Neighborhood Health Teams (NHT)

Ensuring access to care for those who wish to age in place

At Bayshore, we understand the challenges of navigating and accessing home care services when choosing to age in place. Our dedicated Neighborhood Health Teams led by experienced nurses, are built on the principles of trust, autonomy, creativity, simplicity, and collaboration. With a focus on ensuring hands-on in-home care tailored to meet individual needs and preferences, our dedicated nurse-led teams guarantee a personalized experience. Collaborating closely with you and your loved ones, they work together to co-design a customized care plan that ensures seamless access to care at home. Our Neighborhood Nurses not only work closely with you but also collaborate with your healthcare providers and the local community to improve access to care and guide you throughout your care journey.

Our local nurses enjoy the privilege of spending quality time with patients and their families while leveraging modern technology for seamless communication, monitoring, and administrative work.

Care in the neighbourhood

Our Nurse Led Teams provide a range of services, including:

  • Telephone access to your assigned nurse and weekly check-ins
  • Home visits from the Neighborhood Nurse team lead
  • Health system navigation | Accompaniment to doctor visits
  • Phone consultation with physicians and other healthcare providers
  • Basic and complex nursing care
  • Medication administration and management
  • Wound care
  • Specialized dementia care
  • Chronic disease management
  • Palliative and end-of-life care
  • Personal support for activities of daily living such as bathing, grooming, and dressing.
  • Medication Reminders
  • Meal Preparation
  • Customized care bundles for specific daily routines, including wake-up, lunch, and bedtime services
  • 24/7 Services | Around-the-clock care

Our Care Bundles

Our nursing and personal support bundles provide access to care, regular monitoring, and preventative care in the comfort of your home. Neighborhood Health Teams work with physicians, healthcare providers, and other community resources to ensure our client’s safety and comfort at home and provide peace of mind for the entire family.

How it works – Mrs. Smith’s Example

Mrs. Smith, who is 84 years old, was recently widowed and lives alone in her family home. Three of her children live out of the province, while her youngest son lives nearby with his family. Mrs. Smith has diabetes and COPD and often finds it difficult to manage her housework and meal preparation. Since her husband’s passing, she does not feel motivated to make meals, leading to difficulties in managing her blood sugar levels. Moreover, Mrs. Smith recently suffered a fall, leading to her visit to the emergency room. Neighborhood Nurse Nancy received a call from Mrs. Smith’s son and promptly visited her in hospital. Nancy and the Smith family co-designed a care plan to ensure Mrs. Smith’s safe return home. Nancy also spoke to Mrs. Smiths physician and hospital nurses and helped the family understand what to expect next. When Mrs. Smith was discharged, Nancy was there to welcome her home. She diligently monitored Mrs. Smith’s vital signs and blood sugar levels, while administering her fragmin injection as prescribed. Nancy made regular phone calls to Mrs. Smith’s physician and her children as per Mrs. Smith’s request. Together they determined how much nursing and personal support care Mrs. Smith would need to keep her safe at home.

Nancy’s team of dedicated caregivers delivered Rise and Shine services, including a Sharp Minds visit twice a week, supporting Mrs. Smith as she regained her confidence. The caregiver and nurse visits brought Mrs. Smith joy and reassurance, knowing she could reach out to Nurse Nancy directly for any health concerns. The regular visits and monitoring of Mrs. Smith’s physical and mental well-being by the caregivers provided great comfort and peace of mind for her family.

Basic Bundle

Weekly or monthly rates available

  • This package includes 9-12 hours of caregiver support per week
    A weekly check-in by the nurse, virtual or in person
    Basic case management

Safe at home Bundle

Weekly or monthly rates available

  • This package includes 28 hours of caregiver support per week
  • 4 hours of care per day
  • 1 drop in visit by the neighborhood nurse each week
  • Accompaniment to Doctor visits
  • Free ear cleaning and other nursing services
  • Telephone case management by the nurse who can speak to the physician and help clarify questions and co-design an individualized care plan
  • Telephone access to the nurse
  • Help with errands and coordination of other services

Enhanced Bundle

Weekly or monthly rates available

  • This package includes 21-49 hours of caregiver support per week
  • 2-5 hours of in-home nursing care including wellness checks
  • All of the services in the safe at-home bundle as well as our Morning Mid-Day and Evening services

Morning: Rise and Shine services

  • Choose your times:  6-9 am OR 7-10 am OR 8-11 am OR 9-12 pm
  • includes Wake-up routine, Stretch for mobility, Breakfast, and conversations,

Mid-day: Fresh Air, Sharp Minds, and Fun

  • Choose your times:  12-3 pm OR 1-4 pm
  • includes Walk, Errands, Hobbies

Evening: Turndown Service

  • Choose your times: 4-7 pm OR 5-8 pm or 6-9 pm
  • includes End of day tidy up with laundry, Dinner and Bed time routines

Coming soon: Falls detection 24/7, & at home vital signs monitoring

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