Regional Programs

Regional Programs

Primary Care Outreach to Seniors (PCO)
Regional Integrated Care (RIC)
Ontario Telemedicine Network (OTN) Hub

Primary Care Outreach to Seniors (PCO)

We envision a community that works together to support seniors, their quality of life and timely access to care. Registered Nurses (RNs) and Community Health Workers (CHWs) work in partnership with seniors’ primary care providers and other service providers in the community to help seniors achieve their goals, to provide care and appropriate supports that empower vulnerable seniors to live at home. RNs role includes: ongoing communication with primary care provider, medication reconciliation, chronic disease management, vital checks, health education, post-discharge follow up and/or other services as needed. CHWs role includes: advocacy, system navigation, education, health promotion & care coordination. An integrated care approach is used for all new clients (this includes completion of coordinated care plans and care conferences). The team offers clients home visits and virtual visits when appropriate. We provide services using a client-centered, strength-based approach that supports client choices.

The client eligibility criteria are: over the age of 65, at risk of hospitalization or LTC admission, inadequate caregiver support, no formal or informal support network, social isolation, low income, and/or other significant barriers, difficulties managing chronic health conditions leading to increase in ED visits, cognitive and/or functional decline.

PCO Catchment Areas Map:

PCO sites:

• SEOCHC
• Centretown CHC
• Somerset West CHC
• Sandy Hill CHC
• ConnectWell Community Health
• Seaway Valley CHC

Partners we work with:

• Community Support Services
• Regional Geriatric Program of Eastern Ontario (RGPEO)
• Home & Community Care Support Services (H&CCSS)
• Family Physicians & Health Teams
• GPCSO
• Champlain Dementia Network
• Ottawa Hospitals including Queensway Carleton, The Ottawa Royal Mental Health Centre and Montfort

To send referral contact:
ShyRose Baloch, Regional Central Intake
PHONE: 1 844 726 5115 (toll free)
EMAIL: shyroseb@seochc.on.ca
WEBSITE: https://launch.caredove.com/service/referralform/27171
FAX: 613-739-8196

Regional Integrated Care (RIC)

RIC (formerly Health Links) creates seamless care coordination for clients with complex needs, by ensuring each client has a Coordinated Care Plan (CCP) and ongoing care coordination. Care coordination promotes a shared understanding of what is most important to the client through the establishment of a Coordinated Care Plan, inclusive of clear roles and responsibilities for each member of the client’s care team.

The client eligibility criteria are; 4+ complex health conditions (at least one being a physical health condition), at least 1 social determinant of health issue, and frequent users of health services.

For more information: Regional Integrated Care – Champlain – champlainhealthline.ca

RIC Catchment Areas Map:

To send referral contact:
Whitney Harrison, RIC Central Intake
PHONE: 1-844-726-5115 (toll free)
EMAIL: whitneyh@seochc.on.ca
WEBSITE: http://launch.caredove.com/service/referralform/27170
FAX: 613-739-8196
Toll-Free Fax:  1-844-726-3010

Ontario Telemedicine Network (OTN) Hub

OTN offers a private and secure tool to offer virtual care to clients and communication between clinicians across the province. At our site we offer, direct-to-patient video visits and hosted video visits which can include medical peripherals for physical assessments provided with nursing support. Telemedicine can be used for clinical events, direct client care, case consultations, administrative events, and educational events for clients and healthcare professionals. Anyone can request access to OTN services including healthcare professionals, organization, clients, and the general public. We are one of five OTN hub sites in the Champlain region, others include; the Ottawa Hospital, North Lanark CHC, Hawkesbury Hospital, and Pembroke Hospital.

For more information: https://otnhub.ca/

Contact Telemedicine Coordinator at telemedicine@seochc.on.ca or call 613-737-7195 ext. 2416