📽️ Video walkthroughs
Before diving in, watch the short video for your role. Each one is 2 to 5 minutes.
📽️ Getting started with Careteam
📽️ CMHCs at SHIP and PCHS: starting and building an Action Plan
📽️ Overview of the IST Action Plan Dashboard
📽️ Peel Senior Link manager: accepting invitations and building the team
📽️ Peel Senior Link manager: accepting invitations and building the team
👥 Who is this for?
Community Mental Health Counsellors (CMHCs) at SHIP and Punjabi Community Health Services (PCHS), who start and lead each client's Action Plan
The Peel Senior Link (PSL) manager, who accepts invitations and builds the PSL team on each plan
PSWs at Peel Senior Link, who support clients at home
This guide is for staff working together to support older adults in the Integrated Seniors Team (IST).
🎯 Purpose of using Careteam in the Integrated Seniors Team
Careteam replaces the paper Coordinated Care Plan with one live, shared plan for each client. The same information you already collect is kept in one place, always up to date, and seen by everyone on the client's team, including the senior and their support team.
✔️ Replace the paper Coordinated Care Plan with a live plan
✔️ Keep SHIP, PCHS and Peel Senior Link on the same page
✔️ Share updates once, instead of by phone and email one person at a time
✔️ Engage seniors and their families, including family who live out of town
🧭 What Careteam is (and is not)
A shared, live plan for each IST client, across SHIP, PCHS and Peel Senior Link
A place to share updates, tasks, resources and the care plan
A way to coordinate care between visits, and to include the senior and their support team
Careteam is not:
❌ An EMR
❌ A replacement for clinical documentation
❌ A scheduling tool
SHIP and PCHS keep documenting in CRMS, and Peel Senior Link keeps using AlayaCare, including for PSW visit schedules. Careteam holds the coordination work in between: the shared plan, follow-ups and updates everyone needs to see.
🔑 How Action Plans are created and shared
SHIP and PCHS CMHCs start the Action Plan for each new IST client
They invite Peel Senior Link and, with consent, the client and their support team
The PSL manager accepts the invitation and adds the PSW supervisor and PSWs to the team
PSL can invite more family to the plan as they become involved
At discharge, the CMHC exports the Action Plan to PDF for the EMR, then archives it
Peel Senior Link has one Careteam place for clients from both SHIP and PCHS. One shared plan follows the client from intake to discharge.
🚀 Quick start: CMHCs at SHIP and PCHS
1️⃣ Start the Action Plan
Go to People we serve, click Start new Action Plan, choose the Integrated Seniors template and click Create Action Plan. Enter the client's name and date of birth, and add their health card under Medical insurance number. Click Next, then scroll down and click Activate.
2️⃣ Fill in the care plan sections Complete My Story, My Safety Plan, My Medication Coordination and My Allergies with the client. These hold the same information as the paper Coordinated Care Plan.
3️⃣ Invite the client and their support team
With the client's consent, and the substitute decision-maker where needed, invite the client, their support team, or both: • Client: open the client's information in the About panel and click Invite • Support team: open the client's Team, click Add under Support Team, and enter their name and relationship
4️⃣ Invite Peel Senior Link
On the Team page, click Invite organization, check Peel Senior Link, confirm you have the client's consent, and click Confirm.
5️⃣ Post your intro
In General Information, edit the pre-filled "Meet your team" post with your name and phone number. Add your contact card from Resources so the client can always find how to reach you.
6️⃣ Set up My Care Needs
Add the client's current status, next steps and goals of care. Keep items short so the whole team can scan them.
7️⃣ Keep it current
• Post a Status update when something changes
• Update My Care Needs as steps get done
• Add tasks in Things to do and tag who is responsible. Tasks can repeat daily, weekly or monthly.
• Add Resources the client and family can use
8️⃣ At discharge: export, then archive
Post a final update to the client and family, and let PSL know in Status updates
Open About this Action Plan and click Export Action Plan as PDF. Upload the .zip to CRMS, then delete the downloaded copy.
Click Archive Action Plan, then Yes, archive
🚀 Quick start: Peel Senior Link
For the PSL manager
1️⃣ Accept the invite
You get an email when SHIP or PCHS invites Peel Senior Link to an Action Plan. Go to Invitations, open the invitation under External team invitations, and click Accept. The client now shows in your People list.
2️⃣ Update the team
Open the client's Team and, under Peel Senior Link, click Manage team. Add the PSW supervisor and the client's regular PSWs. Team membership is the foundation: only people on the client's team get notifications, can be tagged, and can send secure messages.
3️⃣ Share the PSW schedule
In My Care Needs, add a short line under Current status, like "PSW visits 3x weekly"
In General Information, post the details for the client and family: days, times and who to call to change a visit
When the schedule changes, update both.
4️⃣ Stay connected
Invite more family to the plan as they become involved
Check Status updates and notifications so nothing sits unseen
Respond for PSL to tags, questions and tasks
For PSWs
1️⃣ Save Careteam to your home screen
There's no app to download. Open www.careteam.me/login on your phone and add it to your home screen, so Careteam opens in one tap.
2️⃣ Before the visit
Open the client from your People list and check General Information, My Care Needs, the Safety Plan and the latest Status updates.
3️⃣ Post by exception
There's no need to post after every visit. Post a Status update when there's something the CMHC should know before the next visit, using:
What changed: what you saw or heard
What I did: any action you took
What's needed: the next step, and who owns it
Examples: a fall or near miss, missed medications, a change in mobility, mood or eating, or a new safety risk at home. Anything urgent is still a phone call.
4️⃣ Complete your tasks
Mark tasks in Things to do complete when they're done.
🤝 Where to post
Block | Who sees it | Use it for |
|---|---|---|
General Information | The client, their support team and the care team. The client and family get an email. | Messages to the client and family, like your intro or the PSW schedule |
Status updates | The care team only | Updates between SHIP, PCHS and PSL, like a fall or a missed medication |
My Care Needs | Everyone on the plan | The short summary: current status, next steps, goals of care |
👤 About client and support team involvement
Clients and their support team are invited with the client's consent
They see the plan, complete their own Things to do and view Resources
They don't see Status updates
Family who live out of town, or out of the country, can follow along from anywhere
🙋♀️ What's in it for me?
📞 Fewer phone calls and emails to keep everyone updated
📝 No more paper Coordinated Care Plan to update and re-upload
🧩 Clear view of the client's needs before every visit
👥 Shared accountability across SHIP, PCHS and PSL
🔒 Secure, centralized communication
📚 Helpful links
🔑 Careteam login
👉 https://careteam.me/login
🛠️ Activating your Careteam account
👉 https://help.getcareteam.com/help/activating-your-profile
📲 Saving Careteam on your desktop or home screen
👉 https://help.getcareteam.com/help/how-to-save-careteam-to-your-desktop-for-easy-access
📌 Pro tips for success
Post by exception: only post when there's something the team should know
Use Status updates instead of calls and emails, so everyone sees the same information
Keep My Care Needs current. It's the signal everyone relies on.
Add tasks with due dates and tag who's responsible
Check Careteam before each visit for the latest picture of care
💡 Need help?
Questions or technical issues? Contact:
📧 support@getcareteam.com
New staff: create your Careteam account, watch the video for your role above, and reach out to book a short 15-minute check-in.