Home Care and Support Services

Health Services Provider Series

NATIONAL STANDARD OF CANADA

CAN/HSO 35001:2018(E)

Home Care and Support Services (Draft for Public Review)

Publication Terms of Use (Draft for Public Review) The standard was developed in compliance with Health Standards Organization (HSO), Standards Council of Canada (SCC) and International Society for Quality in Health Care (ISQua) standard development requirements. All HSO standards are developed through a rigorous process that includes a comprehensive literature review, consultation with a standard working group or advisory committee comprised of experts in the field, and evaluation by client organizations and other stakeholders. Intellectual property rights and ownership This publication (“Publication”), and all content contained herein, is owned by HSO and/or its licensors. It is protected by copyright and other intellectual property rights in Canada and around the world. For clarity, HSO claims and grants no rights in the documents identified herein as “Resources”. 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© 2018. Health Standards Organization and its licensors. All rights reserved.

Public review publication date: August 29, 2018 This publication contains 47 pages ICS CODE: 11.020.10

Any suggestion aimed at improving the contents of this Standard may be sent to [email protected]

SCC Foreword National Standard of Canada is a standard developed by a Standards Council of Canada (SCC) accredited Standards Development Organization, in compliance with requirements and guidance set out by SCC. More information on National Standards of Canada can be found at www.scc.ca. SCC is a Crown corporation within the portfolio of Innovation, Science and Economic Development (ISED) Canada. With the goal of enhancing Canada's economic competitiveness and social well-being, SCC leads and facilitates the development and use of national and international standards. SCC also coordinates Canadian participation in standards development, and identifies strategies to advance Canadian standardization efforts. Accreditation services are provided by SCC to various customers, including product certifiers, testing laboratories, and standards development organizations. A list of SCC programs and accredited bodies is publicly available at www.scc.ca. CETTE NORME NATIONALE DU CANADA EST DISPONIBLE EN VERSIONS FRANÇAISE ET ANGLAISE. This standard was developed in compliance with Standards Council of Canada Requirements and Guidance for Standards Development Organizations.

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Technical Committee on Care in the Community and Home Home Care and Support Services The following were selected as Technical Committee members at the moment of approval of the content of this publication. It is important to note that the views of the Technical Committee members are representative of their expertise and not their respective organizations. General Interest

Patient / Family

Britta Nielsen, MHA Canadian Institute of Health Information Ontario, Canada

Beth Campbell Duke British Columbia, Canada

Gabriel Palne de Souza Rodrigues, MBA Grupo Geriatrics Brazil

Craig Elliot Ontario, Canada Paulette Stewart Ontario, Canada

Wayne Miller, MHA Canadian Patient Safety Institute Newfoundland, Canada

Susan Bartleman Ontario, Canada

Policy Maker / Stakeholder

Product User

Alice Kennedy Canadian Home Care Association Newfoundland, Canada

Joanne Greco, BSc.N., M.HSc. Closing the Gap Healthcare Ontario, Canada

Deborah Simon, MBA Ontario Community Support Association Ontario, Canada

Jody Hales, RPM, CRM Canadian Red Cross Ontario, Canada

Megan Bamford, MScN. RN Registered Nurses Association of Ontario Ontario, Canada

Rachelle Van Vliete, Bsc.N., RN Alberta Health Services Alberta, Canada

Patrick Durivage, MSc., TS CIUSSS Centre-Ouest de l'Île de Montréal Quebec, Canada

Shannon Hopkins, RN, RPN, MBA Vancouver Coastal Health British Columbia, Canada

Advisor Bobbi Wignall Lumacare Ontario, Canada Nathalie Valdes Health Canada Ontario, Canada

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Home Care and Support Services

Contents Technical committee II Preface IV Disclaimer V

0 Introduction VI 1 Scope VII 1.1 Purpose 1.2 Applicability

2 Normative References VII

3 Terms and Definitions VIII 3.1 Definitions 3.2 Abbreviations 3.3 Quality Dimensions

4 Providing safe and effective services 1

Bibliography 27

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Preface This is an update to HSO 35001:2011 (E) – Home Care Services Standard. It combines content from the previous edition of the Home Care standard with the HSO 35002 – Home Support Services standard. The previous versions were amalgamated to provide better guidance for health service providers providing care in home settings along the continuum of care including care coordination (case management) and transition across home care services. This latest edition is now a comprehensive standard applicable to organizations that offer clinical and non-clinical services and supports to clients, families, and caregivers in their home and community. The criteria in the standard can all be found under the ‘Providing safe and effective services’ section. The draft standard for public review specifies requirements for these organizations to deliver quality and safe health services to patients and families. The content was prepared by the HSO Technical Committee TC012 –Care in the Home & Community under the authority of the HSO Standards Steering Committee. This standard will be undergoing a periodic maintenance. HSO will review and publish this standard on a schedule not to exceed five years from the date of publication. Standard Type: This standard is intended to be used as part of a conformity assessment. The technical content of the standard consists of clauses, criteria and guidelines. •

Clause: Introductory statement for a set of criteria. It is not a goal statement.

•

Criterion: A requirement that is to be evaluated. May be referred to as a sub-clause.

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Guideline: Additional information to help understand the criterion. It does not contain new information of evaluation content.

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Disclaimer Although the intended primary application of this Standard is stated in its Scope, it is important to note that it remains the responsibility of the users to judge its suitability for their particular purpose. We ask that all comments address the technical content regarding the clauses, criteria and guidelines within the standard. Please note, any comments that do not address the technical content will not necessarily be integrated into the final draft. Some criteria include normative references to other HSO standards, including the former Required Organizational Practices. Reviewers can comment on the presence of these references; however, the content of the referenced standards are not up for review at this time.

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Home Care and Support Services 0 Introduction Home care aims to provide “appropriate and high-quality home-based healthcare and social services, by formal and informal care-givers, with the use of technology when appropriate, within a balanced and affordable continuum of care” (World Health Organization [WHO], 2008). Given the large number of elderly persons who choose to receive care at home, it is reasonable to anticipate that many patients will be in a trajectory of declining health. Even when high-quality home health care is provided, some elderly patients will experience a decline in their ability to carry out activities of daily living (ADL) simply due to normal aging and pathological processes that are associated with advancing age (Government of Saskatchewan, 2015). Therefore,an underlying goal of home health care may also be to support and facilitate a comfortable decline in health (Ellenbecker, Samia, Cushman, & Alster, 2008). Services provided by home care organizations are designed to assist the client with clinical and non-clinical tasks that include the management of medications and conditions, and performing ADL. Home care services begin from the point of transition to home care. This care transition is a crucial point in the continuum of care, and if poorly managed, can impact client safety. A lack of effective integration and communication between services can lead to, for example, improper medication management causing adverse events. These incidences can be prevented through active communication between all necessary parties (Canadian Home Care Association, 2015). Home care provides its own unique challenges when it comes to maintaining a safe environment for both staff and client, which makes it a challenge to implement certain interventions. Home care workers, like staff working in other settings, share similar situational concerns that affect client safety and quality of care. For example, client falls occur both in homes and at hospitals, and some measures aimed at preventing falls are equally applicable to both settings. However, significant differences and variables between home health care environment and other types of health care settings, require these safety measures to be customized to the home setting (Ellenbecker, Samia, Cushman, & Alster, 2008). Individual client variables such as client choice also influence home-based outcomes in unique ways that would not apply to hospitalized patients. For example, in contrast to a therapeutically regulated system of medication management within a hospital, a client at home may choose to take their medication at irregular times, despite advice about the importance of a regular medication schedule. Thus, interventions must account for and respect the client’s choice to not follow recommendations like furniture rearrangements or the fact that sometimes they choose to go against best practice, despite the clinician’s best efforts (Better Home Care Partners, 2016; Sun, Doran, Wodchis, & Peter, 2017). Further unlike hospitalized patients, home healthcare clients’ own reading skills, cognitive abilities, and financial resources affect their ability to safely manage their medication regimens (Ellenbecker, Samia, Cushman, & Alster, 2008) Additionally, home-bound patients frequently receive assistance from family members or other informal caregivers, over which clinicians have little control. In the hospital, care given by support staff may be more easily observed and evaluated, but in the home environment the clinician’s ability to observe the quality of care that informal caregivers deliver is limited (Ellenbecker, Samia, Cushman, & Alster, 2008). Given these unique challenges and their , and potential consequences if not mitigated, the objective of this standard is to guide home care organizations in providing safe and quality care to clients receiving home care services. The references cited in the above paragraphs, in the Definition section, and those used to inform the standard, can be found in the Bibliography.

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1 Scope 1.1 Purpose This version of the standard is intended to be used for public review and consultation by the public only and not fit for the purpose specified above until approval by the Technical Committee. To obtain a final copy, please visit the HSO e-store when published or one of our participating Assessment Bodies.

1.2 Applicability This draft standard for public review specifies requirements for health care organizations that provide clinical and nonclinical services and supports to clients, families, and caregivers in home care settings. The standard, once approved by the Technical Committee, will provide organizations with an evidence-based tool to help improve patient safety and quality of care for clients receiving home care services.

