Older adults who:
-Are age 65 years or older
-Have complex physical and/or psycho-social needs
-Have had a clinical frailty assessment that indicates the need for support (Rockwood Assessment score of 6 or greater)
-Are primarily home bound due to cognitive or functional limitations
-Are experiencing one or more geriatric syndromes (ex: dementia, falls, incontinence, depression, delirium, immobility, sleep disturbance, etc.)
-Would benefit from care coordination support on an ongoing basis
-Are agreeable to receive care from the COACH team
-Are living at home or in a Community Care Facility (long-term care residents are not eligible)

Older adults who:
-Are age 65 years or older
-Have complex physical and/or psycho-social needs
-Have had a clinical frailty assessment that indicates the need for support (Rockwood Assessment score of 6 or greater)
-Are primarily home bound due to cognitive or functional limitations
-Are experiencing one or more geriatric syndromes (ex: dementia, falls, incontinence, depression, delirium, immobility, sleep disturbance, etc.)
-Would benefit from care coordination support on an ongoing basis
-Are agreeable to receive care from the COACH team
-Are living at home or in a Community Care Facility (long-term care residents are not eligible)

Older adults who:
-Are age 65 years or older
-Have complex physical and/or psycho-social needs
-Have had a clinical frailty assessment that indicates the need for support (Rockwood Assessment score of 6 or greater)
-Are primarily home bound due to cognitive or functional limitations
-Are experiencing one or more geriatric syndromes (ex: dementia, falls, incontinence, depression, delirium, immobility, sleep disturbance, etc.)
-Would benefit from care coordination support on an ongoing basis
-Are agreeable to receive care from the COACH team
-Are living at home or in a Community Care Facility (long-term care residents are not eligible)