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Challenges and Changes in Home Care Presentation March 6-7 2009
 

Challenges and Changes in Home Care Presentation March 6-7 2009

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Challenges and Changes in Home Care Presentation March 6-7 2009

Challenges and Changes in Home Care Presentation March 6-7 2009

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    Challenges and Changes in Home Care Presentation March 6-7 2009 Challenges and Changes in Home Care Presentation March 6-7 2009 Document Transcript

    • Challenges and Changes in Homecare British Columbia Association of Geriatric Care Physicians Conference www.bcgeriatrics.ca Maylene Fong & Heather Wright March 6th, 2009 1 Outline • Accessing Services • Key structure – who’s who • Services provided in Vancouver Community Homecare • Hospice Program • Challenges • Community Resources – Internet 2 Community Health Areas Three Bridges CHA#1 North CHA#2 (includes Pender Site) Evergreen CHA#3 Pacific Spirit CHA#4 Raven Song CHA#5 South CHA#6
    • Vancouver Community: Demographics • Housing affordability • Population: 625,000 average- $750,000 • Life expectancy: • Single parent families 17% 79 year + (F>M) 63 % low income • Unemployment • Some age groups 4.3 % (Oct.2006) increasing: • English 2nd Lang: 5 – 9 year olds 40% 80 years + • Visible minorities: 50% Vancouver Community Model Populations Served Complex 28% Chronic Unstable ry Treatment n ju re s/I Ca es Chronic Stable 62 % lln eI di c ut is o Secondary Prevention Ac Ep Well at Risk 6.2% Well Prevention & Promotion Core Functions Homecare/Case Management Team Objectives 1. To deliver homecare (eg. nursing, occupational therapy, physiotherapy, etc.) and case management services to better meet the needs of our clients 2. To provide more chronic disease management in the community setting through self-management strategies, groups, heath centre-based services 3. To develop formal partnerships between community health staff & community family physicians
    • Home Care Services • For clients who are home bound • Access number 604-263-7377 – Central Intake – Transitional Services Team (TST) • Provides link from acute care to community services • Multidisciplinary Home Care Team • Nurses, physiotherapist, occupational therapist, case manager & nutritionist 7 Home Care Structure - CHC 8 Services Provided • Discipline and team assessments • Wound care • Medication management • Chronic disease management • Home IV • Rehabilitation assessment • Assessment for home support 9
    • Client Assessment • Functional, health and mental status • Risk taking behaviours • Social & environmental conditions Determining Priority of Visit • Priority 1A: Intolerable Risk • Visit within 12 hours (same day service) • high probability of immediate negative outcome if not seen within 12 hours • Priority 1B: Intolerable Risk • Visit/Intervention within 12-24 hrs • high probability of immediate negative outcome if not seen within 24 hours • Priority 2: Tolerable Risk • Visit/Intervention within 48hrs • high probability of negative outcome or secondary complications to health, safety of client/family if situation persists over 48 hrs. Determining Priority of Visit • Priority 3: Tolerable Risk • Visit/Intervention within 1 week • high probability of negative outcome or secondary complications will occur if situation persists over 1 week • Priority 4: Tolerable Risk • Visit/Intervention within 2 weeks • moderate probability of negative outcome or secondary complications will occur if situation persists up to 2 weeks. • Priority 5: Tolerable Risk • Visit/Intervention after 2 weeks • low probability of negative outcome or secondary complications will occur if situation persists after 2 weeks.
    • Home Support Services • Based on client need, • Utilize family and community functional status, goals resources first of intervention AND client’s right to make informed choices • Maximizes ability for self care • Equitable distribution to all clients Home Support Service Areas • Personal care • Safety maintenance • Linen and laundry • Nutritional services/meals • Respite Short term hours • To support discharge from hospital and acute illness recovery
    • Convalescent care • To support temporary reduction in physical function and tolerance Palliative care • To support end of life clients – Prognosis < 6 months AND – Palliative performance measure of 50% or less Long term care hours • To support long term clients with chronic illness and disability
    • Home Hospice Program • Hospice Consult Team – Interdisciplinary Team – Supports and supplements GP care • Assist clients to die at home if they wish • Provides symptom management • Supports end of life • For more information, please call the Home Hospice Program at 604-742-4010. 19 Ambulatory Clinics • Each CHC has an ambulatory clinic • Services include: – Wound management – Medication Management – IV infusions – Rehabilitation Assessment • Referrals are through intake, TST, physician and self referrals 20 Community Resources Links • Adult Day Care Centres • STAT Centre (Short Term Assessment & Treatment) • Meal Programs and Shop by phone • Home Oxygen Programs • Caregiver Support Program • HealthLink 21
    • Challenges Impacting Home Care Services • Aging Population • Movement of acute care services to community • Early discharges from hospitals • Ageing workforce – Decreasing available staff 22 Challenges • Adult Guardianship legislation – First responders • Clients with many co morbidities • Complex medication management • Costs – back to client • Increasing acuity from hospital • Electronic Documentation • Complex medical technology i.e. pumps 23 Chronic Disease Prevention & Management Programs • Healthy Living Program • Focus on population Health, screening and CDSM – Community Pulmonary Rehabilitation Program • Kerrisdale community centre • Exercise and Education Program – VC Diabetes Education Centre • Taught in Chinese (2 day workshop with 6 month follow-up) 24
    • Emerging Practices • GP Partnerships – Pacific Spirit – Raven Song • Chronic Disease Initiatives in Primary Care • Frail Elderly Initiative – Development of standard care plan, assessments to support Frail Elderly 25 Questions? 26 www.vch.ca • http://www.vch.ca/facilities/community/vancouver.htm • http://www.vch.ca/community/home_and_community_care.htm