Indian Brook

Home Health Care

Policy & Procedure

Manual

Program Overview

The Home Care Service Delivery plan for the community was developed with service implementation targeted

for April 1, 2001. The home care plan proposed for Indian Brook will provide all residents with more

comprehensive, equitable, and effective home care services. The program will be open to all community

members and will focus on the following areas: client assessments, case management, and liaison with

agencies currently providing services. Components of ensuring the success of this program will be:

To educated and provide more skilled home care workers to the community.

To increase and integrate the financial resources required for community home care.

To strengthen community partnerships between Band Administration, Child and Family Services

and Health Services.

With cooperation from all stakeholders from the community of Indian Brook we will have a home health

care program that will benefit all and ensure its people independence and optimal health for the future.

Values and Believes

The community of Indian Brook will provide a holistic home and community care program, reflective of its

health and social needs, which is comprehensive, accessible, effective, and equitable to all its residents with

the following values and beliefs in mind.

Residents will be as independent as possible and may require assistance within the family and

community environment in order to achieve independence.

Individuals/families will be responsible for their own care, as much as possible. All residents will have equal

access to home health care.

Support from family and the community are essential in providing care and ensuring independence for as

long as possible.

The autonomy and dignity of individuals are to be respected; clients have the right to participate in

decisions; based upon full and accurate information; including the right to:

accept or refuse offered services;

exercise a degree of control over service arrangements;

take risk regarding personal health and/or safety in order to retain or regain independence; and

appeal decisions for care and have the appeal addressed promptly and effectively

The home health care program is an essential component of the health and social services system and will be

coordinated with other service sectors, within and outside the community.

Philosophy

The Home and Community Care Program is guided by the following philosophy and principles:

People can usually retain greater independence and control over their lives in their homes than in a

care facility.

Most people prefer to remain at home and receive required services at home.

Support usually provided by family and friends should be encouraged and preserved and, if

necessary, supplemented.

Services should assist individuals and families to avoid unnecessary dependencies and retain

maximum independence (including access to needed equipment).

People with greatest need for home care should receive priority for service.

Individuals and their supporters should help identify their needs, establish goals, and develop

plans to meet goals.

Home and Community Care should acknowledge, recognize and respect all tribal cultures, traditional

values and beliefs within the holistic concept of healing.

Home and Community Care should respect a person's right to live at risk and accept or refuse

services.

Home and Community Care should assist people to access needed health and social services.

Home and Community Care should preserve and promote volunteer involvement.

Local programs should have significant responsibility for planning and delivering Home and

Community Care services.

Home and Community Care should participate in planning and coordinating local health and

social services.

Elders have gained their wisdom through observing, experiencing and participating in life. They are

the communicators of wisdom and should be involved in Home and Community Care in an advisory

capacity.

To be flexible and adaptable in addressing change trends in client's care needs.

To respect a person's right to live and to accept or refuse services.

To maintain confidentiality at all times.

To bring health and wellness to the lives of our clients.

To commit to professionalism and quality in Service Delivery

Home and Community Care's Mission

"The Indian Brook First Nation Home and Community Care Program aims to preserve and maximize an

individual's ability to remain independent at home by offering services that provide needed care and

support."

"The long term goal is to provide a full range of preventive, therapeutic restorative health services to the

community, so that appropriate home and community care services are available and utilized as responsible

alternatives to institutionalized care."

Goals and Objectives

Goal:

To assist clients to live in the community as independently as possible, preserving and encouraging

enhancement of the support provided by the family and community.

Objectives:

provide a single access point for both health services and support services for individuals needing

home and community care

integrate health promotion goals and practices in care plans and in the provision of care

provide clients with a consistent, comprehensive and client centered assessment of need,

utilizing other health disciplines when required

develop a client-centered, mutually agreed upon care plan, defining a service delivery and

expected outcomes

teach clients, families and other to provide care to promote self-reliance and efficient use of resources

encourage visits to the Health Centre for the provision of treatments whenever possible

coordinate services required by client, including assisting clients to gain access to related services

to meet identified needs

maximize the use of volunteers in meeting identified needs by encouraging expansion and/or

formation of volunteer organizations, creating links with them and other agencies in the community

develop, monitor and revise standards of care on an ongoing basis to ensure clients receive

appropriate services

begin discharge planning immediately on admission

Goal:

To work in partnership with other services providers to increase the effectiveness of community care

and to eliminate gaps and duplication of services.

Objectives:

Develop collaborative working relationships with community health, local hospitals, hospital

liaisons, mental health, social services, schools, physicians and other service sectors to

eliminate duplication of services and to improve the client's ability to gain access to needed services.

Develop a Home and Community Care Advisory Committee involving member from different

agencies within the community.

Develop an Eligibility Review Committee (ERC) involving health team members and

members from other community agencies.

Program Area Objective Activity Performance

Indicator

Data

Home Nursing: to increase individualized number of persons -client records

Adult Diabetes knowledge of teaching and with diabetes -client booklets

persons with guidance for taught and in which

diabetes of how clients to demonstrated glucose is

to monitor their

blood glucose

monitor glucose

records

knowledge recorded

Home to assist those in general number of persons -number of

Management need with household receiving clients satisfied

general

household

cleaning

cleaning assistance with the service

Respite care to provide to provide relief Number of -number of

respite care to to family and/or caregivers caregivers

families to care givers fora receiving respite receiving

decrease the short period of and levels of stress

tress

respite

level of stress time is decreased -client chart

Personal Care to provide to provide number of clients -number of

personal assistance with receiving care and clients

assistance for daily living satisfied with the receiving -care

those unable to

care for

themselves

activities service client charts

Foot care to provide foot to provide foot decrease of -decrease in

care for clients care services in complications and complications

to prevent the both clinical and satisfaction from

onset of

complications

home to those

assessed in need

clients

Section 1

Job Descriptions

Position title: Home Health Care Administrator

Reports to: Health Director

Position Summary:

Home Health Care Administrator will coordinate home care services and provide functional supervision

of support care personnel in cooperation with the Home Health Care Nurse other agencies.

Duties and Responsibilities:

Receive referrals for clients across the life span, with varying health needs from institutions,

community agencies and individuals.

Acts as a consultant and community resource person in order facilitate access to services for eligible

clients.

Establishes and maintains close liaison with families, significant others, attending physicians, and other

health care providers involved in the client's care.

Mobilizes and coordinates the other health and social resources required to permit clients and their families

to function as independently as possible, both as individuals and as a family unit.

Plans effectively with staff providers to ensure all cases are managed and assess equitable and the best

possible care is provided.

Teach Home Care Workers, according to policy guidelines, in conjunction with the Home Health Care Nurse.

Coordinates and participates in quality assurance activities as requested.

Reviews case workload weekly to determine priorities and make appropriate referrals. Coordinates in staff

development and participates in further education as required; maintains confidentiality according to policy

guidelines.

Administrates the overall function of the Health Care Program.

Plans effectively and provides for the Mental Health component of the Home Health Care Project. Other

related duties with administration of the Home Health Care Program.

Liaison inter-agency with other key resources and/or programs.

Prepares and submits month end statistical reports and quarterly activity reports to the Health Director.

Provides supervision of assigned workers in the Home Care Program Position

Qualifications:

Successful completion of the following:

Masters Degree in Adult Education

5 years experience in Administration/Coordination of Projects

Diploma in accounting/financial statements

Knowledge of the Home Health Care Program

Knowledge/awareness of First Nations Culture is preferred

Micmac Language is preferred

Current CPR/Basic First Aid certification

Possession of a valid driver's license

Authority:

The Home Care Nurses and Home Care Supervisor work under the direction of the Home Health Care

Coordinator/Administrator.

Position title: Home Health Care Nurse

Reports to: Home Health Care Coordinator

Position Summary:

Home Care Nurse will provide home care services and provide functional supervision of support care

personnel in cooperation with other agencies.

Duties and Responsibilities:

Promote self-care and independence by providing home management instructions to individuals, families,

and other groups of people.

Assist the Home health Care Coordinator in maintaining close liaison with families, significant others,

attending physicians and other health care providers involved in clients care.

Coordinates the gathering of services provided by Personal Care Workers through the collection of weekly

hour’s submissions, weekly activity reports, etc. and prepares appropriate recording of such for the

administration of payroll and benefits.

The nurse will organize care plans to ensure that the resources work in concert to improve or maintain the

client's/family's ability to function at the best level possible both as individuals and as a family unit.

Maintains client records in the approved in the approval format, ensures the documentation meets the legal

and medical requirements, and ensures records provide for continuity of care.

Maintains working relationship with the Home Care Workers and other Health Care providers. Plans

effectively with the client and family and others care providers for discharge. Participates in

quality assurance activities as requested.

Reviews case workloads weekly to determine priorities and make appropriate referrals.

