Home Care - COACH Program

AKA: Caring for Older Adults in the Community and at Home Program
Provided by: Health PEI

Service Description

Provides in-home support to frail seniors with complex health needs to help them live at home longer, return home from hospital stays sooner or transition to long term care.

The program is offered jointly by professionals from the Home Care, Primary Care and Geriatric Programs who assist seniors in learning to better manage their health and make decisions that positively impact their quality of care and life.


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)
No fees
How to Access:
Contact your health care provider for a referral to the program * Health care providers include: Primary care providers (physician or nurse practitioner) * Geriatricians * Geriatric Program Nurse Practitioner * Home Care Coordinator
Documents Required:
Referral is required
Coverage Area:
Prince Edward Island

Service Locations & Contact Info