System Navigation Program
QFHT’s System Navigation program incorporates a Community Service Worker and a Registered Nurse who support patients with a range of conditions that often require health care and social support. Our approach is to assist patients with navigation of the health care system, social and economic support, care coordination, advocacy, linkage to community resources and coordinating care with the Primary Care Provider.
Appointments may be scheduled in clinic, over the telephone, in the community and/or in the patient’s home.
Registered Nurse can provide:
Care coordination, linkage to home supports/home care, liaison between your family physician and specialists, advocacy, long term care counselling, initiating advanced care planning, follow up post discharge from the hospital, complete a dynamic coordinated care plan, caregiver support, medication reconciliation and to ensure your circle of care are all working together,
Community Service Worker can provide:
Form assistance, financial, employment, food, housing, social, disability, frailty prevention and support resources."