Effective teamwork requires mutual understanding of the roles and responsibilities of each member of the team. Regardless of whether family caregivers live close to the care recipient or at a distance, and regardless of whether the care recipient is at home or in a facility, it is still important to get to know who is who and what each person’s role is, both in relation to their job function (for example, nurse, home support worker) and in terms of their function within the team (for example, team leader, care plan coordinator, chairperson of meetings).
The Home and Community Care program (HCC) of the Vancouver Island Health Authority (VIHA) provides community-based health services intended to support people with acute or chronic illness or a physical disability to remain at home, as independently as possible.
The services that a client is eligible for are based on a standard assessment of needs, may be provided on a short or long term basis and may be subsidized according to the client’s income or provided at no cost. Similar services are provided by the other health authorities throughout BC. HCC services for eligible clients are delivered by teams of healthcare professionals. Below is a list of some of these health care professionals and the services they provide.
The following are some roles/ people you will probably encounter.
Director of Care
This is the staff person who, in a residential facility, manages each individual resident’s care. The Director of Care typically chairs the case conferences and ensures that the care plans are up to date, in place and reviewed regularly. This person typically has a nursing background.
Family physicians typically focus on and are paid to provide primary care/ acute care. Specialists will be necessary as well, particularly in areas such as psychogeriatrics, dementia, or Alzheimer’s.
Registered nurses generally assume many different roles, depending on the setting (i.e., acute care hospital, residential care facility, community care, private in-home care). Because of their education and training, they provide nursing care directly and may supervise the care team. Nurses can be found in the Liaison and Case Manager roles as well as in a variety of supervisory or administrative/management positions where a knowledge of health care is required.
Social workers are found in hospitals, community care and licensing services, residential facilities, and community support agencies. As with nurses, they assume many roles, such as Long-Term Care Assessor or Hospital Liaison Worker. Social workers often pay attention to the social/emotional dimensions of care, help problem solve and assist with other non-medical types of concerns which are also key to one’s health.
Community health worker
Also referred to as home support workers, community health workers typically provide assistance of a non-medical type, in the home. They are assigned through a home support agency after an assessment is completed regarding the level of need or care that is required. Community health workers assist with routine tasks such as meal preparation and home cleaning, as well as more personal tasks such as bathing and incontinence care. They are an important part of the care team and often the most visible to the client. Wherever possible, effort should be made by agencies to provide assignment of consistent workers.
Home support scheduler
These are the people who schedule community health workers. They work for home support agencies or the Health Authority and will call to tell you who is coming and when.
Home support supervisor
This person sets the home support care plan, lets you know what tasks the community health workers will be doing, and monitors the quality of care.
Long Term Care Case Manager
This person works for the Health Authority and determines, for example, how many hours of home support the care recipient is eligible to receive, as well as whether this will be subsidized. They conduct assessments to determine eligibility for home supports, suitability for adult day programs or placement in assisted living and residential care facilities. They will work with the client and their family to address his or her health care goals. They provide access to other services such as facility care, rehab, home nursing care, and nutrition services. Case managers also provide ongoing coordination of services.
Liaison Case Managers
These are case managers in the hospital who organize the community supports necessary to discharge clients safely home or assess for residential facility placement from the hospital. They work in the hospital to organize the community supports necessary to discharge clients safely home or assess for residential facility care placement from a hospital stay.
Resident Care Attendant
This person works in facilities and performs similar types of duties and functions to the community health worker. There are usually several aides assigned to a floor or facility.
Occupational and/or physical therapist
Both occupational therapists and physical therapists are trained and licensed health care professionals. Occupational therapists evaluate the impact of disease on the activities of the patient at home, in facilities and in work situations and then recommend equipment and/or exercises that can assist.
Physical therapists provide services that help restore function, improve mobility, relieve pain, and prevent or limit permanent physical disabilities of individuals suffering from injuries or disease.
Help a person to maintain optimal nutritional health while living at home by providing assessment, consultation, and education.
Community Rehabilitation Services
Provide home-based physiotherapy and occupational therapy services in order to help a person to remain living at home safely.
Adult Day Programs
Provide support in a group setting for older adults, especially those with chronic illness or cognitive impairments. Day centers offer opportunities to socialize, have a hot meal and participate in recreational and health maintenance activities.
Victoria Innovative Seniors Treatment Approach (VISTA)
VISTA offers a program for seniors experiencing day to day problems with the misuse of alcohol and/or prescription drugs, or elder abuse issues.
Quick Response Team
Provides crisis intervention at home to eligible clients when required aimed at preventing avoidable hospital admission, provide crisis intervention at home and to facilitate early hospital discharge. The QRT team includes physiotherapists, occupational therapists, social workers, nurses and home support workers.
Anyone can make a referral to the Home and Community Care program. Each region of VIHA has a
HCC General Enquiries Line. If you live in the South Island region call 250- 388-2273, Central Island
250-734-4101 or North Island 250-898-2255. The above information can be found in more detail on
the VIHA website at www.viha.ca/hcc/. This website also includes a helpful booklet that you can
download entitled, Home and Community Care, A Guide to Your Care.
For additional assistance in navigating the healthcare system and finding the resources that you need,
you can also call us at our Caregiver Support Line, at 1-877-520-3267 8:30 am – 4:00 pm Monday to Friday.