Hospital Discharge Services

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-Centred 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.

Hospital Discharge Services

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-Centred 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.