Service Information
Regional Integrated Care
South-East Ottawa Community Health Centre
Category: Care Coordination
Target Population: Chronic Pain
Service Details
Description:

Coordinating all the services and supports that a person with multiple health conditions requires. The client will be assigned a care coordinator and work with them to identify the care team members and to develop a coordinated care plan that focuses on the client’s goals. Anyone – a family doctor, care provider, friend, family, caregiver or even a client - can identify someone who fits the criteria.


Languages: English
Eligibility Criteria
Criteria:
  • Client has 4 or more complex health conditions (at least one being a physical health condition) for example: heart disease, lung disease, diabetes, mental illness.
  • Client has at least 1 social determinant of health issue (e.g., poverty, housing) or is receiving health services from many different professionals /organizations.
 
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