2 Normative References The HSO Standards below are also referenced in the criteria of this standard. For dated references, only the edition cited applies. For undated references, the latest edition of the referenced document (including any amendments) applies: •

HSO 5010:2018 – Client Identification

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HSO 5014-3:2018 – Medication Reconciliation at Care Transitions - Home and Community Care

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HSO 5061:2018 – Home Safety Risk Assessment

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HSO 5063: 2018 – Skin and Wound Care

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HSO 5012:2018 – Information Transfer at Care Transition

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3 Terms and Definitions 3.1 Definitions Please follow the link to obtain a full list of our standards glossary: https://healthstandards.org/files/HSOMasterGlossaryList-2018E.pdf

3.2 Abbreviations ADL – ACTIVITIES OF DAILY LIVING EMS – EMERGENCY MEDICAL SERVICES HSO – HEALTH STANDARDS ORGANIZATION MAID – MEDICAL-/PHYSICIAN-ASSISTED DYING QI – QUALITY IMPROVEMENT WHO – WORLD HEALTH ORGANIZATION

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3.3 Quality Dimensions HSO Quality Framework: Health and social services stakeholders around the world are committed to delivering the best quality possible. However, given the rapidly changing environment and the numerous challenges facing all health and social service sectors, quality can sometimes be perceived as complicated and difficult to achieve. Using a quality framework – also known as a structure underlying quality – provides common language as to what it means and brings focus on its key elements. HSO Standards are based on the HSO Quality Framework. The framework consists of eight quality dimensions that all play a part in providing safe, high quality care in all health and social services sectors. These dimensions are the basis for the standards, whereby each requirement (criterion) is linked to one of the eight quality dimensions. In this way, the underlying focus of each criterion is clear, and users of the standards understand the intent of the criterion. These are the quality dimensions that underlie HSO’s quality framework:

Population Focus: Work with my community to anticipate and meet our needs Accessibility: Give me timely and equitable services Safety: keep me safe Worklife: Take care of those who take care of me Client-centred Services: Partner with me and my family in our care Continuity of Services: Coordinate my care across the continuum Appropriateness: Do the right thing to achieve the best results Efficiency: Make the best use of resources

These dimensions provide a common language about health care quality. The quality dimensions are strongly related to each other, can be mutually supporting, and help to ensure balance within the framework. At the same time, there may be a stronger emphasis on a particular dimension if the case/situation requires it. HSO encourages health and social services professionals and policy-makers to explore this framework and use the dimensions of quality for strategic planning, program and service delivery, and evaluation and quality improvement activities. Ultimately, the quality framework will help health care providers assess and improve the health care services they deliver to patients and clients.

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Providing safe and effective services

4.1

Provision or facilitation of access to services for current and potential clients, families, teams, and referring organizations is provided in a timely and coordinated manner.

4.1.1

The provider has a process to respond to requests for services in a timely way. Guidelines: “Timely” access is defined as being able to provide or facilitate a service which balances the supply and demand of visits, reduces appointment wait times and backlogs, and develops contingency plans. Requests for service may come from clients, families, other teams, or referring organizations. There may be different processes to respond to a request based on who is requesting the services and what is being requested. The roles and responsibilities of individual teams for wait list monitoring are determined. All individuals waiting for service are assigned to a worker who is responsible for ensuring wait list monitoring support is planned, provided and documented while the client is waiting for service initiation. A plan will be documented which indicates the timeline and nature of the waiting list monitoring contacts. The provider is able to give an average waiting time to receive the service and whom to call should the clinical situation change. Requests for service, the process to respond to requests, and the definition of “timely” will vary by the type of service being offered. Responsiveness is monitored by setting and tracking times for responding to requests for services as well as through gathering feedback from clients and families, referring organizations, and other teams.

4.1.2

The provider has a process to review and respond to the needs of clients who are waiting for service Guidelines: Clients may experience emergency or crisis situations while waiting for services that change the level of urgency to receive services. Waiting lists should be reviewed regularly and access should be prioritized based on immediacy of care required. Each organization determines criteria for their triage process. This may require collaboration with crisis service providers to ensure needs of the individuals within the service or on the wait list are identified so that access can be appropriated and triage prioritized. It is noted that in some cases, the service provider may not have control over the wait list. In these circumstances, it is the funder that maintains a broader waitlist for multiple service providers in a given geographical location.

4.1.3

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The provider informs clients and families about how to access essential services 24 hours a day, seven days a week.

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Home Care and Support Services Guidelines: Essential services are defined with input from clients and families and are based on the types of services provided and the needs of the clients served. Essential services are defined as those types of services that are required to keep the client safe at home. These services may include social support, housing, food security, income, and health services. Services may be offered for family members in distress or who are acting as an advocate for the client. Access to 24-hour services is tracked as an indicator of overall access to services and client responsiveness. If round-the-clock access is not offered, partnerships with other service providers, organizations, and the community are established so those who need help can access essential services through other locations or organizations. Access should be in person or by telephone, as appropriate. 4.1.4

The provider delivers information to clients and families or the team member who is responsible for coordinating their service, and how to reach that person. Guidelines: The assigned team member may be the collaborative team member with the most consistent contact with the client, or the primary provider responsible for care. When that member is not available, clients and families are provided with the contact information of another team member.

4.1.5

Clients and families have access to specialized expertise and other consultants in a timely manner to meet service goals. Guidelines: Access to specialized knowledge and skills to assist with managing care, as per the need of the client, is available to the team (e.g., further assessment, specialized interventions, direct service, or teaching). While timelines to access specialized expertise may not be under the control of the team, rapid access should be strived for to maximize the benefit to the client.

4.1.6

The organization facilitates connections to support clients and/or families in meeting their basic needs (e.g. income, food, clothing, shelter, etc.), as identified by the client and their family. Guidelines: Facilitating connections could include providing clients and/or families with information, advocating on their behalf, or referring them to other services or organizations.

4.1.7

Team members facilitate access to other services when they are unable to meet the needs of a potential client. Guidelines: The needs of potential clients are assessed in relation to the team capacity, expertise, and appropriateness of services offered. In the case where the provider has performed a needs assessment and has determined that the needs fall outside of the scope, expertise and resource level of the organization, and they are unable to meet the client’s needs, the rationale is explained and access to other services is facilitated. This may require

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Home Care and Support Services collaborating with appropriate services to address these needs. The information is documented for use in service planning. Team members follow up with the client to ensure that they have engaged with the alternative service provider. 4.1.8

Providers utilize a virtual health service to support clients in their homes, including vulnerable and remote populations, where feasible and appropriate. Guidelines: Virtual health services are provided to clients using virtual mediums to enable clients to receive care or support. Virtual health services encompass a wide range of tools, both reactive and proactive, including, but not limited to, phone monitoring, telemonitoring, virtual visits, and email reminders. Access to healthcare professionals could include regulated or unregulated staff that have access to the regulated provider during the episode of care.

4.1.9

Providers design virtual health services in partnership clients and families, partners organizations, and the community. Guidelines: Collaboration with clients, partners, and the community in service design is achieved through client advocacy groups, community advisory committees, and client experience surveys. Gaps in services are identified and addressed wherever possible.

4.1.10 Providers have policies and procedures in place, designed with input from clients and families, to govern the delivery of virtual services. Guidelines: For those providers utilizing virtual health, virtual health services policies should be integrated into existing provider policies. Policies and procedures support the sustainability of the services, and guide the delivery of the services between jurisdictions. Policies include establishing contingency plans; managing physical and human resources; liability, licensure and credentialing; ownership of client records; protecting network security; using virtual health services equipment; protecting client rights; maintaining appropriate documentation; and carrying out research protocols. 4.1.11 Providers have a process in place to address confidentiality and privacy as they relate to virtual health services and communication. Guidelines: Providers have processes in place to address the confidentiality and privacy of email correspondence, telephone, and Internet-based communication between client and healthcare providers. Clients and families are made aware that not all forms of communication are private and secure and are notified of the risks associated with utilizing such forms of communication. Clients and families may be provided with a confidentiality agreement addressing the privacy of virtual health services and communication. 4.2

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Clients and families are partners in service delivery.

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Home Care and Support Services 4.2.1

Team members have an open, transparent, and respectful relationship with each client and family. Guidelines: The team supports a respectful and transparent relationship with clients and families by introducing themselves and explaining their role; asking permission before performing tasks; explaining what they are doing; using a respectful tone; expressing concern or reassurance; providing an opportunity for questions, input, and feedback; respecting cultural and religious beliefs or lifestyle; and respecting confidentiality and privacy.

4.2.2

Team members use a person-centred approach to services and supports, with input from clients and families. Guidelines: A person-centred approach considers the person’s wishes, values, family and socioeconomic situation. Providers work with the client and family in making decisions and developing appropriate solutions.

4.2.3

Team members empower clients and families to be actively engaged in their own care. Guidelines: Team members have a process to support, encourage and/or engage clients and families to be active participants in their care, ask questions, share decision making, know their rights, and provide input into their healthcare goals at all stages of the care process. Clients are also encouraged to maintain their appointments. Examples of measures of active participation include asking clients and families about their preferences for care, treatment, social activities and relationships. Team members are encouraged to participate in training on shared decision making.

