Description:
Conduct biopsychosocial and financial assessments, including InterRAI, for clients and caregivers, identifying medical, functional, psychosocial and financial needs. Develop care plans and coordinate follow-up actions to address client and/or caregiver's needs. Work collaboratively with multidisciplinary, healthcare and community partners (doctors, nurses, therapists, Home Care staff, community partners) to ensure continuity, coordination and smooth care transitions. Provide direct counselling, emotional support, and psychoeducation to clients and caregivers, to facilitate coping with …