• prevents repeat admissions to Emergency Departments by assessing and supporting the individual in his/her home through referrals to multiple and relevant services
• makes referral to appropriate placement for short stay, rehabilitation, or long term care needs, including referral to Hospice for palliative care
• acts as a resource for individuals and caregivers to increase ability to assist their loved one
• supports and acts as a resource to First Nation Long-term Care nurses and personal support workers as needed 
• participates in a collaborative environment with all key health professionals to ensure patients are supported with sufficient supports while leaving the hospital and in preventing community members from returning and/or going to hospital
• coordinates some respite services

Services and Programs:

• Transportation (van)