4.2.4

The provider has a process to support and engage the families of the clients served. Guidelines: The provider enhances the role of family caregivers and supports them in this role. This can be achieved through information and education, hands on teaching, and resource materials which can support recovery, reduce hospitalization, and delay relapse. When appropriate, and with the client’s consent, families are also engaged and supported through formal programs such as parenting and sibling support, peer support, and respite care. Whenever possible, and while respecting consent and privacy of the client, families are involved in decisions regarding services.

4.2.5

Team members share complete and accurate information with the client and family in a timely way, in accordance with the client's desire to be involved. Guidelines: Sharing detailed and complete information is critical for informed choice and shared decision making between clients, the team, and the client’s family, if desired or when it is

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Home Care and Support Services necessary. All information contained in the care plan is available to the client and is delivered according to individual needs and interests. Clients, and should the client wish, their families, understand the risks and benefits of care; the client and family’s roles and responsibilities in service delivery; the benefits, limitations, and possible outcomes of proposed services or interventions; how to prepare for tests and treatments; the availability of counselling and support groups; and how to reach team members in an emergency or crisis. Varying levels of information may be required at different points in the client's care and are accommodated wherever possible. Similarly, different messages will require different delivery methods (e.g., serious topics require a more structured approach). 4.2.6

Written and verbal communication and instructions are adapted to facilitate client and family understanding. Guidelines: Clients and families may have different communication abilities. A variety of techniques should be available and tailored to the client and family member’s needs. Teams should use appropriate language and pace as well as augmentative and alternative communication such as visual and/or behavioural cues, pictures, graphics and diagrams. Written communication should be in plain language, use short sentences, and point form where possible, using language that the person is familiar with and using graphics and pictures where appropriate.

4.2.7

Translation and interpretation services are available for clients and families as needed. Guidelines: Written materials are available in the languages commonly spoken in the larger community, as required. Interpretation services are available and offered when required by clients or families, wherever possible. Qualified translators and interpreters with appropriate knowledge of the field should be selected to provide these services.

4.2.8

The team verifies that the client and family understand information provided about their care. Guidelines: The level of understanding, literacy, language, disability, cognitive ability, and culture are considered when providing information to clients and families. Processes to verify clients' understanding include encouraging and allotting time for questions, having the client repeat back information, ensuring a linguistic or cultural match wherever possible, using visuals or videos where possible, and creating an ongoing exchange where confirming understanding is a recurring event. This information is documented in the client record. In some situations, where the client’s and/or family’s capacity is questionable, it may be challenging to verify whether they have understood the information related to their care. Examples of such situations could be if the client is suffering from delirium or during a crisis intervention. In these situations, additional follow up is required by the team.

4.2.9

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The provider has a process to collect outcome information about the client and family’s perception and experience of care for quality improvement purposes.

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Home Care and Support Services Guidelines: Quality improvement (QI) consists of systematic and continuous actions that lead to measurable improvement in healthcare services and the health status of targeted patient groups. Quality improvement initiatives are designed to implement knowledge or assess a process or program. Feedback from clients and families regarding their care and/or services is gathered and evaluated in a continuous and timely manner. This may include formal and informal feedback methodologies such as surveys, interviews, focus groups and client/family meetings. The results of the feedback are synthesized and utilized to plan for improvements in service delivery, as applicable. The data from the evaluation of the care and/or services delivered to clients and families informs decision and quality improvement activities. 4.2.10 Team members provide clients and families with opportunities to be engaged in approved research activities. Guidelines: Research is defined as a systematic investigation, including research development, testing, and evaluation, designed to develop or contribute to generalizable knowledge. Research activities may include clinical trials, assessments of new protocols, or changes to existing protocols. There is an ethical review process to determine when to involve a client in a research activity. Team members follow approved protocols when approaching clients and families regarding research and evaluation activities. All research and evaluation activities are subject to an approval process prior to engaging clients and families. Clients and families are included in participatory research project design and implementation where appropriate. 4.3

Client’s and family’s rights are respected and implemented.

4.3.1

Team members provide clients and families with information about their rights and responsibilities when receiving care or services. Guidelines: Client and family rights include the right to have privacy and confidentiality protected; be aware of how client information is used; have access to their record and information about them; be treated with respect and care; maintain cultural practices; pursue spiritual beliefs; live at risk; and be free from abuse, exploitation, and discrimination. Client and family rights regarding service delivery include the right to: participate in all aspects of their service and make personal choices; have a support person or advocate involved in their service; appeal a care plan decision or file a complaint; take part in or refuse to take part in research or clinical trials; receive safe, competent service; and raise concerns about the quality of service. Client and family responsibilities include treating others with respect, providing accurate information, reporting safety risks, and observing rules and regulations.

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Home Care and Support Services The information is provided at intake or admission to the service is reviewed on a regular basis, at minimum, yearly. The information is adapted to meet diverse needs such as language, culture, level of education, lifestyles, and physical or mental disability. When the information cannot be provided to the client and family on intake, it is provided at the earliest opportunity. 4.3.2

Team members work in partnership with the client and family to determine the client's capacity to provide informed consent. Guidelines: The process of evaluating a client's capacity to consent is carried out on an ongoing basis. With respect to decision making for consent purposes, “capacity” means the ability to understand the information relevant to the decision, the nature of his/her illness, appreciate foreseeable consequences of a decision or failure to make a decision, and weigh the risks and benefits of that decision. Revisiting the extent to which a client has capacity for involvement and informed consent on a regular basis is included in this process. Relevant legislation(s) is followed when working with children and youth. When working with the elderly, minors, or those deemed incapable of consenting, clients are involved to the greatest extent possible in making decisions about their services, and the team values their questions and input.

4.3.3

When clients are incapable of giving informed consent, team members ensure that consent is obtained from a substitute decision-maker. Guidelines: In accordance with applicable legislation, a substitute decision-maker is consulted when clients are unable to make their own decisions. An advance directive is used, where available, to ensure decisions are in line with the client's wishes. In these cases, the substitute decision maker is provided with information about the roles and responsibilities involved in being a substitute decision-maker, and given the opportunity to discuss questions, concerns, and options. Selecting the appropriate substitute decision-maker is done in consideration of the applicable legislation and may be an advocate, family member, legal guardian, or caregiver. If consent is given by a substitute decision-maker, his or her name, relationship with the client, and the decision made is documented in the client record. When working with children and youth, informed consent is received and documented from the child, youth, family or legal guardian before providing services. The consent process includes involving them as much as possible in the decisions about their service, intervention, or treatment, and valuing their questions and input.

4.3.4

Team members obtain and document client's informed consent before providing services. Guidelines: Informed consent consists of reviewing service information with the client, family, or substitute decision-maker; informing the client about available options and providing time for reflection and questions before asking for consent; respecting the client's rights, culture, and values including the right to refuse consent at any time; and recording the

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Home Care and Support Services client's decision in the client record. The consent process is ongoing. The initial consent by the patient should be documented but does not require a signature witness. Implied consent occurs when providing services where written consent is not needed, such as when clients arrive for an appointment or class, have blood pressure taken, present their arm to have blood drawn, arrive for service through Emergency Medical Services (EMS), or present with life-threatening or emergent condition(s) and require immediate resuscitation. 4.3.5

Team members work in partnership with the client and family or client and substitute decision-maker to determine the client’s capacity to be involved in their own care. Guidelines: Each client will have differing levels of ability to be involved in their own care. The appropriate team member works with the client, family, or substitute decision-maker to determine how much and what type of information the client or family requires to be meaningfully involved in their care. There is a process for revisiting the extent to which an individual has capacity for involvement and informed consent on a regular basis. When the client has capacity, they are provided the opportunity to elect a substitute decision-maker and are encouraged to participate in advanced/proactive planning to ensure preferences for care are upheld, even when capacity to participate is limited.

4.3.6

This information is documented in the client record. Team members respect and follow the client's wishes regarding family involvement in their care. Guidelines: When appropriate and desired by the client, the team finds ways to include members of the client's support network in the client's care. Applicable legislation when a substitute decision-maker or family is involved in decisionmaking is respected. There is a process to resolve conflicts regarding level of desired involvement between the client and family. This information is documented in the client record and revised as the client’s wishes change.

4.3.7

Team members respect client and/or family’s decision to refuse services, to the extent allowable by legislation. Guidelines: Team members provide opportunities to consider the team's recommendation and alternative options that may be more acceptable are provided. Teams reassure clients that services will not be limited or restricted, nor have any impact on continuity of care if they refuse care and support clients with health teachings and effective outreach techniques. Alternative options for treatment are discussed with clients and family as needed. The organization is familiar with legislation regarding the refusal of services and has a process to communicate this effectively with clients and families, ensuring that clients and families understand and are made aware of alternative options for treatment. To avoid provider bias, verifying that clients and/or families are aware of these rights may be best performed by an organization member who is not on the client’s provider’s team.

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Home Care and Support Services 4.3.8

Providers have processes in place to identify and address ethical issues, should they arise. Guidelines: Ethics-related issues are ones in which values may be in conflict, making it hard to reach a decision. The issues may be very serious, life-and-death matters, or related to day-today activities. Examples include conflicts of interest; respecting a client's choice to live at risk; triaging community members during an emergency; requests to withdraw or end services, including life-sustaining supports or treatments; and end-of-life care. There is a process to manage and address issues brought forward.