Reviews, reassesses and revises; with client, family and the other care providers; the client's progress,

which may include planning and attending case reviews and client conferences, if required.

Provides supervision of assigned workers in the Home Care Program.

Participates in further education as required.

Maintains confidentiality according to policy guidelines.

Teaching background in nursing/coordination skills and case management/care plans Position Qualifications:

Current registration with the Nurses Association of N. S.

Successful completion of one of the following:

Baccalaureate degree in nursing from a Canadian University or recognized equivalent, or a certificate

or diploma in nursing or community health nursing from a recognized postsecondary institution.

Preferably one year of acute care nursing experience. Experience in home care/community health nursing

would be an asset.

Knowledge/awareness of First Nations Culture is

preferred. Current CPR/Basic First Aid Certificate

Possession of a valid driver's license.

Position title: Home Care Supervisor

Reports to: Home Health Care

Coordinator Position Summary:

The Home Care Supervisor will assist the Home Care Coordinator with the coordination of the home care

services and provide clerical and management supervision of support personnel within the Home Health

Care Program.

Duties and Responsibilities:

Assist the Home Health Care Coordinator in the planning, implementation, and evaluation of the Home

Care Program.

Receives referrals for clients across the life span, with varying health needs from institutions, community

agencies and individuals. Acts as a consultant and community resource person in order to facilitate access to

services for eligible clients.

Assist the Home Health Care Coordinator in mobilizing and coordinating the other health and social agencies

required to permit clients and their families to function as independently as possible, both as individuals and as

a family unit.

Assesses the needs of the persons who cannot function independently in the community, and of their

families, according to policy guidelines.

Collects relevant information related to client's needs, conducts nursing assessments, makes nursing

diagnosis, plans, implements and evaluates the plan of care for clients who may present at any point in the

life span with varying health care needs.

Establishes and maintains close liaison with families, significant others, attending physicians, and other

health care providers involved in the client's care.

Assist the Home Health Care Coordinator in gathering information related to the client's needs and

participates in the assessment process.

Participate in all staff development and team meeting sessions.

Conducts home visits of all Elders and clients who are receiving home care services to review and evaluate

the service provided and client satisfaction.

Maintains client records in the approved in the approval format, ensures the documentation meets the legal

and medical requirements, and ensures records provide for continuity of care.

Participates in quality assurance activities as requested.

Maintains a working relationship with the Home Care Workers and other health service providers. Maintains

confidentiality as per policy guidelines.

Other related duties and services assigned by Home Health Care Coordinator.

Position Qualifications:

Knowledge/awareness of First Nations Culture is preferred and preferably a person of First Nation ancestry.

Current CPR and Basic First Aid Certification

Experience supervising and coordinating staff and services.

Possession of a valid driver's license.

Authority:

The Home Care Supervisor works under the direction of the Home Health Care Coordinator.

Position title: Home Care Worker

Reports to: Home Care Nurse

Position Summary:

Home Care Workers are trained to provide both personal care and home management support services to

clients. The objective of this position is to provide home management, personal care, and respite assistance

to clients based on the assessed need. The goal is to promote the clients ability to live independently in the

home.

Duties and Responsibilities:

Personal Care

Assistance with activities of daily living such as bathing, grooming, dressing, feeding, toilet

transferring and getting ready for bed.

Care of bed bound clients including turning, back rubs, and routine skin care.

Activation including physical exercise and activity/mobility.

routine foot and nail care inspection.

Respite care consisting of supervision of activities of daily living for persons who cannot safely be

left on. their own doe to frailty, or some other functional disability. General household cleaning

including seasonal cleaning.

Assisting the family to provide care for the dying in the home.

To be willing to work odd hours and some weekends.

Maintain accurate records of care given and health status changes observed in the Clients.

Observations, changes or accidents are to be reported immediately to supervisors.

Keep knowledge current through attendance at training projects and workshops available.

Home Management Support

Promoting self-reliance

o General household cleaning including seasonal cleaning

o Menu planning and meal preparation

o Budgeting

o Shopping

o Care of children

o Laundry, ironing and mending

o Changing linens

Position Qualifications:

Knowledge/awareness of First Nations Culture is preferred and preferably a person of First Nations

ancestry.

Must be highly respected in the community.

Ability to work well with others.

Must have demonstrated in caring for the elderly and disabled.

Ability to accept supervision.

Ability to maintain confidential information.

Successful completion of an accredited Home Care Workers training course.

CPR and Basic First Aid certificate.

Life experiences

Authority:

A Home Care Worker is under the direction of the Home Care Nurse/Coordinator

Position title: Support Worker

Reports to: Home Care Nurse Coordinator

Position Summary:

The Support Worker is an untrained staff person who provides home management services to clients.

Duties and Responsibilities:

General household cleaning including seasonal cleaning

Menu planning and meal preparation

Care of children

Laundry, ironing and mending

Changing linens

Shopping

Position Qualifications:

Knowledge/awareness of First Nation Culture is preferred and preferably a person of First Nations

ancestry.

Life experiences

BLS/CPR

Authority:

The Support Worker works under the direction of the Home Care Coordinator.

Comparison: Home Care Nurse versus Community Health Nurse

Home Care Nurse Community Health Nurse

Services are case coordination/treatment

services that require a registered nurse.

Services are largely for health assessment,

teaching, counseling, support and referral.

Works with clients who have a specific Works with individual and groups who are

diagnosis; and with their families. fairly healthy; health promotion.

Primarily case coordination/hands on Primarily prevention, but includes monitoring

intervention such as wound care, parental

therapy, palliative care, etc..

blood glucose, medications, blood pressure,

etc..

Surveillance and treatment of high risk acute Surveillance is follow-up of low risk stable

illness, unstable chronic illness/disability. clients or to detect unknown illness.

Clients are referred for services (by F.P, CHN,

family, friends, etc..).

Nurses do case findings.

Nursing care and treatment is required more Chronically ill, disabled, or elderly clients may

frequently but criterion is more important than require visits fairly often; does not require

frequency. treatment.

Home care nurse identifies the need for home

care and refers to homemaker, dietician,

doctor, etc..

May make referrals to doctor, TP, OT,

dietician, etc..

Supervision of medication may be required for Supervision of medication maybe required for

unstable conditions. stable conditions.

Position title: Community Health Representative

Reports to: Health Director

The CHR's activities are usually planned and implemented in consultation with the Community Health

Nurse. Their role is primarily in three areas;

1. Provision of Direct Health Care

Specific responsibilities might include:

assessing home situations

assisting with health related problems through counseling, and/or referral to

appropriate agencies

teaching families about dental care, communicable diseases, mental health, child

development, drug abuse, etc..

prenatal health teaching

assisting families to cope with chronically ill, sick and aged family members

working with other health professionals in obtaining health histories

providing emergency first aid when necessary

assisting and implementing with school health programs

2. Liaison Activities

Specific responsibilities might include:

advising other health personnel about local Indian culture and traditions and their

implications on specific health problems

assisting in planning, implementing and evaluating programs for the community

participating in health clinics as necessary

making hospital visits to community members

interpreting health programs and services to the Indian people

attending meetings as requested

3. Community Development Activities

Specific responsibilities might include:

working with existing community groups, and assists in the development of others, to

improve the health of the community; and

conducting and assisting in workshops, short courses and health education programs

about topics of interest to the community

Section 2

Rights and Responsibilities

Policy: Confidentiality

Policy:

All clients information is to remain confidential. All staff having access to client records will be

responsible for keeping client information confidential. Upon review of the following guidelines, staff will

be asked to sign an oath of confidentially, which will be kept on the employee's confidential file.

Guideline:

1. Confidential client information, in health services context, includes all personal information about

the client which has been communicated to the agency or individual in the course of providing care

or assistance. In addition to information relating specifically to health services, it may include

information about the client’s financial affairs outside activities, and family members.

2. It is the client's right and expectation that this information will be respected

safeguarded by all staff.

3. Disclosure of information is permitted only in the following instances:

where the client consents to such a disclosure;

where there is a statutory duty or other reason (such as the requirement to testify in court)

requiring such a disclosure and following presentation of a court order identifying the

information required;

where there exists an emergency situation which necessitates such disclosure to protect

life.

4. Client information may be shared with those directly involved in the client's care and with other

health agencies and home care workers involved in the client's care. This information must be

relevant to the client's care, in the client's best interest and not detrimental to the client. Clients must

be made aware and agree that relevant information will be shared in an interdisciplinary manner

where it is in the best interest of the client. All other information can only be released with client's

prior consent, or in the instance of incompetent clients, written consent must be provided by the

client's relative or legal guardian / other delegate.

5. Request from non health agencies are to be referred to the Review Committee. A written request

and the consent of the client is required in these instances. If the client is deceased the information

will only be released with a court order or the written consent of the estate.

6. Unjustifiable disclosures are those made without the client's prior consent and are

prohibited.

