Senior care advisor

Advice no matter what your situation

Our senior care advisor hub is patterned around essential questions about knowing when to get care, where to find it, and when and how to seek more help. This is an ideal starting point, if you are caring for a senior loved one or you are senior with increasing questions or concerns. Links below point to professional, helpful content on this page or to other helpful resources and content on our website.

Content on this page is focused on publicly-funded resources and how to use those resources. This tool was originally created in 2012 and has been updated for 2018.



Facing increasing health challenges

Aging often brings illnesses, many of which are termed 'chronic diseases'. A disease is 'chronic' if it has no cure and causes persistent and recurring health consequences over a prolonged period. Some 82% of Canadians live with chronic disease. Most chronic diseases can be managed with medication and lifestyle adjustments, and seniors may live well for many years with chronic conditions that may have been deadly in their grandparent's generation.

There are a great variety of health challenges faced by seniors. In lieu of trying to cover them all, here are some useful resources regarding chronic diseases:

Family doctor/family health care team

Seniors experiencing health challenges are usually under the care of a family doctor, who will refer to specialists as required.

Family health care team

Increasingly, family physicians are grouping into family health care teams, which consist of doctors, nurses, nurse practitioners and other health care professionals who work collaboratively, each utilizing their experience and skills to manage your health.

This group approach is used for disease management and prevention, disease cure, palliative care and health promotion.

Family health care teams are usually the first point of contact for a senior who is experiencing health challenges. They can be especially helpful to older adults who need to navigate the health care system.

Options for your care include:

Your health information

Family health care teams will also be able to take advantage of specially funded information technology to organize your health information and share it securely with other health professionals.

Find out more about health care teams

For more information contact your provincial Ministry of Health.

Using a Community Social Worker or Case Manager

Social workers (also known as case managers) are trained professionals who work with citizens in the community as well as in institutions. They assist them in resolving health or other issues, often by accessing various social assistance programs.

What training do social workers /case managers have?

Social workers usually major in sociology, psychology, or another social science and take courses in related fields, such as economics, child studies, education, and political science. Graduate study often covers human growth and development, social welfare policies, and methods of social work. Most graduate schools offer work-study programs that give students experience in agencies, hospitals, or schools.

What is a geriatric case manager?

When working with seniors, social workers often assume the role of a geriatric case manager, assisting elders and their families with long term care issues.

Geriatric case manager duties include:

Seniors seeking access to government-funded support programs are assigned a social worker to assess their needs. These needs are usually based on the activities of daily living (ADLs).

Activities of Daily Living

ADLs are defined as "the things we normally do" such as feeding ourselves, bathing, dressing, grooming, working, homemaking, and leisure activities. ADLs is a term used in healthcare to refer to these kinds of daily self-care activities performed within an individual's place of residence, in outdoor environments, or both.

Health professionals routinely refer to the ability or inability to perform ADLs as a measurement of the functional status of a person, particularly with regard to seniors and people with disabilities.

Basic ADLs consist of self-care tasks, including: Instrumental ADLs let an individual live independently in a community

Evaluating a senior's ADL abilities

When assessing a senior for home care and support services, the social worker will evaluate the person's ADL abilities and recommend services to address any deficiencies, while still allowing them to maximize the abilities that are in place.

For example, a low-vision client may need special equipment, but still be able to read documents and pay bills; a client using a wheelchair may need assistance with a shower but still be capable of shopping and making meals.

Finding government-funded home care & support

How do I apply?

Referrals for government-funded home care and support services may be made by a family doctor, the senior themselves or family and friends, with the senior's knowledge and consent. The initial contact will result in the assignment of a case manager or "care coordinator".

What does the case manager / care coordinator do?

Care and support services:

Care resources are scarce and expensive, so each person's requirements are carefully assessed and the hours of care and support assigned are based on that assessment of needs.

Care and support services are delivered by health provider agencies under contract on behalf of the provincial ministry of health.

Care Services: Support Services:

Who will deliver these services to me?