4.3.9

Team members proactively address ethics-related issues with input from clients and families, where appropriate. Guidelines: The provider’s ethics framework is updated based upon input from clients and families and using best available evidence. The ethics framework is used to manage and address ethics-related issues. They may be addressed by an ethics committee or consultation team that may include health service professionals, clergy, ethicists, and family. Where expertise is not available internally, external consultation may be sought for recurring ethical issues in the setting at hand. Ethics-related issues involving clients and families are documented in the client record.

4.3.10 Team members provide clients and families with information about how to file a complaint or report violations of their rights. Guidelines: Where applicable bodies exist (internally or externally), clients are made aware of the complaint process and organizational contact. This could include regulatory colleges, privacy commissioners, client advocates, ombudsmen, executive director, or other point person. The steps involved in making a complaint may be done in a variety of ways, such as through writing or via in-person discussion. Additional resources (e.g., written materials) may be available to clients and families regarding how to file a complaint or report violations of their rights. The provider ensures clients and family members are aware that services will not be limited or restricted, nor have any impact on continuity of care, should they file a complaint or report a violation of their right. 4.3.11 The provider develops and implements a process to investigate and respond to claims that client rights have been violated, with input from clients and families. Guidelines: An environment where clients, families, and team members feel comfortable raising concerns or issues is promoted. Affected clients and/or their families have the opportunity to provide feedback and are reassured that services will not be limited or restricted, nor have any impact on continuity of care, should they file a complaint or report a violation of their right. The provider may provide access to a neutral, objective person from whom clients and families can seek advice or consultation. Where electronic health records are

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Home Care and Support Services used, there is a process to receive and respond to client complaints and questions regarding the privacy of the electronic record. Claims brought forward by team members or other teams are also addressed. 4.3.12 The provider has policies to address cultural safety and competence. Guidelines: Meeting the diverse needs of clients requires policies that address cultural safety and competence. Addressing diverse needs includes, but is not limited to, recognizing differences that arise due to spoken language; cultural identity; gender; sexual orientation; ethno-cultural background; migration history; different physical and mental abilities; stage of life; geographical location; socio-economic status; and spiritual or religious beliefs. Acceptance of the diversity of clients and families served is evident in policies and procedures. This may include having materials available in different languages and versions that are suitable for the hearing or sight-impaired. It may also involve access to interpretation services, and awareness programs and committees. Services and support are delivered in a manner that considers the social, political, linguistic, and spiritual realities of the clients and families with whom they are working. 4.3.13 The provider ensures that the client record is accessible to the team involved in care, including the client and their family, when appropriate. Guidelines: The provider must have processes in place to facilitate access to client records, according to the provider’s policy and applicable legislation. The process to access records are client-centred and support clients to access their information, including electronic documentation. Clients have opportunities to discuss the information, ask questions, and provide feedback. 4.3.14 Team members maintain regular communication with relevant stakeholders while respecting confidentiality and privacy of the client. Guidelines: Communication may refer to verbal and/or written communication. Team members clearly communicate to all stakeholders in a coordinated approach, to ensure alignment with a client’s care plan, objective, outcomes, and progress. Content and method of communication is adapted in a manner in which all stakeholders can understand and fully participate. Relevant stakeholders include the client and family, case manager, and the funding, insuring, or regulatory body. 4.4

Care plans are developed in partnership with the client and family based on a comprehensive assessment.

4.4.1

The provider uses evidence-informed protocols to support pathway decisions for initiating services for clients, with input from clients and families.

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Home Care and Support Services Guidelines: The provider uses evidence-informed protocols and defined criteria to determine when to initiate services with clients. Pathway decisions will include details as to what services will be initiated and when. The needs assessment should include elements of the client’s physical and psychosocial health and includes information from the client, family, and other community partners, as needed. To increase efficiency, the protocol should recognize the validity of prior assessments that could have occurred in other settings. Where the agency does not have access to a standardized assessment tool, a comprehensive needs assessment is performed in its place. When initiating services, timing is determined based on priority/urgency of a client’s needs. 4.4.2

The provider designs the assessment process with input from clients and families. Guidelines: The assessment process is as streamlined and straightforward as possible, so that clients are not required to repeat information to multiple providers or team members. Where applicable, an interdisciplinary or collaborative assessment may be completed with the client, family, and appropriate team members.

4.4.3

Any existing assessments or care plans for the clients are identified and related information is collected from the client, family and other service providers. Guidelines: Familiarizing themselves with a client’s existing assessments or care plans, where applicable, is the responsibility of the team. Recognizing and following a care plan improves the integration and coordination of services with alternate levels of service or community-based interventions.

4.4.4

The provider assesses and documents the client’s health using a comprehensive approach, in partnership with the client and family. Guidelines: This process may occur during admission, intake, pre-admission, screening, start of service, discharge, or re-assessment and may involve collaboration with other teams to address the client’s needs, strengths and preferences. The information is reviewed, and the client is reassessed at regular intervals. It is used to determine if the organization's services fit with the client's needs and preferences, identify the client's immediate needs, and decide on service priorities. The team performs the comprehensive assessment in partnership with the client and family, focusing on the client as a whole, including the connection between the client’s physical and psychosocial needs. The client's physical and psychosocial needs, strengths, and preferences as identified in the client assessment are used to develop service goals. Service goals and expected outcomes include support from the needed services and suit the client's individual circumstances. Goals are appropriate, measurable, and complement those developed by other team members and organizations with which the client is involved.

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Home Care and Support Services Team members ensure that clients and families are full partners in the identification of their goals and outcomes. Patients and families feel informed, involved, and have the information needed to make required decisions. The intake process is adjusted as needed for clients and families with diverse needs such as language, culture, level of education, lifestyle, and physical or mental disability. Elements of health may include: • • • • • • • • • • • • • • • • • 4.4.5

Medical history Allergies Medication profile Health status Nutritional status Palliative care needs Dietary needs Cognitive degenerative diseases Mental functioning Developmental Needs Functional and emotional status family and caregiver involvement Communication and self-care abilities and strengths Mental health status, including personality and behavioural characteristics Cognitive status Socio-economic status Environmental challenges Cultural and spiritual beliefs and needs

Team members discuss each client's preferences and options for services to direct the client’s assessment, in partnership with the client and family. Guidelines: The client's expressed needs, preferences and the options for care and service are discussed with the client and family. The team and client engage in shared-decision making that considers client preferences, readiness for treatment, expected outcomes, and risks and benefits of the options. For example, various strategies to manage pain—such as analgesics, including opioids and adjuvants, as well as physical, behavioural, and psychological interventions—may be discussed when risks to the client are discussed. The client and family are able to select the preferred option. Other preferences that are discussed include options for self-care, privacy, visitors, treatments and testing, and personal care, such as sleeping, bathing, and eating. Alternative approaches used by clients are also documented (e.g., acupuncture, aromatherapy).

4.4.6

The care plan and assessments should be conducted by an appropriate member of the client’s care team. Guidelines: Appropriate team members may include, but are not limited to, a physician, physiotherapist, occupational therapist, social worker, or nurse if home nursing, medical,

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Home Care and Support Services social or palliative services are to be provided. Services are administered by the appropriate staff person when it is identified to be a part of the treatment plan. The appropriate staff person(s) should discuss, document and assesses a client’s symptoms, problems and concerns (physical, psychological, social, practical and spiritual) in the care plan and should so according to an agreed process. 4.4.7

The provider uses standardized, evidence-based assessment tools during the assessment process. Guidelines: Tools are standardized and adopted across the team, and where applicable, across the organization. The assessment tools should be based on high-quality evidence that has been translated and is culturally sensitive. Assessment tools should be designed to assist the team to systematically collect and interpret all of the information gathered during the assessment process. Benefits of using standardized tools for the client and the care provider include being more efficient, collecting more accurate information, consistency of assessment, and reliability of results and improved opportunity for communication between the client and the care provider. The standardized assessment tools used will vary depending on the needs of the client and the type and range of services provided. The standardized assessment tools used are evidence-informed and meaningful for the services provided.

4.4.8

The provider uses standardized, evidence-based clinical measures to evaluate the client's pain in partnership with the client and family. Guidelines: Standardized clinical measures are used to determine pain intensity, quality, location, alleviating and contributing factors, and impact on usual activities. Several tools exist to guide pain assessment for both adults and pediatric patients, as well as for those who are non-verbal or cognitively impaired. Pain may also be assessed in combination with other symptoms by using a comprehensive assessment tool.

4.4.9

Medication reconciliation is conducted in partnership with clients and families for a target group of clients when medication management is a component of care (or deemed appropriate through clinician assessment), to communicate accurate and complete information about medications. Guidelines: Medication reconciliation for a target group of clients who require it, is conducted in accordance with HSO 5014-3:2018 - Home and Community Care Services"

4.4.10 An interprofessional and collaborative approach is used to assess clients who need skin and wound care and provide evidence-informed care that promotes healing and reduces morbidity and mortality. Guidelines: Clients who need skin and wound care are assessed and cared for in accordance with HSO 5063:2018 - Skin and Wound Care.