7. Staff must be aware of confidentiality in all situations at all times.

8. Client records are legal documents. All staff working within the Home Care Program are responsible

for the security of the clients records in their possession and must make every effort to ensure that all

client information is locked in a secure area.

See Oath of Confidentiality in the appendix section of this manual.

Policy: Oath of Confidentiality

Family Name:_____________________________________

Given Name:______________________________________

I solemnly and sincerely affirm that I will faithfully and honestly fulfill the duties that devolve on me by reason

of my employment in Indian Brook Home Health Care Program, and that I will not, without due authority in

that behalf, disclose or make known any matter that come to my knowledge by reason of such employment. I

acknowledge that, subject to all lawful exceptions, should I breech my duty of confidentiality in any matter,

my employer has that right to dismiss me without giving prior notice and without payment in lieu of notice,

and my employer may further seek damages from me by action in a Court of Law, for the disclosure of any

information concerning the business and affairs of Indian Brook Home Health Care Program and all

matter relating to clients of Indian Brook Home Health Care Program.

Signature: _______________________________________________

Affirmed and subscribed before me at the place and date mentioned below.

City/Town: _______________________________________________

Province: _________________________________________________

Date:_______________________________________________

Signature of person administering affirmations: _______________________________________________

Policy: Consent for Care

Policy:

The client and/or family are required to provide written consent for care and agreement of a care plan task list

of services to be provided.

See Consent for Care, Care Plan Task List in appendix section of this manual.

Procedure:

1. Upon referral for Home & Community Health Care Services arrange a time for a nursing visit

suitable to the client and/or family.

2. Introduce yourself to the client and/or family.

3. Describe the Home & Community Health Care Program.

4. Explain the consent for care to the client and/or families to ensure it is understood and ask the

client and/or family to sign it.

5. Assess the client and/or family and formulate the care plan.

6. Give a copy of the agreed care plan task list to the client and/or family. Other copies of the care

plan task list will for the client's home health care chart and the Home Support Worker.

7. Document the client's and/or family's participation and approval of the care plan on the client's

worksheet.

8. Always explain treatments to the client and/or family prior to performing them.

9. Do not provide services or treatments if the client and/or family refuse it.

Consent for Care

Name of Client:__________________________ Date:___________________________

I hereby consent to Indian Brook Home Health Care Program, its personnel and such other persons

as it may select and retain, to provide home health care services.

I authorize and consent to the performance of treatment and incidental services required as stated care plan.

I understand that I and/or my family/care giver will be taught that home care procedures required for my

treatment and care as outlined in the care plan to enable us to provide as much care as possible ourselves.

The home care services have been explained to me and I understand that nature of the services.

I understand that my health information may be shared in an interdisciplinary manner with other health

professionals when that sharing of information is in my best interests.

This information will not be disclosed to any other person(s) without my written consent, except when

disclosure is authorized under the Privacy Act.

______________________________

Signature of Client Date

Witness Date

If the client is unable to sign by reason of age, mental or physical disability, complete the

following:

The client's age is _________ years. The client is unable to sign because ___________________

As parent/guardian of the client, I am signing this consent on the client's behalf.

Signature of Parent/Guardian

Name and Relationship to Client

Witness Date Time

First Nation Home Health Care Program

Care Plan Task List

Name

Address Phone

We have agreed that the Care Plan will include help with the follow tasks (please check):

Personal Care Homemaking Task Client/Family

Responsibility

When

(times/day/week)

Bath Bedroom cleaned

Oral Care Bed change

Shampoo Sweep/Wash floors

Shave Vacuuming

Skin Care Bathroom cleaned

Foot/Nail Care Dusting

Dress Kitchen cleaned

Feeding Fridge cleaned and/or

Defrosted

Toilet Transfer Stove top cleaned

Transferring Oven cleaned

Turning &

Positioning

Laundry/Ironing/

Mending

Activation Dishes cleaned & dried

Back rubs Meal planning &

preparation

Respite Shopping

Companionship

visits

Care of Children

Baby Care

Other Seasonal cleaning

Empty garbage

Other

Please notify Home Care Support Worker if you will not be home for service.

Please note that Clients must supply all cleaning and cooking supplies.

Home Care Nurse Coordinator Signature: _____________________________ Date: ___________

Client/Family Signature: ___________________________________________ Date: ___________

Policy: Consent for Release of Information

Policy:

Disclosure of specific health information will only occur with the written consent by the client except when

disclosure is authorized under the Privacy Act.

Authorization will:

Be in writing and contain the signature of the client, family next of kin and/or the legal guardian as well as a

witness;

be dated;

specify the name and title of the person and the institution intended to release the information;

include a description of the specific health information to be disclosed;

specify the name and title of the recipient of the information to be disclosed;

specify the name and the title of the recipient of the information;

include an expiration date or time limit for validity of the authorization:

specify that the client may rescind or amend the authorization in writing at any time.

Procedure:

1. Complete the Consent for Release of Information (see records section of the manual)

2. Copy and write "Not to be Duplicated or Shared".

3. Send authorized copies of the information to the agency/professional requesting the record, retaining the

original documentation for the client file.

Policy: Consent for Release of Information

Consent for Release of Information

Re Name: Date of Birth:

having received services from

I hereby consent to the release of the following information:

To (name of agency/professional): I

Let this consent be deemed valid for the period of _____________________________ from the date hereunder.

I reserve the right to rescind or amend the authorization, in writing, at any time prior to the expiration date,

except where action has been taken in reliance on the authorization.

Dated at_____________this____________day of____________________,2009

________________________________ _____________________________

Witness Signature of Client

_________________________________

Address

If the client is unable to sign by reason of age, or mental, or physical disability, complete the

following:

The client's age is years. The client is unable to sign because

As parent/guardian of the client, I am signing consent on the client's behalf.

Signature of Parent/Guardian: ________________________________________

Name and Relationship to the Client: __________________________________

Witness: Date:

Time:

Policy: Refusal of Treatment/Withdrawal of Consent

Policy:

It is the client's right to refuse treatment or advise offered by the staff of Home & Community Care Program.

Procedure:

1. Discuss with the client reasons for refusal of treatment/advise to determine if it is based on accurate

information and rationality. If the reasons are based on a conflict with the care giver, offer to send in

another person, if possible.

2. Documenting the client's file the discussion with the client regarding refusal of the treatment or the

advice. If consent has been signed, write Refusal or Withdrawal across the consent form in red ink

and have the client date and sign the form.

3. Verbally notify the physician, if necessary, of the client's refusal and document on the file.

4. Verbally notify the next of kin of the client's refusal and document on the file.

5. If the client is at extreme risk due to refusal of care, always verbally notify your supervisor and

document on the client file.

6. Approach individual after a reasonable length of time, especially if high risk, to see if that stated

reason for refusal or withdrawal of treatment still apply and assess readiness to consent. If consent is

obtained, have the client complete a consent form.

7. Render the best care possible within the limits imposed by refusal of treatment if the client is still

receiving other home care services.

Policy: Incident Reports

Policy:

Incident reports are to be completed by home care staff when an unusual incident (medication error, treatment

error, sharps injury, fall, assault, etc..) occurs. .

Procedure:

1. Complete the Incident Report (in the records section of this manual) and forward to your

supervisor. Verbally contact your supervisor immediately if the situation warrants.

2. Document the incident on the client file if it involves the client.

3. The supervisor will complete the follow-up required.

4. The confidential internal incident report is forwarded to the Director of Health and Home &

Community Care Coordinator.

Policy: General Responsibility

Policy:

The Indian Brook H.C. Program, is committed to providing program that will assist and enable all

residents with health problems maintain optimal health and independence in their homes and community.

The program aims to supplement and support, not to replace, the care provided by.

Policy: Client/Family Responsibility

Policies:

1. Individuals/families will be responsible for their own care, as much as is possible.

2. Any new referrals for Home & Community Care will be assessed by the Nurse and will be provided

service by a trained staff member. Previous adult care clients will be given the opportunity to enter in the

Indian Brook H.C. Program, based on assessment by the nurse, hours and services provided may change.

It is hoped that family members will willingly participate in their loved one's care without

reimbursement for services.

3. The client and/or family is responsible to provide an environment that is safe and suitable for the provision

of home health care services.

4. A Home & Community Care staff member may provide service to a family member if all of the following

circumstances apply;

it is an assessed need;

the need is based on a professional assessment and care plan

the care provider holds the qualifications and training required to provide the service

the service follows the care plan and is closely supervised

the Confidentiality Policy is strictly enforced

the Review Committee approves the care being provided by a family member

the staff member and/or client have the option to refuse if they are uncomfortable about the

situation.

Definition of family

Immediate family means: husband, wife, daughter, son, mother, father, mother-in-law, father-in-law, common-law

spouse, step-mother, step-father, step-son, step-daughter, sister, brother, foster parent, and custom adopted child.

