🎥 Quick reference video
Before diving in, watch this short video overview of how Careteam supports the program: Link
👥 Who is this for?
Staff supporting the program from Kemptville District Hospital
Staff supporting the program from Seniors Community Services
Staff supporting the program from Leeds Grenville Community Paramedics
This guide is for team members involved in coordinating and delivering care through the North Grenville Integrated Hospital to Home program.
🎯 Purpose of using Careteam to support integrated care
The North Grenville Integrated Hospital to Home Program uses Careteam to support coordinated, person-centred care across organizations.
Careteam provides a shared digital workspace where hospital staff, community partners, patients, and caregivers can collaborate in real time through a dynamic shared care plan.
Instead of relying on fragmented communication (e.g., phone calls, fax, or disconnected systems), Careteam brings everyone together on one platform—ensuring that updates are visible instantly to all members of the care team, including the patient and their support network.
Careteam provides a shared, secure workspace where teams can collaborate with patients and families in real time.
✔️ Support coordinated, home-based care
✔️ Reduce fragmented communication across organizations
✔️ Create one shared, up-to-date Action Plan
✔️ Improve visibility for patients, families, and care teams
🧭 What Careteam is (and is not)
Careteam is:
A shared, live workspace for cross-organization collaboration
A place to coordinate updates, tasks, referrals, and next steps
A way to include patients and families in the care plan
Careteam is not:
❌ An EMR
❌ A replacement for clinical documentation or encounter notes
Careteam supports what happens between visits and encounters, where integrated care coordination is most important.
🚀 Quick start guide
1️⃣ Accept the invite
You’ll receive an email when you’re invited to a shared Action Plan. Click the link in the email to accept and join.
2️⃣ Review the Action Plan
Get oriented quickly by reviewing:
Recent updates
Completed and upcoming tasks
Team members (KDH, SCS, Community Paramedics, patient, family)
Resources, documents, and checklists
🔑 Important:
KDH Social Worker is responsible for starting all Action Plans.
SCS and Community Paramedic staff do not create Action Plans—they join and collaborate once invited.
3️⃣ Add your support
Contribute to care by:
Sharing practical updates (e.g., equipment delivery, safety concerns)
Adding or completing tasks and appointments (e.g., home visits, follow-ups)
Attaching helpful resources (e.g., falls prevention, home safety)
Marking tasks complete so everyone stays informed
🔔 Good to know:
When updates are added to the Action Plan, patients and families are notified automatically—reducing follow-up phone calls and repeated questions.
🏡 Seniors Community Services (SCS) – Step-by-step: What to do
This section walks SCS staff through exactly what to do when a new referral comes in from Kemptville District Hospital (KDH).
1️⃣ Accept the invitation
You'll receive an email invitation from Kemptville District Hospital to join the client's Action Plan. Click the link and accept it to get access.
2️⃣ Update the Team
Go to the client's Team page and edit the SCS team members list so it includes everyone from your organization who is involved in this client's care.
3️⃣ Identify who to call
Before reaching out, confirm the right contact:
Open "Client Name" Information, or
Go to the Team page and find the support team members list
Click into a team member's name to view their contact details (phone, email).
4️⃣ Call the key contact
Reach out by phone to confirm receipt and next steps.
🔑 If they haven't accepted their invitation yet, let them know you're resending it:
"As I see you haven't activated your invitation to join the Careteam Action Plan, I'll resend it now—please accept it. We'll use this as our source of truth and keep it updated as things change."
5️⃣ Add your updates
Once you're set up, keep the Action Plan current:
General Information → client-facing details (e.g., changes in condition, equipment, safety notes)
Things To Do → tasks and appointments (e.g., home visits, follow-ups, referrals)
This keeps KDH, SCS, Community Paramedics, and the client/family all working from the same up-to-date plan.
🤝 How collaboration works in North Grenville Integrated Hospital to Home Program
Careteam replaces fragmented communication (phone calls, emails, fax, unsecured texts) with one shared, live Action Plan.
When:
KDH adds or updates information → SCS + Paramedics sees it immediately
SCS/Paramedics adds tasks or resources → KDH, the patient, and family see it right away
This ensures:
No stale paper care plans
No duplicated updates
One source of truth for everyone involved
👨👩👧 How patients and families participate
Patients and their invited support people are active participants in Careteam. They can:
View updates, tasks, and upcoming activities
Receive notifications when changes are made
Complete regular check-ins
Add and track personal goals
Access shared resources and documents
Including patients and families helps keep everyone aligned and supported throughout care at home.
💬 Introducing Careteam – script to use
(Client name or caregiver), staying connected and clear on next steps makes a big difference when receiving care at home. That’s why we use a secure app called Careteam—it brings everything together in one shared Action Plan.
We’ll send you an email invite today—please accept it. Your Action Plan will guide you through your care with North Grenville Integrated Hospital to Home Program, and we’ll keep it updated as things change. You’ll get notifications when updates are added, and you can also invite family members or support people you’d like involved.
🙋♀️ What’s in it for me?
📞 Fewer phone calls and less back-and-forth
🧩 Less confusion, more clarity
⏱ Time saved—share updates once instead of multiple times
👥 Shared accountability across organizations
❤️ Better support for patients and families at home
📚 Helpful links
🛠️ Activating your Careteam account
👉 View Guide
📲 Saving Careteam on your desktop or home screen
👉 View Guide
📌 Pro tips for success
Invite family members or caregivers early to strengthen collaboration
Use General Information to share important changes in real time
Keep tasks and referrals—it helps everyone stay aligned
Visit the Action Plan—it’s a living document that evolves with the client’s needs
💡 Need help?
Questions or technical issues? Reach out to:
📧 support@getcareteam.com