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Home Care and Support Services 4.4.11 Team members complete a standardized, evidence-based assessment of the client's palliative and end-of-life care needs, where appropriate, in partnership with the client and family. Guidelines: The need for palliative care assessment may be expressed by the client or family or identified by the team. The types of services that may be required are identified. Early identification of palliative care needs allows clients and families to be involved in care planning and can improve the quality of care and family satisfaction throughout the process. Team members should introduce clients and families to the palliative approach to care and discuss prevention measures for palliative care as early as possible in the client’s journey (e.g, information and resources). At this time, the provider may begin to form the appropriate connections for the client and family (e.g., palliative care time, spiritual needs). Team members re-assess the client on a regular basis and update the care plan accordingly. In an organization or service area that does not provide palliative and end-of-life care, the assessment identifies the need to connect the client and family to the appropriate services. 4.4.12 The provider has a process in place to identify and respond to any clients at risk of delirium, where appropriate, in partnership with the client and family. Guidelines: Healthcare providers should assess their clients for delirium risk factors upon initial contact and should document any changes in the client’s condition throughout service delivery. Older adults believed to be at risk should be assessed using validated tools, on a weekly basis (when appropriate), and whenever changed in the client’s cognitive function, perception, physical function, or social behaviour is observed or reported. Once a client has been identified as being at risk for delirium, a prevention plan should be developed that addresses the various risk factors which can include non-pharmacological interventions. The prevention plan should be designed collaboratively with the client and family, alongside an interprofessional team of healthcare providers. Assessment results are shared between organizations to ensure critical information is shared with all providers. 4.4.13 The provider has a process in place to identify and respond to any clients at risk of cognitive degenerative diseases, where appropriate, in partnership with the client and family. Guidelines: Healthcare providers should assess their clients for cognitive degenerative disease risk factors upon initial contact and should document any changes in the client’s condition throughout service delivery. Older adults believed to be at risk should be assessed using validated tools, at minimum on a weekly basis (when appropriate), and whenever changes in the client’s cognitive functions, perception, physical functions, or social behaviour are observed or reported. Once a client has been identified as being at risk for cognitive degeneration, a prevention plan should be developed that addresses the various risk factors, which can include non-pharmacological interventions. The prevention plan should be designed collaboratively with the client and family, alongside an interprofessional team of healthcare providers.

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Home Care and Support Services The provider should make appropriate referrals for additional interventions where necessary. These interventions include but are not limited to: • • • • • •

Home environment assessment and modification to reduce or remove external stimuli; Mind-stimulating activities to minimize cognitive decline; Medical services for pharmacological interventions; Nursing and/or allied health services for non-pharmacological interventions: Education and training in mental health to caregivers; and Elder-sitting and respite services for caregivers experiencing stress.

4.4.14 The provider ensures that clients suspected of depression or who are at risk for depression are screened in partnership with the client and family. Guidelines: Clients suspected of depression or at risk of depression should be screened by qualified, trained, healthcare professionals. Older adults experiencing depression, including those at risk for suicide, should be monitored regularly for changes in symptoms and results of treatments using a collaborative-based approach. Whenever depression is suspected, healthcare providers should ask people directly about suicidal ideation and intent. Those identified as “at risk” for suicide should receive immediate medical attention to ensure their safety. 4.4.15 The provider has a process in place to identify and respond to any clients at risk of selfharm, in partnership with the client and family. Guidelines: Warning signs of potential self-harm include withdrawal from family or friends, change in sleep patterns, an increase in reckless behavior, anxiety or agitation, dramatic changes in mood, and/or talking or writing about death, dying or suicide, when this is not normal behaviour for the client. Monitoring clients for risk of harm to self or to others includes documenting identified risks to ensure team members are made aware. Caregivers are provided with a mechanism to alert the provider of suspected, alleged, or actual self-harm, and to implement measures to prevent further harm. A “managed risk agreement” may be prepared with each client which demonstrates that the client has been educated on the risks of particular activities and are responsible for deciding to still participate in that activity. 4.4.16 The provider facilitates access to specialized consultation and diagnostic testing in a timely way to support a comprehensive assessment. Guidelines: The provider may provide these services internally or work in partnership with other organizations such as primary care clinics to meet this criterium. Partnering with diagnostic and laboratory testing providers can help overcome geographic, resource, and expertise barriers. Once the necessity for testing or referral has been determined, the organization has a process in place to facilitate the service on behalf of the client. Adherence to this policy will ensure a timely, relevant, comprehensive assessment for every client.

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Home Care and Support Services 4.4.17 Team members assess the service and support needs of the client's family members, personal support group, or caregivers. Guidelines: The client’s family, personal support groups and caregivers should be screened to determine their physical and mental health needs (e.g., emotional, cultural and social support, or counselling), both during and after the client’s involvement with the organization. This process occurs early on in the relationship with the client, family, and caregiver, and may involve collaboration with other teams to address the caregiver’s needs. Elements of physical health include: • • •

Medical history Health status Developmental Needs.

Elements of psychosocial health include: • • • • • • •

Functional and emotional status family and caregiver involvement Communication and self-care abilities and strengths Mental health status, including personality and behavioural characteristics Cognitive status Socio-economic status Environmental challenges Cultural and spiritual beliefs and needs.

4.4.18 Team members assess the caregiver’s needs for respite care. Guidelines: Caregivers should have access to respite care and be informed on how to access it. An assessment determines if respite is needed to relieve caregivers, and a care plan is developed to meet that objective. The content of the respite care plan will depend on the needs of the dependent person and their supporters. At a minimum, the care plan will include supervision of activities of daily living, but may also include other aspects of personal care, such as a meal or home management. In addition to clients, caregivers and families should also be encouraged to practice selfcare activities that may minimize stress and promote their wellbeing and safety. 4.4.19 Team members share the client’s assessment results with the client and family in an effective manner. Guidelines: Team members share results in a timely and meaningful manner with the client and family. The provider should demonstrate a full understanding of the results and be able to effectively communicate the results and the impact on the care of the client. Sharing assessment results as applicable improves clarity and prevents duplication. In order to provide information that is easy to understand, information is tailored to the client's literacy level, language, and culture.

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Home Care and Support Services 4.4.20 Team members record and use information gathered from client assessments to direct the client’s care in partnership with the client and family. Guidelines: Actions may include appropriate examinations, further investigations, and decisions about future treatment. The findings of the assessment, examinations, further investigations, as well as decisions about future treatment are recorded in the client record. 4.4.21 The team members develop a comprehensive and individualized care plan, in collaboration with the client and family. Guidelines: The care plan is informed by the outcomes of the assessment and the client's service goals and expected outcomes. The assessment includes the roles and responsibilities of the team, other organizations, and clients and their families. It includes detailed information about the client's history, social support, assessments, diagnostic results, allergies, and medication, including any medication issues or adverse drug reactions. When appropriate, consent to release personal health information is obtained. The care plan addresses where and how frequently services will be delivered; timelines for starting services, reaching the service goals and expected results, and completing services; how achievement of the service goals and expected results will be monitored; and plans for transition or follow up once service ends, if applicable. The care plan aligns the goals, needs, strengths and preferences of the client and family with the services of the care provider. Collaborative ongoing communication is required between the care provider and the client and family regarding the care plan. 4.4.22 Team members include strategies to manage a client’s identified safety risks within the client’s care plan. Guidelines: There is a policy that defines how clients with identified safety risks will be monitored and supported, including the method of observation, communication, scheduling and documentation required. 4.5

Care plans are implemented in partnership with clients and families.

4.5.1

Team members follow the client's individualized care plan when services are provided. Guidelines: The care plan is developed with the client and family based on the results of the assessment. This plan includes the client’s service goals and expected results. The client’s individualized care plan is accessible to the team, inclusive of client and family and is followed by all team members when making treatment decisions and providing care for the client. The individual care plan ensures that everyone involved in the client’s care is working towards the same goals and provides an opportunity for everyone involved to monitor client progress toward the expected goals.

4.5.2

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Working in partnership with clients and families, at least two person-specific identifiers are used to confirm that clients receive the service or procedure intended for them.

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Home Care and Support Services Guidelines: Client identity is confirmed in accordance with HSO 5010:2018 - Client identification. 4.5.3

The provider follows evidence-based treatment protocols to provide the same standard of care in all settings to all clients. Guidelines: Selected guidelines and evidence are used to develop procedures and protocols to improve service delivery and provide standardized care to clients. The procedures and protocols may enhance patient safety, improve inter-team collaboration, increase efficiency, and minimize variation in service delivery. Client and family perspectives are considered when evaluating improvements. As the recipients of services, clients and families are often best positioned to help identify unnecessary variations or duplications in service. Research knowledge is adapted and applied to each unique setting.

4.5.4

The team provides care in a way which maintains and respects the privacy, dignity, and lifestyle of the person receiving care. Guidelines: Particular regard is given to safeguarding privacy and dignity when providing care and services (e.g., assisting the client with dressing and undressing; bathing, washing, shaving, and oral hygiene; toileting; manual handling; handling personal possessions and documents; and entering the bedroom or bathroom). Care and support should be provided in the least intrusive manner possible.

4.5.5

The provider helps connect clients and families to psychosocial and/or supportive care services as required to suit individual needs. Guidelines: Emotional support and counselling can help clients and families cope with the social determinants of health needs, such as housing, education and employment, social inclusion, community integration, and other health-related issues. Connecting clients and families with supports should include verifying whether contact has been made. Support may address coping with a diagnosis, help with decision making, dealing with side effects, or ethics-related issues such as advance directives. Client and family contact with services are documented in the care plan.

