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Home and community care

​​Description

Home and Community Care is a coordinated system of services that enables First Nations people of all ages with disabilities, chronic or acute illnesses to receive needed care in their homes and communities.

Care is provided primarily through contribution agreements with First Nation communities and aims to equal services offered to other Canadians in similar geographical areas. Care is delivered primarily by home care registered nurses and trained, certified personal care workers. Service delivery is based on assessed need and follows a case management process.

Essential services include:

• Client assessment

• Home care nursing​

• Case management

• Home support (personal care and home management)

• In-home respite

• Linkages and referral to other health and social services

• Provision of and access to specialized medical equipment and supplies

•​ Record keeping and data collection

Additional services may be provided, depending on community needs and funding availability. Support services include, but are not limited to: rehabilitation and other therapies; adult day care; meal programs; in-home mental health; in-home palliative care; and specialized health promotion, wellness and fitness.

Objectives

• Build capacity in First Nations communities to plan and deliver comprehensive, culturally sensitive and effective home care services

• Assist First Nations living with chronic and acute illness to maintain optimum health and independence in their homes and communities

• Ensure all clients who need home care services have access to services in the community, where possible

• Assist clients and their families to participate in the development and implementation of the client's care plan; and use available and appropriate community support services for clients' care

 

Elements​

Client Assessment

The structured client assessment includes ongoing reassessment and determines client needs and services required. Assessment and reassessment processes can involve the client, family and other caregivers and/or service providers.

Managed Care

A managed care process incorporates case management, care planning, referrals and links to existing services provided both on- and off-reserve/settlement.

Home Care Nursing Services

Home nursing services include: direct service delivery; supervision and teaching of personnel; personal care services; and support to family caregivers.

Home Support Services

Home support includes services such as: bathing; grooming; dressing; transferring; and care of bed-bound clients. Home management assistance can include general household cleaning, meal preparation, laundry and shopping. FNIHCC home support services are intended to enhance, not duplicate, INAC's Assisted Living services.

Provision or Access to In-Home Respite Care

This service is intended to provide safe care for clients and short-term relief for family and caregivers so that they can continue to provide care, thereby delaying or preventing the need for institutional care.

Access to Medical Equipment and Supplies

This involves the provision of and access to medical equipment, supplies and pharmaceuticals to meet client needs in home and community care.

Information and Data Collection

This is a system of record keeping and data collection for program monitoring, planning, reporting and evaluation activities, and to provide safe storage and handling of confidential client health records.

Management and Supervision

This component includes the capacity to manage delivery of a quality home and community care program in a safe and effective manner, including professional supervision/consultation.

Established Linkages with other Services

Linkages with other professional health and social services, both within and outside the community, may include coordinated assessment processes, referral protocols and service links with hospitals, physicians, respite care, therapeutic services, gerontology programs and cancer clinics.

 

 

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