Policy: Service Providers Responsibility

Policy:

The Indian Brook H.C. Program is responsible to ensure that staff:

promote independence and self care and preserve dignity;

promote informed decision making;

accept a client's right to risk;

reinforce personal responsibility for health and health care;

respect the privacy of individuals and their families;

deliver quality services to clients based on established procedures and standard;

participate in professional development as it arises.

Policy: Client Rights

Policy:

Each client has the right to individuality and recognition of his/her uniqueness by recognition of the

following basic rights:

to be treated with dignity, respect, and courtesy;

to privacy;

to self-determination and the right to accept risk;

to participate in decisions, stated preferences, and make choices regarding care, treatment and

personal lifestyle;

to maintain relationships with family and friends;

to have his/her person and property respected and protected.

It is the responsibility of each employee and provider of service for Indian Brook H.C. Program, to safeguard

these rights of the client.

Policy: Clients Rights Regarding Appeal

Policy:

A client, family member or anyone directly involved in a client's care has the right to appeal decisions

regarding:

eligibility and admission decisions;

assessment for service levels to meet client needs;

service schedule or discharge and;

quality of care.

Appeal Process

1. The Home Health Care Program has two levels of appeal.

2. The first level of appeal must be make to the review Committee. Every effort will be made to resolve

the client's concerns at the lowest possible level of authority.

3. The second to the Appeal Committee appointed by Chief and Council. The Appeals Committee

should be make up of three unbiased persons and one of these acting as chair of the committee.

4. The Home Care Nurse Coordinator and Chief and Council are responsible for ensuring that the

Appeals Committee has adequate understanding of the Home Health Care Program and its policies

and procedures.

5. The Home Health Care Program should request that appeals be make in writing to the Home Care

Nurse Coordinator and that they include an explanation of the basis for appeal.

6. The Review Committee must conduct a review of the case within two weeks of receiving the

appeal.

7. The Review Committee must conduct a review of the case within two weeks of receiving the

appeal.

8. The decision of the Review Committee stands until the appeals Committee has make its

decision.

Assessment Team Eligibility Review Committee Appeal

Committee

(Names) (Names) (Names)

9. The Appeals Committee must hear an appeal within one month of receiving it.

10. The Appeals Committee must render its decision within six weeks of the hearing.

11. The Appeals Committee must hear from representatives of the Review Committee and from the

client or advocate and may invite opinions from appropriate others.

12. The Appeal Committee must provide a copy of the appeal decision, including the rationale from the

decision, to the Review Committee and to the client and/or advocate.

13. The decision of the Appeals Committee is final.

Framework for Appeal

The following details maybe included;

Client name

Age

Diagnosis

Physical health history

Reason for the appeal

Family situation

Financial situation

Care plan which is being appealed

The care plan the client and/or advocate wishes

Details of the appeal

Family support

Activities of daily living

Current services

Alternatives for service

Other appropriate information

Policy: Clients Rights Regarding Assessment

Policy:

Individuals are major participants in the assessment process. All applicants have the right to:

a) have their views and desires recorded during the assessment

b) choose whether a third party is present during the assessment process

c) be present if an advocate or translator is required for the assessment interview

d) refuse to answer any questions or to refuse to undergo any or all of the assessment

process

e) view the client assessment record on request and to restrict its release to third parties

f) be consulted before the views of the third parties are sought, and to approve, restrict, or

deny such access and

g) be fully informed of the program's services and to participate in the care planning

process.

Nurse Coordinators ensure that all applicants or their advocates are informed of their rights prior to the

assessment interview.

Nurse Coordinators are responsible for advising applicants, or their advocates, of any possible

consequences of their decisions regarding the exercise of rights.

No applicant is automatically refused admission to program because of an unwillingness to co-operate fully in

the assessment process. The Nurse Coordinator and Review Committee will decide each case by reference

to available information.

Policy: Information to Client

Policy: 2.12

All Clients and/or family will be provided with information about the Home Health Care Program including:

the services

the client's rights and responsibilities for his/her care

the care plan

how to contact staff during and after regular working hours

time and duration of the home support worker's visits, nurse's visits, other services

limitations of services

Policy: Clients Records Policy: 2.13

Indian Brook H.C. Program will maintain records on all clients admitted to the home care program for the purposes of

case management and accountability.

The client's record maintained by the program is the property of the Indian Brook H.C. Program.

The client retains the right to view his/her record. Upon request for viewing an appointment should be made with the

Coordinator. Do not provide copies of the record.

All client records are considered confidential and are covered by the Confidentially Policy. All copies must be kept in secure

cabinets that must be locked when not in use.

Retention, storage and destruction of records will be consistent with provincial Department of Health policies and

procedures for Record Retention.

The Client's file is a legal record that includes at minimum, the following documentation:

Request for services form

Initial assessment form and subsequent assessment and reassessment forms

Care plan with goals and current updates

Any correspondences or referral and consultation reports. concerning the client

If receiving homemaker services form, doctor's orders, flow sheet, narrative progress notes.

Recording client information is designed to serve four functions:

1. To provide a record of service time for each client.

2. To gather program statistics/historical data.

3. To record the condition of the client.

4. To become a permanent legal record on the client's file.

At month end the Nurse Coordinator will review each client record to ensure all services provided are appropriate and

accountable.

Section 3

Client Access to Service

Policy: Eligibility

Policy: 3.1

The Indian Brook H.C. Program, will provide services to people of all ages in the community who have a

physical, emotional, mental and social need for assistance, in order to continue living independently in

their community. This care will be provided for all stages of illness or disability, including palliative care.

Service needs will be assessed in a fair and consistent manner.

Services will be provided as needed to enhance the individual and family's independence.

Policy: Priorities for Assessment and Referral

Policy: 3.2

Priorities for home health assessment will include:

Those living in the community of Indian Brook, H.C. Program, First Nations with priority to those

who are Band Members and Canadian Citizens.

Elders 65 years of age and over.

Individuals living with a short term illness (i.e. those to be discharged or those recently

discharged from an acute care facility).

Individuals living with a chronic illness or disability.

Individuals losing autonomy.

Individuals whose situation is at risk due to care giver support breakdown.

Individuals at greater risk have priority over individuals at lower risk. Risk will be assessed at the time of

referral and/or time of assessment.

Request for assessment/referrals for the Home & Community Care Program may come from anyone.

They may include the client, family, friend, physician, clergy, institution, community health nurse,

community health representative, Child and Family Services personnel, etc.

Policy: Guidelines for the Assessment Process

Policy: 3.3

Guidelines

1 Upon referral for assessment the Coordinator assess the individual's priority for assessment ( Is

service required and wanted?). Response time to complete the assessment will be determined by the

Coordinator with the maximum response time being five working days.

2. With the consent of the client and/or client advocate the Coordinator and/or Supervisor will arrange a

time to visit and complete the care assessment form.

3. Assessment should primarily take place in the client's home because the assessment will include

appraisal of the client's ability to cope in the home environment and the assistance or care required.

4. Some assessments may be initiated prior to hospital discharge but it is important to complete the

assessment in the home environment as anticipated needs may differ from actual needs once the

client gets home.

5. The client's and/or advocate rights must be adhered to in completing the assessment. (See client's

rights regarding assessment in Chapter 3)

6. Upon completion of the assessment form the Supervisor, Nurse, Home Support Leader and the client

and/or advocate will develop a plan for care.

7. A plan for care will identify the following:

health needs or problems

the goals for care

the type and frequency of service

which needs will be addressed by whom or the role of home care, client and family the plan

of how and when the outcome will be reached

referrals made

date of reassessment

8. Following the review of the assessment and the care plan, the Review Committee will determine a

client's admission to the Home Health Care Program.

9. The Review Committee will be made up of the Coordinator, nurse, home support leader, child and

family, social, elder, disability, community member, physio and supervisor.

10. Criteria for admission will include the following:

must be a resident of the community

the client and/or family are agreeable to the treatment and services provided in the home

the assessment has taken place

services can be provided with safety to both the client and the care giver

care services required to support the client are not available through the family care givers

11. Upon approval of the admission to the Home Health Care Program services will be

implemented.

12. In emergency situations the Supervisor and Home Support Leader may approve the admission of the

client and implement services.

See Screening Tool for Priority Care, Care Plan Task List, Care Assessment Form, Short Term

Assessment/Hospital Discharge Form, and Home Care Admission in the records section of this manual.

Policy: Reassessment Criteria

Policy:

A review visit will be made 30-60 days of initial implementation of services to see if the services provided are

meeting the health needs of the client and/or family, or if changes are required. This may occur in the form of a

telephone call or an in person visit by Home Support Leader, Field Supervisor and/or Nurse.