4.5.6

Team members document all services received by the client, including changes and adjustments to the care plan in the client record. Guidelines: The care plan can be revised and modified as appropriate during any point in the care of the client. This may include modalities of services used, medication changes, symptom management, safety plans, as well as other care providers involved.

4.5.7

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Team members monitor client progress toward achieving goals and expected outcomes in partnership with the client and family, and the information is used to adjust the care plan as necessary.

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Home Care and Support Services Guidelines: Team members reassess the client on a regular basis and update the care plan accordingly. Documenting progress toward goals is done using both qualitative and quantitative methods and includes the client and family. It may include the use of standardized assessment tools, discussion with clients and families, and observation. 4.5.8

Team members reassess the client's health status in partnership with the client, particularly when there is a change in health status. Guidelines: Delays or failures to report a change in health status, in particular the deterioration in a client's condition, are significant barriers to safe and effective care and services. A client’s health status is reassessed and changes in the client's health status are documented accurately, in a timely manner, and communicated to all team members. The client is informed and encouraged to communicate any changes in health status with service providers.

4.5.9

The provider follows a process for initiating palliative and end-of-life care, as required. Guidelines: Services are initiated by the team, client, or family, and take into consideration the assessment results. Involvement in palliative and end-of-life care will differ depending on the services provided by the team and the clients served. Where palliative and end-of-life care is not provided by the team, clients are connected with the appropriate services.

4.5.10 The provider has policies and procedures in place regarding the request for medical assistance in dying (MAID). Guidelines: Providers should develop policies and procedures on medical-/physician-assisted dying (MAID) specific to: identifying clients that may ask for MAID; following appropriate processes when conducting MAID; documenting decisions made that determined MAID is appropriate; use and establishment of ethical framework that addresses referrals to other healthcare provider if a staff member refuses to engage in and perform MAID; and access to necessary medication to enable MAID. 4.5.11 The provider offers support for the family, team members, and other clients throughout and following the death of a client. Guidelines: The provider has relevant resources available, ready to be shared as needed. Relevant information is shared, based on client, family, and team member needs, about the dying process, such as the signs and symptoms of imminent death, coping strategies, how to provide support and comfort during the final hours, and grief and bereavement services. Protocols for death as a result of expected or unexpected circumstances, and deaths by suicide are sought and resources/protocols are considered for clients and staff. The client's family and friends are encouraged to use community support systems. When these are insufficient, or when family and friends are identified as being at risk for

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Home Care and Support Services complex grief reactions, access is facilitated to bereavement services for clients, families, team members, and volunteers, including volunteer support or professional services. 4.5.12 Information relevant to the care of the client is communicated effectively during care transitions. Guidelines: Relevant information is communicated during care transitions in accordance with HSO 5012:2018 -Information Transfer at Care Transitions. 4.6

Safe and effective home care services are provided to clients, families, and teams.

4.6.1

Team members have an identity card available when delivering services. Guidelines: The identity card should display a photograph of the team member, the name of the team member and organization in large print and the contact number of the organization. Cards should be laminated or otherwise be tamper-proof and returned to the organization when employment ceases. Upon termination, a team member’s identity card is returned to the issuing agency.

4.6.2

A safety risk assessment is conducted for clients receiving services in their homes. Guidelines: Safety risk assessments at home are conducted in accordance with HSO 5061:2018 – Home Safety Risk Assessment.

4.6.3

The security and safety of the home and the client is protected while providing home healthcare services. Guidelines: Procedures for ensuring safety and security include knocking on the door/ringing the doorbell and identifying oneself before entry to the client's home; securing doors and windows; the action to take when unable to gain entry to the home at the scheduled time; and dealing with emergency situations.

4.6.4

Team members and/or clients and families report and document safety risks which arise in the client's home. Guidelines: Risks to team members include slips, trips, and falls in the client's home; the presence of guns or other weapons in the home; violence; and motor vehicle accidents while travelling between work assignments. Risks to both clients and team members include problems with equipment; spills, waste, or infectious materials; client behaviour that may lead to injury; and problems with handling, storing, or dispensing medications.

4.6.5

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The provider develops and implements a process to assess and investigate claims of safety risk, with input from clients and families.

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Home Care and Support Services Guidelines: Ensuring a safe work environment is the provider’s responsibility and may be achieved in collaboration with clients and their families, regulating agencies, and Joint Occupational Health and Safety Committees. Team members assigned to complete investigations into claims of safety risk would benefit from specialized occupational health and safety knowledge and training to identify and eliminate hazards and risks. Assessment procedures should state the conditions that would require a reassessment, the team member responsible for completing the assessment, and how that process is initiated. 4.6.6

The provider implements control measures following the identification of safety risks in the home. Guidelines: Once safety risks are identified in the home, control measures are required. Control measures may include, but are not limited to: • • •

•

4.6.7

Elimination and substitution for the removal of hazards from the workplace; Engineering controls that physically change the work environment to permanently address a hazard or risk; Administrative controls that alter either the way work is performed, or the organizational factors that support the way work is performed. Administrative controls may include work practices and policies that reduce exposure to a hazard or risk; Personal protective equipment, including any physical device or clothing, that is specifically designed to protect a team member against hazards and risks.

The provider delivers training in evidence-based crisis prevention and intervention techniques for team members. Guidelines: Team members are trained to respond to verbal, psychological and/or physical risks, appropriate to the practice setting. Training enables team members to identify stages of crisis development and intervene appropriately to the needs of the person in crisis. Training reinforces the importance of prevention and de-escalation, as well as facilitates the team member’s capacity to identify and respond to physically aggressive and/or violent situations. Team members are trained to use physical intervention only when necessary and only in response to the presence of physical harm. Crisis intervention training highlights the importance of client-centred care and is suited to the unique needs of different client groups. Examples include children, adolescents, seniors, individuals with cognitive disabilities, and individuals with trauma histories.

4.6.8

The provider provides education on the safe and appropriate use of seclusion and restraints to the team. Guidelines: Use of seclusion and chemical or social restraints should align with government legislation and use the best available evidence. Use of seclusion and restraints are minimized and used only as a last resort, and when all other positive interventions have

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Home Care and Support Services failed been attempted. The use of seclusion and restraints considers the trauma-informed approach and details how frequently the client must be observed, and the specific types of care required when the clients are in seclusion or restraint. 4.6.9

The provider uses evidence-based policies and practices to minimize use of seclusion and restraint. Guidelines: The least intrusive, least restrictive care refers to providing safe, competent and ethical care which respects individual rights, including human rights, dignity and autonomy. Seclusion and restraints, which are the mechanical, chemical, environmental or physical measures used to limit the activity or control the behaviour of a person or a portion of their body, are used as a last resort. The use of seclusion and restraints is shown to be linked to negative health outcomes for clients and their caregivers including physical/psychological and emotional wellbeing. Policies and protocols promoting the least restraints is grounded in a trauma-informed approach and recognized guidelines and includes criteria and procedures for the safe use of seclusion and restraints, such as how frequently clients in seclusion or restraint must be monitored, or how clients' are cared for during the use of restraints. Control interventions are used only as a last resort to reduce imminent harm to self or others when all positive person-centered/recovery-oriented/alternative practices have failed. Restrictive methods are not used to teach acceptable behaviour, punish, or for the convenience of the program. Organizations should seek alternatives to the use of seclusion and restraints to improve the quality and safety of services.

4.6.10 The provider establishes a process to monitor and document the use of seclusion and restraints by the team. Guidelines: Monitoring mechanisms are congruent with relevant legislation and include documentation of the use of seclusion and restraints: when, where, why, and for how long seclusion or restraint was used. Restraint may include mechanical, chemical, environmental or physical measures. 4.6.11 The provider follows policies and procedures regarding the team members' role in safe preparation and handling of food for clients. 4.6.12 Safe food preparation and handling policies and procedures comply with applicable laws and regulations. 4.6.13 Safe food preparation and handling training is provided to team members, as appropriate to their job. 4.6.14 The provider follows policies and procedures regarding the safe handling of a client's money and property.

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Home Care and Support Services Guidelines: The policy should address safeguarding property while delivering services, reporting loss or damage to property that occurs while providing services, paying bills, or shopping for the client. 4.7

Clients and families are partners in planning and preparing for transition to or from another service or setting.

4.7.1

Team members actively engage clients and families in preparing for transitions in care. Guidelines: Clients and families are involved in all transition planning, but the level of engagement may differ based on the type of transition and setting. Examples of key transition moments include: The team, client and family discuss the client's needs, care plan, goals, and preferences, including the care provided and outstanding issues that remain at the time of transitions, clinical or otherwise. The team, client, and family discuss what to expect during transition, including follow-up appointments and post-transition plans of care. Where applicable, contact information for the relevant post-transition care provider(s) should be provided to the client and/or family. Details should include when and how to contact the care provider(s). Continuity of care is improved when clients, families, primary care, and other providers/supports participate in transition planning and preparation and have comprehensive information about transitions, outstanding needs/goals, and end of service. Talking with the client and family about transitions helps them understand the process and provides an opportunity to ask any questions. It also helps ensure all information is accurate and complete, and that the client's wishes are respected.