Care and support services are delivered by health provider agencies under contract on behalf of the provincial ministry of health. Care will be delivered by Personal Support Workers (PSWs) who are trained in care techniques, and by Homemakers, who are trained to deliver meal preparation, housekeeping and companion services.

Facing a health crisis

A health crisis may occur suddenly for a senior, or as an expected result of a chronic illness; either way, its effect on the patient and family can be catastrophic. If the ill person has been filling the role of caregiver to a spouse or family member, the illness may create the need for a quick response from private, community and government-funded services.

A health crisis can be addressed by a number of services:

It's important to understand how Emergency departments are run, the alternatives, and some tips for preventing a health crisis.

Be Prepared

Be sure emergency information is collected, updated and accessible, including medications, pharmacy name, family doctor's name, medical history, valid health card (photo-ID health cards have expiry dates) and updated contact names and phone numbers. Families often post these lists on the refrigerator.

Attend medical appointments with your parents, meet their doctors and learn about their medical conditions. Become a partner in your parents' wellness; it will pay off when emergencies do arise.

Visiting Emergency

Medical professionals advise a visit to Emergency when any acute change occurs; in the case of the elderly, this might include trouble breathing, decline in cognition, a bad fall or perhaps excessive bleeding when taking blood-thinning medication such as aspirin.

Rather than driving your parent yourself, you may wish to call 911. The Emergency Medical Services will arrive quickly, assess and stabilize your parent, and advise whether an Emergency visit is required.

Making the Most of Your Visits

Emergency room staff strongly advise that patients bring an advocate, ideally a close friend or family member. That person should have a list of the patient's current medications and dosage, provide information as requested by the staff as to how their behaviour or condition compares to their normal state, and generally act as an advocate for the patient, who is usually confused, in pain and fearful. The advocate should also make notes about findings and recommendations.

When all patients enter Emergency, they are seen by a triage nurse who determines the urgency of their condition using a 5-level assessment tool known as the Canadian Emergency Department Triage and Acuity Scale. For example, Level 1 patients, in critical, unstable condition, such as cardiac arrest, must be seen immediately. Patients are therefore seen based on the acuity of their condition, not arrival time, nor the fact that they arrived by ambulance.

Geriatric Emergency Nurses:

A new innovation in many Emergency departments is the Geriatric Emergency Management, or GEM, nurse. This is a practitioner who will make a full geriatric assessment, including physical condition, cognitive level and home support. GEM nurses can diagnose, order tests and prescribe, working in consultation with the physician and emergency team. Their goal is to treat seniors, and to discharge them with a care plan that will ensure better long-term health and prevent future Emergency visits.

Alternatives for Emergency Care

Urgent Care Centres are clinics designed for low-acuity emergency patients, usually with a referral relationship to major hospitals. Check your Yellow Pages and/or your local hospital to learn if there is an urgent care centre in your area.

Telephone information lines such as Telehealth Ontario (1-866-797-0000) allows 24/7 telephone access to a registered nurse, who can help assess the seriousness of symptoms and suggest your options. MedicAlert bracelets, which contain medical history and contact information, and personal emergency response systems such as Lifeline allow 2-way communication to help guide your parents in assessing their problem and receiving help.

Admission to a Hospital

A health crisis will often result in admission to the hospital. Depending on the treatment, a patient may be eligible for a stay in a rehabilitation unit, either within, or affiliated with, the hospital.

Most hospitals have adopted a team approach to patient care. Hospital units contain a team of professionals including a social worker, dietician, speech/language therapist, physiotherapist, occupational therapist, psychogeriatrician, as well as doctors, nurses and specialists. Patient care is the result of the efforts and input of the team, and decisions regarding treatment, admission to rehab and discharge are made in accordance with insight from each member of the team.


Once the patient has been deemed as an alternate level of care (ALC), they are no longer considered to require hospitalization, and are ready for discharge.

