cardiac rehab, and stroke rehab.

The First Nation/Aboriginal System Navigators provide discharge planning, service coordination, advocacy and facilitate client-centred care for seniors who are being discharged from hospitals to address their health care needs, and to help access services necessary to ensure their continued care when they return home.

The Assisted Living Services Coordinators assist high-risk (frail or cognitively-impaired) seniors who do not need 24-hour nursing care and can live at home, but whose care requirements cannot be met solely on a scheduled visitation basis.

Our Arthritis Management Program features one of only 54 ACPAC therapists in Canada.  Services offered include full assessment with review of symptoms and limitations, review of medical history and current medications, and musculoskeletal assessment.  Recommendations for the management of your arthritis may include suggestion of additional testing, assistance with other healthcare providers, education, and more.

Enhanced services were made possible through additional funding received from the North East Local Health Integration Network (NE LHIN). The funding was utilized to expand services to the long-term care and disabled patients who require personal support care after regular work hours and during weekends. Services are provided for individuals who require temporary services while waiting for long-term care placement, palliative care, convalescence care, or who would otherwise occupy an alternate level of care bed in hospital.

Access a searchable database of community support services in the North East LHIN at .

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.


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.


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.)


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:

  • What you can and cannot do physically (this includes your strength, coordination, balance, or other physical abilities)
  • What you can and cannot do mentally (your memory, organization skills, coping strategies, or other mental abilities)
  • What materials you use to participate in the occupation (for example, work tools, furniture, cooking utensils, clothes, or other materials)
  • The social and emotional support available to you in your home, school, work and community
    the physical setup of your house, school, classroom, work place, community, or other environment.

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:

Helping you overcome your disability

An occupational therapist may help you overcome your disability by:

Educating or instructing you on how to do things with the abilities you have. Some examples are:

  • How to remember things when your memory is poor
  • How to dress or cook using one arm
  • How to manage your time and money
  • How to use public transit when you are having problems
  • How to get around in your community, while using a wheelchair
  • How to manage your stressors
  • How to advocate for an integrative community

Suggesting activities that will help improve or maintain the abilities you have or are weak in. Some examples are:

  • Improving your coping strategies
  • Increasing your strength
  • Increasing your confidence and belief in yourself
  • Increasing your coordination
  • Improving your concentration
  • Iminimizing or preventing deformity of your hands after an injury

Adapting the tools that you use

The occupational therapist may adapt the materials you use in the occupations you want to do by making or recommending

Changes in the things you use around the house. Some examples are:

  • Large push buttons on your telephone
  • Can opener that can be used with only one hand
  • Special key holder to make turning keys easier

Changes in the things you use in sports leisure, or recreation. Some examples are:

  • A playing cards holder
  • A grasping cuff to help you hold a pool cue or a racquet
  • A knitting needle holder
  • Wrist stabilizer

Changes in the things you use at work or school. Some examples are:

  • A special chair to help you sit up straight
  • Self-opening scissors
  • Special hammers and other tools that are easier to use and prevent injury to hands and back
  • Writing boards to help keep paper still

Changes in the things you use to take care of yourself. Some examples are:

  • Clothes with velcro ties
  • Equipment that helps you put on your socks or stockings
  • Built up handles on toothbrushes, forks, spoons, or knives to help you hold them
  • Special bath or toilet seats
  • Long handled and curved brushes for hair and bath

Changes in the things you use to get from place to place. Some examples are:

  • Recommend wheelchairs
  • Special seating and positioning for chairs to help sit right
  • Car modifications such as one-handed steering wheels or hand operated accelerators/brakes
  • Bicycles/tricycles modifications such as foot straps for pedals or seat support

Recommending changes to the environments where you work

Recommending changes to the physical layout of your work place, home, or school. Some examples are:

  • Wheelchair ramps
  • Widening doorways
  • Lowering/raising desk tops, counter tops, or cupboards
  • Reorganization of living space

Recommending and finding out about the support in your community. Some examples are:

  • Self-help groups
  • Community recreational programs
  • Specialized public transportation
  • Funding agencies for transportation needs, special equipment such as wheelchairs, bath seats, or specialized computer equipment

Working with the people in your community byproviding education about a disability to the family, teachers, parish members, employers, or employees.

Working with the government to encourage people to stay healthy. Some examples are:

  • Request funding for special equipment
  • Request funding for programs such as exercise programs for Seniors, or a work training program for People with physical or mental disabilities
  • Respond to legislation that may affect your health care

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:

  • Heart and lung disease
  • Arthritis and osteoporosis
  • Stroke, brain injury, spinal cord and nerve injury
  • Amputations
  • Diabetes
  • Cancer
  • Pre-and postsurgical needs
  • Incontinence

Depending on your situation, your physiotherapy treatment may include:

  • Therapeutic exercise
  • Functional training
  • Manual therapy
  • Work hardening
  • Techniques and modalities that reduce pain
  • Acupuncture
  • Corrective techniques to improve hear and lung function and cardiac condition
  • Education

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:

  • Therapeutic Programming
  • Facilitate Restorative Care Education and Training
  • Home Support Exercise Program Trainer
  • Caregiver Back Care
  • Caregiver Lifts and Transfers
  • Falls Prevention
  • Heart Health—Cardiac Rehab
  • Stroke Rehab
  • Rehabilitation Services

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

  • To assist clients to reach their full potential.
  • To maintain or restore clients’ current abilities and strengths through a variety of physical programming designed to meet individual needs. Programs such as walking, range of motion (active and passive), and falls prevention encourage clients to stay physically active as long as they are able.
  • To deliver therapeutic exercise programs; individually or in group sessions.
  • To relearn skills or learn new ways to accomplish activities of daily living, such as ambulation, bathing, dressing and eating.
  • To enable clients to remain independent in their own homes, reduction of falls—diverting ER visits.