4.7.2

Team members assess the client and family’s readiness for transition. Guidelines: The client and family’s physical, psychosocial, and financial readiness for transition is assessed, which may include the client’s capacity to self-manage their health. Capacity to self-manage is influenced by factors such as perceived self-efficacy, access to a support network, recovery supports, cognitive and physical ability, housing stability, selfsufficiency and employment, community care options, community integration, emotional and spiritual wellness, and literacy level. This assessment happens as early as possible within the care process. Instances where self-management would benefit the client are determined.

4.7.3

The provider documents the transition plan in the client record and makes it available to other service providers, as applicable. Guidelines: Clients and families identify, plan, and coordinate to access supports and services that are responsive to meet the client’s needs after leaving the support service.

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Home Care and Support Services Including information in the care plan about transition planning, whether to home, another team, an alternate level of care, or end of service, enhances coordination among teams or partner organizations and helps prepare clients for the end of service. Client involvement in end-of-service planning ensures the client and family are prepared and know what to expect. Discussions about the client's transition and post-care needs and preferences are part of developing the care plan. The discussion may include post-care follow up, ability to perform self-care, referrals to social services, community supports, or other services for anticipated/unanticipated needs or challenges. Talking with the client and family about transitions helps them understand the process and provides an opportunity to ask any questions. It also helps ensure all information is accurate and complete and that the client’s wishes are respected. The transition plan is shared with all providers and agencies in a timely manner, as appropriate. 4.7.4

Team members empower and support clients to manage their health, well-being and recovery by providing the appropriate tools. Guidelines: Supporting clients in self-management also includes assessing readiness for transition to the next stage of recovery and maintaining follow-up contact. Education that promotes empowerment and helps clients self-manage chronic conditions may include action planning, modeling behaviors and problem-solving strategies, reinterpreting symptoms, and social persuasion through group support and guidance for individual efforts. Selfmanagement training topics should include exercise; nutrition; symptom management techniques; risk factor management; fatigue and sleep management; use of medications; managing emotions; cognitive and memory changes; training in communication with health professionals and other individuals; and health-related problem solving and decision making. Tools, education, and resources made available to help clients to self-manage and are tailored to each client's needs. For example, tools and resources can be modified based on level of understanding, literacy, language, disability, and culture.

4.7.5

Team members identify gaps in a client’s transition plan and implements mitigation strategies to minimize risks at transition. Guidelines: Mitigation strategies may include communicating with clients about what to do while waiting for services and where they can access emergency or crisis services in the interim. Wherever possible, an in-person introduction to the next service provider is facilitated, particularly in youth-to-adult and adult-to-geriatric service transitions. A mandatory home visit should be considered to ease the client and family’s transition.

4.7.6

The provider develops partnerships or networks with other providers and programs to facilitate continuity of care. Guidelines: The network may include community-focused services and programs such as school or spiritual health education programs, nutrition services, community-based services, therapy services such as physical therapy and occupational therapy, community pharmacists, public health services and programs, medical transportation services,

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Home Care and Support Services support centers for the elderly, community-based mental health centres, urgent care clinics, shelters for the abused or homeless, rehabilitation services and long-term care. 4.7.7

The organization identifies and plans for the ongoing continuum of care for clients in partnership with clients and families, through communication with support groups, other service providers and community partners. Guidelines: While it may lay beyond the capacity of the team to provide services for clients after leaving the service, the team communicates with providers of other health and social services, community support groups, peer support or social networks, and employment providers to identify and plan for clients' continuity of care needs. Until the service has ended or until the client has been transferred to another team, service, organization, or returns to the community, the team is responsible for the client. The process for determining placement includes outlining the steps to follow when transfers or end of service do not occur as planned, or are unplanned, to ensure clients receive the most seamless and continuous care possible. Receiving services agree to identify and communicate risks and warning signs and refer the transferred client back to the referring provider for evaluation and re-assessment if required.

4.7.8

Transition of clients to and from alternate levels of care, social and other community services is facilitated by the team, in collaboration with partners. Guidelines: Partnerships for home care may include community-focused services and programs such as school or spiritual health education programs, nutrition services, therapy services such as physical therapy and occupational therapy, community pharmacists, medical transportation services, support centers for the elderly, community-based mental health centres, urgent care clinics and rehabilitation services. Programs may also target highrisk or hard-to-reach groups (e.g., ethnic minorities, people with disabilities, people with diverse learning and literacy capacities or people living in rural or remote areas). Connections between partner organizations need to facilitate transition of clients both in and out of different levels of service provision and promote client well-being across the continuum of care. The team communicates with partners to identify and plan for clients' continuity of care, and to support and strengthen services in the community.

4.7.9

The provider coordinates appropriate follow-up services for the client based on their needs, where applicable, in collaboration with the client, family, other teams, and providers. Guidelines: Responsibility for the client's care continues until service has ended, the client assumes self-care, or the client has been transferred to another team, service, or organization. Follow-up services may include primary care, social inclusion, community-based rehabilitation, recovery support programs, psychological counselling services, and recommendations for ongoing care. Working together to establish proper placement for

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Home Care and Support Services the client helps ensure the client receives the most appropriate services in the most appropriate setting and minimizes temporary solutions or unnecessary transfers. The development of an individualized patient care plan that can follow the individual during transitions may be developed. The organization should provide follow up contact with the client post transfer. To ensure clients receive seamless and continuous care, placement and follow up includes a process for when transitions do not go as planned. Services to families may continue to be offered and provided even if services are discontinued to the client. 4.7.10 Team members respect a client's wish to end or limit services or transfer to another service. Guidelines: Shared decision-making regarding a client's transition takes place in consultation with the family or substitute decision maker, when required, and takes the client's decision-making capacity into consideration based on legal requirements to assess capacity to consent. The risks of the transition are discussed with the client and family, as well as other community-based services that are available to them after the transition. An ethical or values-based decision-making framework is used when working with clients who have chosen options against the team's recommendation. In the event the client wishes to continue service against the team's recommendation or beyond the capacity of the organization, an ethical or value-based decision-making framework is used to ensure a fair and equitable outcome for the client and the organization. When multiple patients are withdrawing or transferring from a service, the program should be reviewed, and retention issues should be addressed. 4.7.11 The provider evaluates the effectiveness of transitions and the information is used to improve transition planning, with input from clients and families. Guidelines: At regular intervals, families or referral organizations are contacted to determine the effectiveness of the transition or end of service, monitor client perspectives and concerns after the transition, and monitor follow-up plans. Evaluating transitions is an opportunity to verify that client and family needs were met, and concerns or questions addressed. Client feedback and the overall results of the evaluation are shared with the organization's leaders and the governing body and the information is used to improve transitions.

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Home Care and Support Services Moir, C., Roberts, R., Martz, K., Perry, J., & Tivis, L.J. (2015). Communicating with patients and their families about palliative and end-of-life care: comfort and educational needs of nurses. International Journal of Palliative Nursing, 21(3), 109-12. doi: 10.12968/ijpn.2015.21.3.109. Muller, C., Lautenschlager, S., Meyer, G., & Stephan, A. (2017). Interventions to support people with dementia and their caregivers during the transition from home care to nursing home care: A systematic review. International Journal of Nursing Studies, 71, 139-152. doi: 10.1016/j.ijnurstu.2017.03.013 National Health Service. (2011). Draft spiritual support and bereavement care quality markers and measures for end-of-life care. Retrieved from https://www.bl.uk/collection-items/draftspiritual-support-and-bereavement-care-quality-markers-and-measures-for-end-of-life-care National Institute for Health and Care Excellence. (2011). End-of-life care for adults. Retrieved from https://www.nice.org.uk/guidance/qs13 National Institute for Health and Care Excellence. (2013). Falls in older people: assessing risk and prevention. (CG161). London, UK. Retrieved from https://www.nice.org.uk/guidance/cg161 National Institute for Health and Care Excellence. (2015). Caring for adults in their last days of life. Information for the public. London, UK. Retrieved from https://www.nice.org.uk/guidance/ng31 National Standards Assessment Program. (2013). Standard 13: Staff and volunteers reflect on practice and initiate and maintain effective self-care strategies. Retrieved from https://www.caresearch.com.au/Caresearch/Portals/0/NSAP/Mapping%20CareSearch%20wit h%20Standard%2013.pdf New Zealand Ministry of Health. (2017). Review of adult palliative care services in New Zealand. Wellington: Ministry of Health. Retrieved from https://www.health.govt.nz/system/files/documents/publications/review-adult-palliative-careservices-nz-mar17.pdf Nguyen, D., & Vu, C. M. (2013). Current depression interventions for older adults: A review of service delivery approaches in primary care, home-based, and community-based settings. Current Translational Geriatrics and Gerontology Reports, 2(1), 37–44. Retrieved from https://link.springer.com/article/10.1007/s13670-012-0035-0 Organization for Economic Co-operation and Development. (2017). Caring for quality in health: Lessons learnt from 15 reviews of health care quality. Retrieved from http://www.oecd.org/health/caring-for-quality-in-health-9789264267787-en.htm Palliative Care Australia. (2005). Standards for providing quality palliative care for all Australians. (4th Edition). PCA, Canberra. Retrieved from http://palliativecare.org.au/wpcontent/uploads/2015/07/Standards-for-providing-quality-palliative-care-for-all-Australians.pdf Pantilat, S. (2009). Communicating with Seriously Ill Patients: Better Words to Say. Journal of the American Medical Association, 301(12), 1279-1281 Parand, A., Garfield, S., Vincent, C., & Franklink, B. D. (2016). Carers’ medication administration errors in the domiciliary setting: A systematic review. PLos One, 11(12), e0167204. doi: 10.1371/journal.pone.0167204