Reassessment will take place:

whenever there is a change in the health or level of functioning of a client

whenever there is a change in the living situation of the client (Le. loss of support person)

2 months for stable long term clients such as elder who has had no health or living situation changes

during the year.

Policy: Discharge Criteria

Policy:

Clients will be discharged from the Home & Community Care Program when either of the following as occurred:

Deceased

Moved off the reserve

Admitted to a health care facility

Requires a service not provided in the community

Individual and/or family refuses home care services

Individual and/or family can manage care

Individual and/or family no longer requires care

Individual is verbally or physically abusive toward service providers

Safety of the service provider is threatened

The Home & Community Care Program has insufficient funds.

Procedure for Discharge

1. The Supervisor will notify the client and/or family verbally and in writing of the discharge plan and make

referrals to other services if appropriate.

2. The Supervisor will document the individual's discharge on the client's record.

3. The Supervisor will notify the service providers of the client's discharge and the date of same, and where

appropriate send notification of the discharge to the appropriate professionals.

4. The Home Support Workers are required to inform the Home Support Leader of any client who no

longer needs services and meet the criteria for discharge.

5. Where the well being of the Home Support Worker is an issue (due to abuse or safety) the Supervisor may

inform the client and/or family of potential discharge or immediate discharge.

6. Short term clients will be provided home health care services for a minimum period of two weeks and a

maximum period of twelve weeks. Length of care will be determined by the Review Committee and the

client will be notified of discharge 10 days prior to discontinuation of services prior to discharge will

have to go through the reassessment process.

7. Clients previously discharge from service is required to initiate any subsequent request for service as a

new client.

Policy: Physician's Role in Acute Home Care Services

Policy:

The client's physician determines the medical suitability and stability for acute care nursing services and

recommends admission by notifying the Hospital.

The physician may make a referral to Indian Brook H.C. Program, for Home Support Services but a

physician's referral is not necessary for assessment and admission for Home Support.

The Hospital will continue to provide acute home care nursing services to all residents in the community.

Indian Brook H.C. Program will not be responsible for this service in the community.

Upon referring the client the physician should provide:

The primary diagnosis and any secondary diagnosis

Pertinent medical information

Medical orders for new medications and/or treatment for a specified time period. All medical orders

must be signed by the physician.

See Physician's Orders in records section of this Manual.

Policy: Coordinating Care to the Client on an Ongoing

Basis Policy:

1. Care coordination will include ongoing communication between the home care program, the

client and/or family, informal care givers and agency care providers regarding the client's needs

and the services provided.

2. Care coordinator will include regular consultation with other individuals and care providers;

including regular progress updates from agencies involved in assisting the client.

3. Care coordination will include case conferencing among the Home Health Care staff involved and

where appropriate, the client and/or family, informal care givers and agency care providers to share

perspectives on the client's current needs.

4. Care coordination will include conducting case reviews (i.e. monthly Review Committee meetings)

and re-assessments, as necessary and required, to continue meeting the client's needs. The

Coordinator will review the case review or re-assessment report and determined if the care plan

requires any adjustments.

Policy: Presence of the Client when Home Care Services given

Policy:

The client must be present in the home to receive services.

This policy will protect Home Care staff from legal action for trespassing or other wrongdoing and will

protect the Home Care Program from service abuse that may result in giving services to people who are not

clients of Home Care.

Guidelines:

1. Only assessed clients of Home Care shall receive Home Care services.

2. The Home Care Leader will notify the Home Support Worker and RNA's of the client who will

receive service.

Time sheets for home services shall indicate the client's name, the services provided, and the signature

of the client. If the client is unable to sign the time sheet, then the client may advocate another to do

so (expect the Home Support Workers and/or RNA's). At no time will a Home Support Worker or

RNA sign a time sheet with the client's signature. This is forgery. Time sheets shall indicate time

actually spent working in the client's home. Staff will not increase or decrease the amount of time on

time sheet for the benefit of the client.

5. Where the possibility exists that a person other than the client may require services, the

assessors will use good judgment in assessing more than one person in the home.

Policy: Client's House Keys to Staff Policy:

Home Care staff are NOT allowed to accept a client's house key in orders to enter a client's home at the

client's request, without prior approval from the Review Committee. The Review Committee will not give

approval without the written consent of the client.

This policy will protect the staff member and the Program from legal action for alleged wrongdoings.

Guidelines:

Staff shall inform their immediate supervisor if a client requests that they carry a client's house key in

order to enter the client's home for any reason.

The staff member must inform the client that acceptance of the house key is discouraged and is against

Home Care Policy, unless approved by the Review Committee.

At least two members of the Review Committee must investigate all alternatives and document the

same.

If there are no alternatives found; if the client is unable to answer the door to receive service;

if the client has no support system; and if a decision is made to allow a staff member to carry a

client's house key to give Home Care services, then written consent must be obtained from

the client and placed on the client's file.

All this information must be documented on the care plan.

Staff must take reasonable precautions to safeguard the client's key while the key is in the staff

member's possession.

Arrangements will be made for the staff member to return the house key when other arrangements have

been made.

The staff member shall write a memo to the immediate supervisor informing them of the date and return

of the house key to the client. This memo shall be signed by the client and placed on his/her file

indicating the return of the key.

Policy: Entering a Client's Home when there is No Response

Policy:

Home Care staff assigned to deliver services to a client at an agreed-upon date and time shall not enter a

client's home except in unusual circumstances as defined in the procedural policy below.

This policy protects the Home Care employee from any legal action of trespassing and ensures the client

receives help if emergency medical assistance is needed.

1. If the Home Care staff does not receive a response to loud knocking, then the door should be checked to

see if it is locked.

2. If the door is locked, the staff member withdraws from the client's home and leaves a door hanger to

indicate a staff member attempted a visit.

3. If there is a real concern based upon the client's recent medical history, the Field Supervisor should be

notified and action should be taken based on the report received. The family, the client's doctor or the

local hospital should be contacted in case the client has been admitted. The local RCMP can be

contacted. If the client is found and requires medical assistance, a written report shall be submitted to

the Coordinator.

4. If the door is unlocked the employee shall walk in and loudly announce their presence. Usually this is

sufficient, as many times the client may not have heard the knocking. If the client is not at home the

employee shall leave and leave a door hanger to indicate a visit was attempted. If the client is at home

and requires medical assistance 911 should be called, and Field Supervisor and/or Coordinator must

be notified.

Policy: Death in the Home

Policy:

Home Care staff who finds a client deceased at home shall follow the procedures outlined below:

1. In any death regardless of circumstances staff must call 911. The 911 operator will notify the appropriate

people to respond the deceased home.

2. In no circumstances are Home Care staff to disturb the deceased body.

3. After contacting 911, the employee shall contact the Coordinator.

4. The Coordinator will then notify the client's physician and family support persons.

5. If the family members are present provide emotional support and comfort to the family while the staff

member awaits arrival of emergency personnel.

6. Provide support to the family in arranging transfer of the deceased. The deceased body cannot be

release to the funeral home until the physician has signed the death certificate.

7. Careful recording concerning the death must be properly recorded including the time the

person was found, the position of the body and conditions surrounding the death, what Home Care's role in

the home was, who was contacted and by whom, and where the body was released.

Section 4

Home Health Care Services

Policy: Core Home Health Care Services

Policy:

Individuals admitted to the Home Health Care Program, based on their assessed needs, maybe

entitled to receive one or more of the following services;

Case Management including assessments, referrals, etc..

Home Care Nursing including foot care.

Home Support Services including home management, personal care, respite care and palliative care.

Dietician Services including diabetic education.

Policy: Guidelines for Case Management

Policy:

Once a client and/or family are admitted to the Home Health Care Program the services it provides are

case management to allow for the following:

Provision of care that is consistent, safe, effective, organized and cost effective.

Matching of the client's needs to appropriate services.

Ability of a client and their family to function as independently as possible.

Medical Equipment and Supplies

Guidelines for Case Management

Case management will include ongoing communication between the home health care program, the

client and/or family, informal care givers, and program care providers regarding the client's needs and

services provided.

2. Case management will be the responsibility of the Home Care Nurse in collaboration with the Review

Committee. Case management meetings will take place monthly or more frequently, if necessary, as

stated prior in Chapter 3 - Client Access to Services. Regular consultation with other health

professionals and agencies assisting the client will also occur on an as needed basis.

3. Case management will also coordinate the reassessment, discharge and appeal processes.

Criteria for each are as stated in Chapter 3 - Client Access to Services.

4. It may be necessary at times to provide extended services to clients with an assessed high need for

services (i.e. palliative care). Provision of funding for these high need clients will rest with the Review

Committee and Band Administration taking into consideration cost, length of time that services are

needed and the potential unpredictable high need periods.

