Home and Community Care Contacts 2015

The Home and Community Care Program is a dynamic process that will ensure that home and community care services will continually evolve with innovative, adaptable and culturally appropriate means of responding to the identified needs in each of the communities Three Corners Health Services Society (TCHSS) serves.

At the present time, the home and community care program is the only program Three Corners Health Services Society provides under the primary health care cluster.

Program Team

The team delivering the Home and Community Care Program will consist of the Home Care Nurse or Community Health Nurse (RN), Home Care LPN and Home Support Workers. Other TCHSS staff will assist when required.

Program Management and Support

The TCHSS Director of Nursing provides supervision and consultation to the Home Care Nurse/s and Home Support Workers. The Director of Nursing also provides regular monitoring and evaluation of HCCP service delivery.

Information and Data Collection

Staff in the HCCP utilize the Mustimuhw electronic health records database for record keeping and data collection. All care plan based activities are documented on a client health record by the health care providers. Client health records are stored and handled in a confidential and secure manner. Service delivery data are collected as per the e-SDRT.

Essential Services

Client Assessment and Case Management

Requests for home care services may originate from any source including client self-referrals or referrals from family members, nurses, physicians, TCHSS staff, area hospitals, or other Band staff.  All incoming referrals are forwarded directly to the Home Care LPN. A registered nurse conducts the standardized client assessment and, if the client is determined eligible, a client care plan is developed. Clients, families or other care providers are involved in the planning of care.

The Home Care Nurse or Community Health Nurse (RN) acts as the case manager and is responsible for the development, implementation and on-going review of a care plan for each HCCP client. The care plan summarizes the needs of each client and the type and frequency of home care services required to meet those needs. The care plan also states clear goals and the expected outcomes of care. Clients are reassessed on a regular basis and care plans are evaluated and revised to reflect changing client needs.

There is timely and appropriate hospital discharge planning for acute/long term care and planning for transition from the HCCP to other services as required.

Home Care Nursing Services

The target client group for the Home Care Nurse is the frail elderly, persons living with disabilities, the chronically or acutely ill requiring home-based treatment or care and persons recently discharged from hospital requiring care. Home nursing services include, but are not limited to, the following:

  • performing nursing assessments, treatments and procedures
  • teaching and supervising self-care to clients, family members and other caregivers
  • supervising and instructing Home Support Workers regarding personal care services
  • hospital discharge planning and follow-up
  • hospital liaison
  • consultation with other health care providers
  • health education
  • wound management
  • health monitoring
  • client advocacy

Home Support Services

Home support services are determined by the client assessment and care plan. These services include the two key elements of Personal Care and Home Management.

Personal Care services include the following:

  • bathing, grooming, toileting and assistance with personal hygiene
  • assistance with maintaining specific care, activity and exercise regimes
  • dressing, mobility assistance and transferring
  • skin care, foot care, and related tasks
  • client advocacy

Home Management services include the following:

  • housecleaning, laundry
  • assistance with shopping, meal planning and preparation
  • transportation
  • companionship and related tasks

Resources and services provided under Indian and Northern Affairs Canada (INAC) Adult In-Home Program will be integrated with those of the HCCP.

Non-Essential Services

While the Home Support Worker’s main tasks are personal care and home management services with individual clients in their homes, they also provide other services such as Elders activity programs, health education and awareness activities and other related activities.

Respite Care

Respite care is provided on a short-term basis to high need clients who can not safely be left on their own; and includes companion care, light housekeeping and meal preparation. Respite care supports the role of the family as the primary caregiver. Respite care is provided in two ways:

  • in-home respite is provided by Home Support Workers for short periods of time during the day;
  • short-term out-of-community respite is arranged through the Home and Community Care Program of the Interior Health Authority.

Access to Medical Supplies and Equipment

The Home Care Nurse assists clients to obtain specialized medical equipment, medical supplies and specialized pharmaceuticals as identified through the assessment process. Equipment, supplies and pharmaceuticals are accessed through Non-Insured Health Benefits (NIHB), Red Cross Loan Program and HCCP as the budget permits.

Transportation Services

Many clients do not have access to transportation services in order to attend medical appointments, rehabilitation and therapeutic services as well as shopping and other services. Thus, as long as essential service elements are being maintained, the HCCP may provide or partner with other programs to make available transportation services to Williams Lake for clients.

Elder Activity Program

The HCCP recognizes the importance of emotional and social well-being to the health of community members. As long as essential service elements are being maintained, the HCCP may partner with other programs to provide regular elder activities, which may include luncheons, health education and information, arts and crafts, social and recreational activities and meals on wheels service.