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Home Care and Support Services Parker, E., Zimmerman, S., Rodriguez, S., & Lee, T. (2014). Exploring best practices in home health. Home Health Care Management & Practice, 26(1), 17-33. https://doi.org/10.1177/1084822313499916 Prince, H., Kelley, M. L., Brazil, K., & Darnay, J. (2013). Provision of Palliative and End-of-life Care Services to Ontario First Nations Communities: An Environmental Scan of Ontario Health Care Provider Organizations. Lakehead University. Retrieved from http://eolfn.lakeheadu.ca/wpcontent/uploads/2013/08/Provision_of_Palliative_Care_to_Ontario_FN_Communities_April_2 013_FINAL.pdf Quality End-of-Life Care Coalition of Canada. (2010). Blueprint for Action 2010 to 2020. Retrieved from http://www.qelccc.ca/media/3743/blueprint_for_action_2010_to_2020_april_2010.pdf Reid, M. C., Henderson, C. R., Trachtenberg, M. A., Beissner, K. L., Bach, E., Barron, Y., … Murtaugh, C. M. (2017). Implementing a pain self-management protocol in home care: A cluster-randomized pragmatic trial. Journal of the American Geriatrics Society, 65(8), 16671675. doi: 10.1111/jgs.14836 Richter, T., Meyer, G., Mohler, R., & Kopke, S. (2012). Psychosocial interventions for reducing antipsychotic medication in care home residents. Cochrane Database of Systematic Reviews, 12, CD008634. doi: 10.1002/14651858.CD008634.pub2 Riolfi, M., Buja, A, Zanardo, C., Marangon, C. F., Manno, P., & Baldo, V. (2015). Effectiveness of palliative home-care services in reducing hospital admissions and determinants of hospitalization for terminally ill patients followed up by a palliative home-care team: a retrospective cohort study. Palliative Medicine, 28(5), 403-411. doi: 10.1177/0269216313517283 Royal College of Physicians and Surgeons of Canada. (2015). The CanMEDS 2015 milestones guide. Retrieved from http://www.royalcollege.ca/rcsite/canmeds/framework/canmeds-rolecollaborator-e Sauvé, M. J., Lewis, W. R., Blankenbiller, M., Rickbaugh, B., & Pressler, S. J. (2009). Cognitive impairments in chronic heart failure: A case-controlled study. Journal of Cardiac Failure, 15(1), 1–10. doi: 10.1016/j.cardfail.2008.08.007 Scheepmans, K., de Casterle, B. D., Paquay, L., Van Gansbeke, H, & Milisen, K. (2017). Restraint use in older adults receiving home care. Journal of the American Geriatrics Society, 65(8), 769–1776. doi: 10.1111/jgs.14880 Schoenmakers, B., Buntinx, F., & DeLepeleire, J. (2010). Supporting the dementia family caregiver: The effect of home care intervention on general well-being. Aging & Mental Health, 14(1), 44–56. doi: 10.1080/13607860902845533 Sinclair, S. (2011). Impact of death and dying on the personal lives and practices of palliative and hospice care professionals. Canadian Medical Association Journal, 183(2),180-187. doi: 10.1503/cmaj.100511 Smith, L. (2010). Evaluation and treatment of depression in patients with heart failure. Journal of the American Academy of Nurse Practitioners, 22(8), 440–448. doi: 10.1111/j.17457599.2010.00533.x Solet, D. J., Norvell, J. M., Rutan, G. H., & Frankel, R. M. (2005). Lost in translation: challenges and opportunities in physician-to-physician communication during patient hand-offs. Academic Medicine, 80(12), 1094-1099. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/16306279 CAN/HSO35001:2018 (E)

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Home Care and Support Services Steinhauser, K. E., Alexander, S. C., Byock, I. R., George, L., & Tulskey, J. A. (2009). Seriously ill patients' discussions of preparation and life completion: an intervention to assist with transition at end of life. Palliative and Supportive Care, 7(4), 393–404. doi: 10.1017/S147895150999040X Steinhauser, K. E., Christakis, N. A., Clipp, E. C., McNeilly, M., Grambow, S., Parker, J., & Tulsky, J. A. (2001). Preparing for the end of life: preferences of patients, families, physicians and other care providers. Journal of Pain Symptom Management, 22(3), 727–737. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/11532586 Sun, W., Doran, D. M., Wodchis, W. P., & Peter, E. (2017). Examining the relationship between therapeutic self-care and adverse events for home care clients in Ontario, Canada: a retrospective cohort study. BMC Health Services Research, 17, 206. doi: 10.1186/s12913017-2103-9 The Canadian Nurses Protective Society. (2017). Cannabis for medical purpose: Legal implications for nurses. Retrieved from https://www.canadiannurse.com/en/articles/issues/2017/january-february-2017/cannabis-for-medical-purposeslegal-implications-for-nurses The Joint Commission. (2012). Hot topics in health care: Transitions of care: The need for a more effective approach to continuing patient education. Retrieved from https://www.jointcommission.org/hot_topics_toc/ The Scottish Government. (2015). Strategic framework for action on palliative and end of life care 2016 - 2021. Retrieved from www.gov.scot/Publications/2015/12/4053 Thompson, G. M., Chochinov, H. M., Wilson, K., McPherson, C. J., Chary, S., O'Shea, F., … Macmillan, K. A. (2009). Prognostic acceptance and the well-being of patients receiving palliative care for cancer. Journal of Clinical Oncology, 27(34), 5757-5762. doi: 10.1200/JCO2009.22.9799 Torjesen, I. (2016). Home care services should give patients more responsibility for medicines, NICE says. British Medical Journal, 355: i5640. doi: https://doi.org/10.1136/bmj.i5640 Travers, C., & Bartlett, H. P. (2011). Silver memories: implementation and evaluation of a unique radio program for older people. Aging Mental Health, 15(2), 169–77. doi: 10.1080/13607863.2010.508774 Udo, C., Lovegren, M., Lundquist, G., & Aselsson, B. (2017). Palliative care physicians’ experiences of end-of-life communication: A focus group study. European Journal of Cancer Care, 27(1). doi: 10.1111/ecc.12728 VanderSchaaf, K., Olson, K. L., Billups, S., Hartsfield, C. L., & Rice, M. (2010). Self reported inhaler use in patients with chronic obstructive pulmonary disease. Respiratory Medicine, 104, 99–106. doi: 10.1016/j.rmed.2009.07.003 Waller, A., Dodd, N., Tattersall, M. H. N., Nair, B., & Sanson-Fisher, R. (2017). Improving hospital-based end of life care processes and outcomes: a systematic review of research output, quality and effectiveness. BMC Palliative Care, 16(1), 34. doi: 10.1186/s12904-0170204-1 Williams, A. M. (2016) Educating, Training and mentoring caregivers of Canada experiencing a life-limiting illness. [Abstract]. Presented at the Palliative Care Matters Consortium 2016, Ottawa, ON. Retrieved from https://www.liebertpub.com/doi/full/10.1089/jpm.2017.0393

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Home Care and Support Services Williams, A. M., Eby, J. A., Crooks, V. A., Stajduhar, K., Giesbrecht, M., Vuksan, M., Cohen, S. R., … Allan, D. (2011). Canada's compassionate care benefit: Is it an adequate public health response to addressing the issue of caregiver burden in end‐of‐life care? BMC Public Health, 11, 335. https://doi.org/10.1186/1471-2458-11-335 Wolkowski, A., & Carr, S. M. (2017). Does respite care address the needs of palliative care service users and carers? Their perspectives and experiences. International Journal of Palliative Nursing, 23(4), 174-185. doi: 10.12968/ijpn.2017.23.4.174 Working Group of the Clinical Technical and Ethical Principal Committee of the Australian Health Ministers’ Advisory Council. (2011). A national framework for advance care directives. Retrieved from https://www.dementia.org.au/files/start2talk/5.0.4.1%20AHMAC%20framework.pdf World Health Organization. (2012). Home care across Europe. Retrieved from http://www.euro.who.int/__data/assets/pdf_file/0008/181799/e96757.pdf?ua=1 Yohannes, A. M., Willgoss, T. G., Baldwin, R. C., & Connolly, M. J. (2010). Depression and anxiety in chronic heart failure and chronic obstructive pulmonary disease: Prevalence, relevance, clinical implications and management principles. International Journal of Geriatric Psychiatry, 25(12), 1209–1221. doi: 10.1002/gps.2463 Yukon Health and Social Services. (2013) Yukon palliative care framework. Retrieved from http://www.hss.gov.yk.ca/pdf/palliativecareframework.pdf Zabalegui, A., Hamers, J. P. H., Karlsson, S., Leino-Kilpi, H., Renom-Guiteras, A., Saks, K., ... Cabrera, E. (2014). Best practices interventions to improve quality of care of people with dementia living at home. Patient Education and Counseling, 95(2), 175–184. doi: 10.1016/j.pec.2014.01.009

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