Policy: Functions of Case Management

Policy:

Case Management for the Home Health Care Program will include the following functions:

Client assessment

Review of care

Care planning

Skilled intervention

Teaching Coordination of community services

Documentation of client's response to service

Efficient use of resources

Appropriate referrals for services and/or supplies

Facilitating communication and Liaison

Admission, readmission, discharge planning and appeal

Policy: Guidelines for Home Care Nursing

Policy:

Home Care Nursing services for the community will continue to be provided by the "Hospital Program".

Characteristics of this program include:

It is a program of the provincial government in Nova Scotia.

It is covered under the province's MSI program.

It provides acute and long term home care nursing therapy, social services, psychological services,

etc...

Care is available twenty four hours a day, seven days per week.

All aspects of services with regards to staff, duties, responsibilities, qualifications, policies and procedures,

employee benefits are under the direction of the Program

It is available to residents of the province.

It is available upon referral from a family physician or hospital agency.

Guidelines for the Home Care Nursing - General

I The Home Care Nurse will make referrals to the family physician for home care nursing if there is an

assessed need for the same.

2. The Home Care Nurse will provide local physicians, local hospitals discharge coordinators and other

health providers with appropriate request forms for assessment/referral. This will aid the Home Care

Nurse's knowledge of which clients need home health care services prior to and/or upon discharge.

3. The Home Care Nurse will Liaison with local physicians, local discharge coordinators and other health

providers to educate them as to the services the community's home health care will

program will provide and thus help ensure a comprehensive home health care program.

4. The Home Care Nurse will provide an assessment, planning care, monitoring a client's condition, teaching

self-care activities to clients, coordinating services, providing counseling to the client and/or their family,

and supervising home support staff but will only perform acute care nursing services upon referral

from a family physician if

there is time permitting;

orders for treatments are provided;

it is an exceptional instance i.e. client needs treatment more than 2-3 times per day and client and/or family

are unable to perform task, client unable to travel to local outpatient department;

the nurse coordinator has the skills to perform such treatment i.e. educated if it is a medical transfer

function.

Policy: Guidelines for Home Care Nursing

Policy:

Home Care Nursing - Foot Care

1. Home Care Nursing for foot care will be provided by the Foot Care Nurse on an as needed basis if there is an

assessed need for the same.

2. Upon completion of an accredited foot care course the Home Care Nurse will provide foot care to clients

with an assessed need for the same.

3. Home Care Workers will be able to provide basic foot care such as washing and drying feet, applying lotions or

creams. Nail cutting, corn and callous care and other advance foot care will be a function of the Foot Care

Nurse or Home Care Nurse.

Policy: Home Support Service

Policy:

Home Support Services will be provided in the client's home and consist of the following services:

Home Management Support

This service assist the client to maintain the cleanliness and safety of his/her home by assisting with those

activities that the client is unable to perform due to health problems. The goal of home management is to

enable to client to remain living independently in his/her own home for as long as possible. The care provided

will be only for those activities which the client cannot do for hirn/herself, and the Home Care

Worker/Nurse/Supervisor may teach the client to do the activities whenever possible. During the assessment

the client and the Nurse Coordinator, Supervisor and/or Home Care Leader will clearly define the activities

that the client cannot manage and those that are manageable. The care plan task list will document those

activities to be done by the Home Care Worker/Home Support Worker and those to be done by the client or

care giver. If the client has high needs and lives with a care giver, the goal for providing home management

will to support the care giver to continue to care for the client in the home setting.

Home management activities may include the following: house cleaning i.e. kitchen, bathroom,

bedrooms, laundry, meal planning and preparation, seasonal cleaning, shopping, etc..

See Care Plan Task List in the records section of this manual.

Personal Care

Personal care maybe provided by the Nurse and/or a trained Home Care Worker. Task for personal care may

include bathing, dressing, feeding, turning and positioning, shaving, activation, etc.. Aides to independent

living may be required before bathing can safely be provided. A client's initial bath provided by the Home

Care Leader to ensure the care can be safely provided. Lifts and transfers will also be supervised to ensure

safety and will only be done if there is no risk to the client or staff.

Respite

Respite will be provided for a high need client who is presently cared for in the home by a family or other

community member and requires supervision because he/she cannot be safely left alone. A home support

worker will be assigned to stay with the client for a period of time, or could be scheduled to come in at

periodic intervals during the time the primary care giver is away from home. The goal of this service is to

provide "respite" or provide safe care of the client for a short period of time to support the care giver so

that he/she can continue to provide care to the client and therefore delay or prevent the need for

institutional care. Care will be taken to ensure that in home respite for one client does not take a

disproportionate amount of time and leave other clients without services.

Palliative Care

Palliative care is defined as the active, compassionate care of the terminally ill at a time when their disease is

no longer responsive to treatment and/or intervention aimed at cure or prolongation of life. The focus of this

service will be on easing the pain, both physical and emotional, for the client and their family. Palliative care

is a multi-disciplinary approach that will encompass the client, the family and the community. It will be

comprised of pain and symptom control, counseling and bereavement services, and be provided by the Nurse

Coordinator, Field Supervisor, and the Home Care Workers.

Policy: Guidelines for Wheels to Meals Program

Policy:

1 Home Health Care Program in conjunction with the community's Elder Committee will

provide a meal program to all elders in the community every two weeks.

2. This service will be supervised by the Home Care Leader and will call upon volunteers to help notify

the elders, prepare and cater the meal.

3. Menu planning will take into consideration traditional meals of the community and the

contribution of the elders.

4. The Home Care Leader will also Liaison with the Dietician to plan nutritious meals that the elders

may enjoy.

5. The Home Care Leader and/or volunteers will provide transportation, if needed, for all those elders

wishing to attend the Wheels to Meals Program

6. Those unable to attend due to health reasons will be provided with an in-home (Meals on Wheels)

meal for that day. Those requesting in-home meal services must notify the Home Care Leader.

7. On special occasions (i.e. Christmas, Thanksgiving, Easter) attempts will be made to provide

entertainment including bingo, card games, music, and storytelling.

The goals of this program are to:

provide elders with a nutritious meal

provide elders with an opportunity to socialize with their peers

provide elders with a change of environment, especially if living alone, no family support, no

transportation

Policy: Guidelines for Dietician/Diabetic Education Services

Policy:

Dietician services will be available to the community once a month at our Diabetic Satellite Clinic at

the Indian Brook Health Center.

Dietician services will be provided by a licensed dietician.

Referrals for services may come from the Home Health Care Program, Community Health Nurse,

family physicians and other health care providers to Colchester Hospital Diabetic Satellite Clinic.

A client with an assessed need for diabetic screening will be referred to his/her family

physician.

A client with an assessed need for diabetic education, Le. poor control, lack of knowledge, will be

referred to the family physician for regional follow up with a Diabetic Educator or Dietician and a

Diabetic Nurse. Further intervention/follow up in the community will be performed by the Home

Care Nurse, the Community Health Nurse.

Policy: Guidelines for Mental Health Services

Policy:

This community has at time found access to Mental Health Services difficult. Referral processes are slow, wait

lists are too long, and there seems to be little or no consistent follow up after discharge. Thus to address these

concerns the new Home Health Care Program in partnership with the Mental Health and Wellness and

Colchester Mental will attempt to ease these problems by:

Providing financial assistance in partnership with Mental Health and Wellness to fund a position (I

day per week) for Mental Health Services.

The Mental Health position will be housed under the Health Center for administrative and operating

support.

Mental Health Services will be provided by a licensed Psychologist or Mental Health Nurse.

Referrals for services may come from the Home Health Care Program, Community Health Nurse, Mental

Health and Wellness Coordinator, local hospitals, family physicians and other health care providers.

A client with and assessed need for mental health services will be referred to the community's Mental

Health Nurse/Psychologist for further assessment and intervention. Due to limited funds and time restrictions

there may be a waiting list for services. Placement on the waiting list will be at the discretion of the

mental health professional.

A client with an acute assessed need for mental health services will be referred to his/her family

physician for follow up. Further intervention/follow up in the community will be performed by the

Mental Health and Wellness Coordinator/Community Health Nurse.

Policy: Guidelines for Medical Equipment and Supplies

Policy:

Medical equipment and supplies are required to provide effective health care in the home, and to promote

independence of the client. Often mobility equipment such as walkers and wheelchairs are needed only for

a short time during rehabilitation, but at other times the need for supplies and equipment maybe long term.

The Home Health Care Program will access such supplies with the Non-Insured Health Benefits Program

with Indian Health Services and/or the local Red Cross chapters in clients present with an assessed need

for the same.

Because at times there is urgency when supplies and equipment needed, the Home Health Care Program will

attempt to purchase (if budget allows) supplies to be kept on hand so that support can be provided when

needed.

Home Care Nova Scotia will be responsible for supplying acute care clients with supplies for dressing changes.

The Home Health Care Program will keep and supply items needed for acute care nursing for clients within

the Home Care Program.

