Transition Services - Community

Assists clients to access designated living options within the Edmonton Zone (Edmonton, St. Albert, Morinville, Leduc, Devon, Thorsby, Sherwood Park and Fort Saskatchewan)through assessment of individual health care needs.

Helps seniors who are part of the Seniors Health program when they need to access a different level of care by:

• assessing and documenting the situation
• determining the right level of care, program, or site to meet the person's needs
• offering support and information for the person and their family regarding designated living options
• partnering with the Community Bed Hub

What is the role of the Transition Coordinator (TC)?
The Transition Coordinator will:

• complete comprehensive client assessments to determine health care needs for continuing care services
• provide information and referrals for Continuing Care Services and/or AHS living options
• discuss and develop the transition plans with clients and their families including identified goals
• waitlist clients for appropriate Continuing Care Living Options or alternate levels of care
• assist the client and family through the transition to another health setting or supported discharge home with Home Care
• assist with connecting clients and families with other health care teams or community programs as well as recommend non- health related community services and supports