Caring for Older Adults in the Community and at Home (COACH) Program

Caring for Older Adults in the Community and at Home (COACH)

The COACH Program provides frail Island seniors with in-home support for their complex health needs.

The program is led by a specialized team of health care professionals who support frail seniors to live at home longer and return home from hospital sooner. The team works with three partner programs – Home Care, Primary Care and the provincial Geriatric Program.  

How can the COACH Program help me?

As a client of the COACH Program, the care team will focus on supporting you to live at home. 

Based on previous participant experiences, clients were better able to manage their health and make decisions that positively impacted their quality of care and life. The program also helped provide a smooth transition to and from hospital (acute care) and to long-term care (nursing home/manor), if needed. 

Who is on the COACH team?

The COACH team includes the Geriatric Program Nurse Practitioner, your primary care provider (physician or nurse practitioner) and a Home Care Coordinator. Other team members will be determined based on your needs and can include other Home Care staff, Primary Care staff and a Geriatrician.

The Geriatric Program Nurse Practitioner will play a key role on the team, acting as the interconnecting “glue” between various areas of the health care system.  

Am I eligible?

If you are a frail senior, you may be eligible for the COACH Program if you:

  • are an older adult (65 years and over) with complex needs, including physical and 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 (for example:  dementia, falls, incontinence, depression, delirium, immobility, sleep disturbance, etc.);
  • have a referral from your primary care provider (physician or nurse practitioner) in support of receiving care from the COACH team;
  • would benefit from care coordination support, on an ongoing basis;
  • are agreeable to receive care from the COACH team; or
  • are living at home or in a Community Care Facility (long-term care residents are not eligible).

Admission to the COACH Program is based on assessed need, prioritized by available resources and approved by a panel that includes health care professionals from Home Care and the Geriatric Program.

Will I need a referral?

Yes, all Island seniors must be referred to the COACH Program by their primary care provider (physician or nurse practitioner), Geriatrician, Geriatric Program Nurse Practitioner or a Home Care Coordinator.

NOTE:  This program is not meant to replace referrals to the Geriatric Program. The COACH Program is a separate initiative for frail seniors with complex health needs.

How can I contact the COACH Program?

If you have questions or would like more information about the COACH Program, please contact your local Home Care office:


17 Knights Avenue
Souris, PE   C0A 2B0
Telephone:  (902) 687-7096


6 Harmony Lane
Montague, PE   C0A 1R0
Telephone:  (902) 838-0786


165 John Yeo Drive 
Charlottetown, PE   C1E 3J3
Telephone:  (902) 368-4790


Wedgewood Manor
310 Brophy Avenue
Summerside, PE   C1N 5N4
Telephone:  (902) 888-8440


Community Hospital
14 MacKinnon Drive
O'Leary, PE   C0B 1V0
Telephone:  (902) 859-8730

Published date: 
March 20, 2020
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