The Family Caregiver - The Healthcare Team

By Barbara Small

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Are you confused about the roles of the various members of the VIHA Home and Community Care Team? Don't worry, you are not alone. Figuring out the who, what and why of Home and Community Care can be daunting because unlike the hospital where the health care team directs care given to individuals throughout their stay, community health is focused on families as active participants and organizers of the care that comes into their homes.

Services provided by Home and Community Care:

- Home Care Nurses - provide assessment, teaching, treatment, counselling and monitoring. The service is provided in clients' homes, if they are home-bound, and in nursing clinics for those able to attend.

- Case Managers - carry out assessments to determine eligibility and need for home support, attendance at adult day centres or placement in assisted living and residential facility care. Case managers also provide ongoing co-ordination of services, referrals and monitoring.

- Liaison Case Managers - these case managers in the hospital organize community supports necessary to discharge clients safely home or assess for residential facility care placement from a hospital stay.

- Home Support Agencies - three agencies are contracted to VIHA to provide community health workers to assist with in-home care. These agencies work closely with the Home and Community Care team to ensure adequate home support is provided to assist individuals to continue living independently in their home and provide respite to family caregivers. This care may be subsidized, depending on the financial assessment completed by the Case Manager. In addition to the three contracted agencies, there are many private home support agencies available that caregivers can utilize, but not at a subsidized rate.

- Community Health Workers - home support workers who provide personal care and respite care to individuals in their homes and are employed by the Home Support Agencies.

- Clinical Social Workers - provide assessment and counselling for issues such as adjustment to illness, client/family anxiety, caregiver issues and advocacy.

- Rehabilitation - includes non-urgent physiotherapy and occupational therapy services in order to promote and maintain optimal functional independence in a safe home environment.

- Nutritionists - provide assessment, consultation and education to nutritionally compromised individuals who are home-bound.

- Quick Response Team - an interdisciplinary team, who provide rehabilitation, nursing, social work and home support. Their goal is to provide short-term service to prevent hospital admission and to facilitate early hospital discharge. They are involved in more urgent home assessment and treatment until the Home and Community Care team is able to take over care.

Hopefully this overview will answer some of your questions about Home and Community Care. However, next time someone shows up from the community health team and you are not sure what role they play, please ask them. They will be happy to respond to questions, or find out the answer, if they don't know it. If you are not yet known to Home and Community Care, but have questions please call the General Inquiries Line at 388-2273.

Adapted from an article by Amanda Proznick, Community Case Manager, VIHA, which appeared in The Network News, Family Caregivers' Network Society, July 2006. Next month: Coping with the Ongoing Losses Experienced When Providing Care

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