Alternative Level of Care

ALC is defined as when a physician (or designated other) has indicated that the patient occupying an acute care hospital bed is well enough to be cared for elsewhere and therefore they are awaiting admission to a long term care, designated assisted living (DAL) or personal care home (PCH). This indicator is designed to assess the processes that ensure the placement of patients in the most appropriate care setting. It identifies the proportion of patients who are occupying acute care beds due to the unavailability of services in another more appropriate setting. Maintaining a lower percent of ALC days requires aggressive management and placement of the most complex patients.

Physical medicine and rehabilitation

Physical medicine and rehabilitation is a branch of medicine, which aims to enhance and restore functional ability and quality of life to those with physical impairments or disabilities, often caused by brain injury or stroke. A physician who has completed training in this field is referred to as a physiatrist or rehab medicine specialist. Physiatrists specialize in restoring optimal function to people with injuries to the muscles, bones, tissues, and nervous system (such as stroke patients). Patients are referred to rehab programs from acute-care hospitals, remain a maximum of 90 days (usually 30-45 days) and return to an appropriate level of care in their homes and communities.

Palliative care is an approach to care for people who are living with a life-threatening illness, no matter how old they are. The focus of care is on achieving comfort and ensuring respect for the person nearing death and maximizing quality of life for the patient, family and loved ones.

Palliative care addresses different aspects of end-of-life care by: lists retirement homes that support palliative care.

Palliative care may also be called hospice palliative care or end-of-life care. In some cases, these terms are used interchangeably or in combination. The field of palliative and end-of-life care includes providing care services directly to the patient, family and loved ones. It also includes the education and training of care providers, research, surveillance and advocacy. Individuals, families, communities, the private sector and governments all play important roles in the field of palliative and end-of-life care.

More information is available on palliative and end-of-life care in Canada, including information on service delivery and the involvement of the federal government at Health Canada's website,

Hospital social worker / discharge planner

A key player in this process is the social worker, who often assumes the role of discharge planner. In this role, the social worker is responsible for discharging the patient back to the community with the appropriate level of care. This may entail counseling the patient on options for housing, care and other services, since returning to the former home and lifestyle may no longer be viable for the level of care now needed. The discharge planner works with social work counterparts in the community to set up services in the home, source housing such as respite or retirement residence stays, or admission to a long-term care home. In some cases, admission to palliative care is recommended.

Long term care

Long-term care, or nursing homes, are designed for persons requiring 24-hour care. Long-term care homes provide a wide range of services for people who can no longer live independently, and may be coming from their homes with community and government support, from a retirement residence that does not offer heavy care, or from hospital.

Cost subsidies:

The provincial ministry of health subsidizes the costs of long-term care; residents must pay the accommodation portion of the cost. Additional subsidies are available if income is insufficient. Provincial ministries of health also administer and regulate these homes, which may be private, non-profit or municipally owned.

Services include:


Long-term care homes have short-stay programs for up to 60 days at a time, to a maximum of 90 days during the calendar year to provide respite for a senior recovering from an illness or surgery, or for caregiver relief.

Eligibility and Admission

The community social worker / case manager is usually the point of entry to the long-term care system. In most provinces, applications are not made directly, but after the case manager has:

Applicants must be over the age of 18, have a valid provincial health card and have health needs that cannot reasonably or affordably be met in the community, and can be met in a long-term care home.

Typical Rates – reviewed annually:

Type of AccommodationDaily RateMonthly Rate
Long-Stay Basic$53.23$1,619.08
Long-Stay Semi-Private$61.23$1,862.41
Long-Stay Private$71.23$2,166.58

If there is insufficient annual income to pay for the basic room, a subsidy is available for a 'basic' level room. Based on Canada's principles of universal health care, if a potential resident is deemed to be eligible for placement in a long-term care home, admission cannot be refused because of an inability to pay.

Choosing A Home

It is strongly recommended that you or someone you trust make appointments to visit the long-term care homes you are considering before you make a final decision.

Here is a checklist of things to consider:

Developed by Comfort Life with help from ElderCareCanada

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