Home Community Based Care


44 Community Health Workers that work directly in the community and deliver services in the patient’s own homes.

4,5 hours per day.

Focus on:  Health Screenings, Basic Care, Referrals to Primary Health Care, Prevention and Promotion, Wellness and Self-Management of Community Members

In close partnership with Primary Health Care and Government structures.

Care is free of charge.

** Funded by Department of Health


Definition of Home Community Based Care:

The provision of health services by formal/informal caregivers in the home; in order to promote, restore and maintain a person’s maximum level of comfort, function and health including care towards a dignified death.

Goals of Home Community Based Care:IMG_3581

  • 10% Basic Care
  • 90% Health Screenings of Households and Crèches; including promotion of Wellness and Self-Management with Primary Health Care support.
  • To promote health and prevent illnesses.
  • To support screening and health
  • To mobilize around community needs.
  • To identify household’s health needs.
  • To provide psycho-social support to community members.
  • To identify and manage minor health problems.
  • To support screening and health promotions programs in the community.
  • To support continuum of care.
  • To ensure de-hospitalization and family involvement.
  • To help users maintain independence and achieve best possible quality of life.
  • To develop user’s ability to self-care.

Services and Guiding Principles:

Home Community Based Care recognizes people’s capacity to self-help and involves a comprehensive range of context-specific interventions that positively influences environmental- and personal factors such as psycho-social abilities, lifestyle issues, behaviour patterns and habits.  It’s an array of interventions that support the actions people take to maintain health and well-being; prevent illness and accidents; care for minor ailments and long-term conditions; and recover from periods of acute illness or hospitalization.

The services are Patient-centred and Multi-Professional.

Stakeholder engagement.

Community-based participatory approach.

Typical Admission/Patient:

  • Needs screening, health education and support to stay healthy, safe and free from abuse and neglect.
  • Compromised functional status requiring personal care and support.
  • Requires adherence support.
  • Requires promotion of wellness.
  • Requires guidance towards self-management.
  • Requires Primary Health Care Interventions/Support.
  • Requires end of life care.
  • Requires multi-disciplinary interventions to be holistically healthy and function (as possible) as a member of a family/the community.

Staff Members:

  • 1 Home Community Based Care Manager
  • 2 Professional Nurse Coordinators
  • 1 Community Health Workers Supervisor
  • 44 Community Health Workers
  • 1 Integrated School Health care worker (** part of NHI Pilot project in Eden Health district)
  • 1 Occupational Therapist
  • 1 Occupational Therapy technician
  • 1 Social worker (shared with Intermediate Care)
  • 1 Spiritual worker
  • Outsourced Physiotherapy: Integrated Physiotherapy (George)
  • 1 Psychologist


  • Health Screenings
  • Referrals to Primary Health Care
  • Wellness Support
  • Basic Medical Care
  • Palliative Care
  • Occupational Therapy
  • Provision of Assistive Devices and Wheelchairs
  • Physiotherapy
  • Adherence Support
  • Psycho-social- and Emotional Care
  • Spiritual Care
  • Family Support and -Empowerment







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