Home Community Based Care

Description:

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:

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

Interventions:

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