Policy: Guidelines for Home Maintenance

Policy:

Home maintenance will include such services as minor home repairs and general upkeep to ensure the home

environment is safe. Activities may include installing grab bars in a bathroom, installing ramps, taking out the

garbage, cleaning snow and ice off the front steps, yard maintenance, etc ... major home renovations are not

included here. This program will be closely linked the community's public infrastructure and will be an

important link in enabling the client to remain in a safe home environment.

Section 5

Orientation

Section 8

Records

Instructions for First Nations and Inuit

Basic Home Care Monthly Statistics

Recording monthly work done is not only a requirement for funding, but is a valuable tool for supervising

staff and program planning. Monthly reports record the care received by each client by type of service and

the amount of time provided by each care giver.

Each staff should fill out their own form for the month from their time sheets or client files and should be

submitted within the first week of the next month.

There are three sheets provided, the Nursing and Case Management Statistics sheet to be filled out by the

nurse or the nurse assessor, the Home Support Statistics to be filled out by each home support worker, and

the Total Program Statistics. The Home Care Director or Coordinator may wish to compile the data from all

staff on the Total Program Statistics sheet which will show all the services provided to each client from all

the home care staff. These forms are on spread sheet and can be done on computer. Formulas may be added

to total up the care given.

Overview of the Report Form(s)

The forms have three main sections. Section 1, Client Information consists of Column% A, B, and C which

are descriptors of the client who is receiving the service.

Section 2, Home Visits includes all visits to a client's home.

The last section(s) includes cobinins describe, the services provided to each client in time and type of care

which was provided.

The last column describes the staff time that does not directly relate to a particular client.

How to Record Time

1. Do not record any time less than 15 minutes

2. When recording time, use decimals to indicate partial hours

For 1 hour of time 1.00

For 15 minutes 0.25

For 30 minutes 0.50

For 45 minutes 0.75

SECTION 1: CLIENT DATA

A. CLIENT IDENTIFIER

Each client should be assigned a confidential number which cannot identify them to an outside person

or agency. This number should be kept by the home care program in a locked cabinet. No one outside

the program should be able to identify the person receiving on the month end sheets. The number

should only be assigned once and if a client is discharged or deceased, the number should not be

reused.

B . A G E C O D E S

This age codes are listed below. The appropriate code can be circled to make filling out the form

easier.

AGE CODES

A - under 15

B - 15 to 44

C - 45 to 64

D - 65 & over

C. SEX

Circle the M if the client is male and F if the client is female.

D. PRIMARY DIAGNOSIS CODE

Select from the diagnosis code the category which best describes why the client is receiving

services. For example, a person may be a frail elderly, but did not require services until she fell and

broke her hip. In this case the primary reason for the services is the fracture.

SECTION 2: HOME VISITS

This section is to be filled out in number of visits and not by time.

E . H O M E V I S I T S

The home visits category includes all visits to a client's home including those in which home care a

service was provided.

F. ATTEMPTED VISITS

Those times that the staff went to the client's home but no services was provided because the client

was not home or other reasons such as refused service; visits to the home of a client take time even

when service has not been provided.

G. TOTAL HOME VISITS

The total of columns E and F to give the total times the staff person went to the client's home in the

month.

SECTION 3: HOME SUPPORT TIME

Provides a record of home support services time for each client under the four main categories for home

support services: Home Management, Personal Care and Respite Services, Meal Services, and other client

related services.

G. HOME MANAGEMENT

This includes the time spent doing home services for the client. It includes all cleaning, laundry,

and seasonal cleaning.

H. PERSONAL CARE

Describes the time to provide personal care assistance with such activities as activation,

rehabilitative exercises, bathing, foot care and hair care to client.

I. RESPITE

This category includes time spent giving respite to a care giver.

J. MEAL SERVICES

This category captures the time spent assisting a client with meals through any of the following:

preparing a meal for a client

bringing food to a client or

providing the client with a meal with others through a type of congregate dining or

elders meal.

L. OTHER CLIENT RELATED TIME

This category includes time spent with arranging services for the clients, charting, reporting client

needs to supervisor or other home care staff etc.

M. TOTAL HOME SUPPORT TIME

The addition of the columns E, F, G and H give the total hours of home support services provided to

an individual client for the month.

SECTION 4: CASE MANAGEMENT

N. CASE MANAGEMENT TIME

This time category is primarily for the Nurse Assessor, or the Case Manager. It includes the time spent

visiting the client and supporters to assess the service needs for home care services. The time category.

may include:

visits to clients and support persons;

charting;

consulting with physician(s);

consulting with family members;

case conferencing; and

time required to set up all aspects of the services.

O. CASE MANAGEMENT CODE

The case management code will indicate the types of care a person has received from the case

management or nurse assessor. Circle the one or two codes which best describe the services provided in

the month.

DC - Discharge planning is the assistance with planning and assessing needs for equipment and support

and care before discharge from a medical care facility. It may include: case conferencing, hospital

visits, equipment orders, etc.

IA - Initial Assessment is the first full assessment done fora client to determine the needs for care. It

maybe the first request for admission or a readmission of a previously discharged client.

RV - Review is the full or partial review of a client's health condition to ensure that the home care

services are currently meeting the needs of the client, and to provide quality control of client care.

CC - Client Conferencing is the meeting with family, or health and/or other agencies such as social

development to determine how care providers can best work together for the best care and support of a

client.

HL - Hospital Liaison includes hospital visits and assistance to clients and staff in a medical facility

to promote client care and communication.

OTR - Other care coordinator services not listed above

SECTION 5: HOME NURSING TIME NURSING TIME

This time category captures all the activities related to providing nursing care to a particular client. The time

includes direct patient care, travel on reserve to the client's home, all charting, referral, and calls to physicians

and other members of the health care team that relate to care for the client.

The Home care nursing services includes: Performing nursing assessments;

Performing nursing treatments and procedures;

Providing on-going personal care when the Assessment specifies that the condition of the client is such that a

nurse should perform the services;

Teaching and supervision self-care to clients who are receiving personal care or nursing services;

Teaching personal care to family members and other supporters; Teaching and supervising home support staff

providing personal care;

Indirect Nursing Time - other time spent which is related to a specific client:

Charting

Consulting with physician(s)

Consulting with family members

Case conferencing

Arranging for supplies, etc.

On-Reserve travel between clients

Q. NURSI NG CO DES

These codes were developed by medical services in 1995 when MSB first took on the mandate form home

care nursing.

1. Acute Post Hospital Care involves clients who are post-surgical or have had acute illnesses which

have been diagnosed, treated and the client is stabilized. The home nursing program Would monitor the

client's condition and ensure that the treatment is continued as per physician's instructions (e.g. Treatment of

draining wounds, post cardiac surgery)

2. Short Term Active Care

Acute care that would provide home nursing care services to clients who are experiencing an acute illness, but

have the potential for returning to a pre-illness level of functioning and self care. The main objective of a

home care nursing program would be to control symptoms and prevent deterioration of the client. (e.g.

respirator, cardiac disease)

3. Continuing Active Care

Time limited provides home care nursing to those clients with an illness/disability who will not return to their

previous level of functioning, but will have the potential for increasing their level of functioning or self care,

and will eventually function without home care nursing services. The home care nursing objective is to

prevent deterioration and reach maximum level of physical and social functioning without continued home

care nursing services. (E.g. bums, bowel/bladder problems)

4. Sustaining Care

Would provide home nursing treatment services to clients with advanced disease(s) who cannot be maintained

at home without ongoing home nursing care. The objective for this group is maintenance of a chronically ill

client at home to their maximum level of functioning with ongoing home care nursing services. (E.g. home

dialysis, catheter maintenance)

5. Palliative Care

Would provide home nursing treatment services to clients with terminal illnesses. The objective of the nursing

service is to enhance the client's comfort, dignity and quality of life and to eliminate and or control symptoms.

(E.g. HIV/AIDS, cancer)

R. TOTAL CLIENT TIME

The time that the client received from each care giver is totaled in this column to record the total home

care services provided to the client during the reporting period.

SUPERVISION

"Supervision Time" is time spent relating to the supervision of another staff member or student. This

includes:

providing direction and guidance;

assigning caseloads;

preparation time;

actual time spent in the client's home doing hands-on supervision; and charting time.

CASE LOAD

The box at the bottom of the page on the total program stats will indicate the number of clients

admitted/discharged/re-admitted during the month. The last category for inquiries will track the number of

request for services that require screening, assistance, etc. but were not admitted to the program.

EDUCATION SESSIONS/CLINICS

Record in this are the types of education sessions held during the month and the number who attended each

session.

Home Care Diagnosis Codes

1-a Conditions of the endocrine

l-b-I Diabetes - diagnosed in past year

1-b-2 Diabetes - diagnosed over I year

1-b-3 Diabetic - newly put on insulin

1-b-4 Diabetes - gestational/pregnancy diabetic

1-b-5 Diabetes - early signs of or existing renal diseases

1-c Hepatic, Biliary, and Pancreatic

2-a Cardiovascular disease/heart, circulatory

2-b Cerebrovascular Disease and/or CVA

3-a Genitourinary Condition

3-b Renal Condition

4-a Gastrointestinal

4-b Difficulty feeding (tube feeds, dysphagia, etc.)

5-a Central Nervous System Condition (MS, Parkinsonism, MD, CP)

5-b Dementia and related conditions (Alzheimer, etc.)

5-c Mental/Emotional Condition

6-a Musculoskeletal Condition - arthritis type condition

6-b Musculoskeletal Condition - fracture, amputation, etc.

6-c Musculoskeletal Condition - other

7 Respiratory Condition

8 Skin and Subcutaneous Condition

9 Communicable Diseases

10 Cancer

11 Frail Elderly

12 Required Nursing Treatment not related to a diagnostics code

13 Accident Victim

14 Severe Blindness

15 Severe Deafness

18 Autoimmune Condition (lupus, etc.)

19 Lack of diagnostic information

21 Other

22 Lifestyle related, ex addictions

Policy: Guidelines for Orientation of Staff

Policy:

Principles

The orientation process should be the employee's first introduction to the Home Health Care Program

The orientation process must be relevant to all employees.

A holistic picture of the community's home health care program will be received by all employees.

Every employee should have an understanding of their role in the organization when they have completed

the orientation.

All personnel involved in conducting the orientation process should be aware of their

responsibility.

Structure Standards

All employees receive an orientation to the Home Health Care Program before commencing hands on

duties.

The orientation begins with the hiring process conducted by the immediate supervisor.

The Home Care Coordinator explains the payroll system to all new employees.

The Home Care Coordinator is responsible for the introduction to the daily operations as it concerns the

new employee.

An orientation package that includes written, as well as, verbal clarification shall be prepared for each

employee.

Policy: Orientation Checklist for Staff

Policy:

Topics Reviewed Not

Reviewed

Date Initials

Overview of Home Care Program

including core services i.e.

assessment, case management, home

support, linkages, etc.

Tour of offices including physical

layout and introductions to staff

Personnel policies including code of

ethics, hours of work, termination of

employment, dismissal, probationary

period, etc.

Job descriptions

Confidentiality

Incident Reports

Financial reviews including salaries,

leave, time sheets, monthly client

records, pay periods, etc..

Organizational structure including

lines of communication and

supervision

In-services and continuing education

Reporting and documentation

requirements i.e. sample chart

Emergency Situations

Policies and procedures related to

providing service i.e. home

management, personal care, etc..

Other Topics

1.

2.

3.

Policy: Guidelines for Orientation of Staff

Policy:

Process Standards

The orientation is held in the Indian Brook Health Center within five days of the

commencement of employment.

2. The Home Care Coordinator begins the orientation process when the application is reviewed and an

interview is conducted.

3. The job description is discussed with each new employee. The oath of confidentiality is explained,

signed by the employee, and witnessed.

4. The pay schedule is reviewed and determined.

5. The Coordinator presents an introduction to the community's home health care program the includes"

description of the community i.e. population, health needs, services available, etc.

the organizational structure of the Health Department

tour of the offices and building

introduction to her staff

the personnel policies of the organization

the job descriptions the need of confidentiality

the employee health program

incident reports

6. The Supervisor discusses the payroll system with the new employees and includes time sheets, mileage,

pay periods, benefits, etc.

7. The Home Care Coordinator discusses, reviews, and clarifies the following aspects of the

orientation:

the assessment process and their role in the process

the job expectation

emergency situations

reporting and documentation requirements

policies and procedures relevant to that employee

hours of work

areas of work

how confidentiality is insured

staff meetings

supervision on the job

probation and performance appraisals

lines of communication

8. The written orientation package contains;

copy of the personnel policies

sample of a completed time sheet

sample incident report form

Home Health Care Program brochure

Section 6

Employee Policies

Policy: Employee Policies

Confidentiality

Any breach of confidentiality will be subject to disciplinary action.

Harassment

Harassment, physical, mental or verbal abuse is not acceptable. Situations or alleged situations shall be

brought before the Director of Health. The incident will be recorded and any action against such person

will be decided.

Alcohol/Drug Use

Being at work under the influence of alcohol or drug or use of alcohol or drugs during the

working hours is absolutely unacceptable.

The first infraction will result in a two-day suspension without pay and a second infraction will result

in a dismissal.

Use of alcohol or drugs after working hours to the extent that it affects the employee's

performance of duties may result in dismissal.

Dress Code

All employees are to be clean, neat and dressed appropriately for their position.

Personnel Selection

Personnel will be selected by Chief and Council, or the person's designated by council.

Positions will be posted for 30 days whenever practicable.

Priority for positions will be to First Nations people with appropriate qualifications.

Probationary Period

See Personnel Management

Policy: Employee Policies

Performance Appraisals

Written performance appraisals will be done by the Home Care Coordinator and/or Field

Supervisor on all employees.

Appraisal will be done after the probationary period and bi-annually from the date of hire

thereafter.

The performance appraisal will be reviewed by the employee and maybe amended by the Home

Care Coordinator if required.

In the event an employee disagrees with any component of the appraisal they may be placed on

the employee's file.

Termination of Employment

Termination maybe required due to lack of funding or other causes beyond the control of the

employer or employee.

Employees are required to provide at least two weeks written notice to the Home Care

Coordinator of their intention to resign.

Hours of Work

Normal Offices hours are 8:00am to 4:00pm Monday to Thursday with Friday hours being 8:00am to

3:00pm. Lunch hour usually occurs from 12:00pm to 1:00pm. Full time employees usually work a total of

40 hours per week. Due to the nature of a Home Care Worker's job, hours of work may be flexible in that

clients may need help during a lunch hour, a Friday afternoon or during a evening or weekend. Any service

provided after normal working hours has to be based on need and approval by the Home Care Coordinator.

Sick Leave

See Personnel Management Manual

Absence and Lateness

Employees including Home Care stag y must notify the office as soon as possible if they are going to be

absent or late arriving for work. Habitual tardiness and/or absence may result in loss of pay or dismissal.

Home Care staff, the client or the client's family cannot make their own arrangements as to relief

replacement. The Home Care Leader must be notified and they will be responsible for finding suitable

replacement.

Policy: Employee Policies

Dismissal

An employee maybe dismissed for specific causes, as follows:

Incompetence - poor quality of work

Irregular Attendance - frequent absences, tardiness, and/or leaving the job before the end of a

working day without permission

Misconduct - breach of confidentiality, violation of rules, disorderly conduct.

Salaries

Salaries/wages are paid weekly. Salaries and employee benefits are fixed by council.

Paid Holidays and Vacation Leave

See Personnel Management Manual

The dates for the Christmas vacation shall be fixed by Chief and Council.

Leave of Absence with/without Pay

See Personnel Management Manual

Telephone Calls

Personal telephone calls are discouraged while working in a private home. If necessary use the phone only

upon permission of the client. Ensure you client is not being deprived of care because you are on the phone

unnecessarily.

Gifts from Clients

Employees’ are not permitted to accept gifts and/or money from clients or give gifts or money to

clients. Never let yourself be accused of favoritism because of something you might gain from tending

to one client's needs before another.

Accidents and Errors

When accidents happen or errors are made, you should report them immediately to the Home Care

Leader. An accurate account at the time will protect you from false accusations and will allow corrections

or treatment to be done right away to protect the client from further harm.

Policy: Employee Policies

Reporting Abuse

Any suspicion and/or actual evidence of physical, verbal or emotional abuse in a client's home is to be reported to

the Home Care Coordinator, Home Care Supervisor or to the Child and Family Services Department immediately.

Section 7

Quality Assurance

Policy: Quality Assurance

Reference: National Home and Community Care Program, Health Canada, 2000

Guidelines and specifics as to the evaluation and quality assurance of the new Home Care Program is still

being developed by the National Home and Community Care Program in Ottawa.

A Self Evaluation Tool was completed from the pilot projects in April 2000. In April 2001 this tool was

again reviewed for the progress of the program: its strengths and weaknesses and future plans.

Some tasks that will preformed throughout the year to help ensure quality of the program will

include:

Continual use of a formal assessment tool

Monthly reviews of client records and care plans i.e. services provided are needs based

Monthly review of staffing schedules, client caseloads, and services provided by staff

Monthly statistical recording of the coordination, assessment, nursing and home support services

provided

Monthly meetings of the Review Committee

Reassessments of clients as needed

Revisions of policies and procedures if needed

Quarterly activity reports for Band Council

Client satisfaction reviews

Continual strength of linkages with both on and off reserve agencies

Approval of and implementation of the Home Care Policy Manual