Home Health teams across VCH have been redesigning their work to support clients who are frail and elderly, or have a chronic disease, as the best place for those clients to receive care is at home in their community.

“One of our 78-year-old clients has dedicated herself to making incremental changes to her diet and lifestyle, thanks to a strategy staff have adopted called telephonic care management,” says Laurie Leith, the new regional director of the Home Health program and director for the Coastal Community of Care. “With a nurse providing regularly-scheduled support and coaching over the phone, her health has been steadily improving.”

And that is just one of the redesign strategies staff have adopted in the past year

The goal is to bring Home Health teams closer together – with family physicians and clients – to increase their capacity, promote client self-management, strengthen care planning and ultimately improve service quality and health outcomes.

Priorities continue into next year

Home Health teams will continue to focus on the following priorities:

• GP Care Conferencing: Scheduling 15-minute meetings to create and manage shared care plans for complex clients with all involved team members and the client’s family physician.
• Telephonic Care Management: Supporting stable clients over the phone, with coaching to build their self-care skills.
• Care Management Education: Training and support for staff, including the Introduction to Care Management online module.
• Powell River’s Care Management Model: Creating shared care plans, holding daily team huddles, assigning a most responsible clinician for each client and maximizing the use of ambulatory care.
• Ambulatory care clinic: Maximizing clinic capacity and reviewing innovative practices to reach a broader patient population.

“We want to empower local Home Health teams, in every community across VCH, to be innovative in how they integrate care management into their service models,” says Laura Case, chief operating officer for Vancouver Community and the new executive sponsor for the Regional Home Health Program. “Looking at our priorities, each team will work with their local leaders to decide what works best for their own client population.”

For instance, each team can decide how to maximize the use of their ambulatory clinic for clients who are able to leave their homes.

The need for redesign

Home Health teams offer essential services that can help clients avoid the hospital and stay safely at home, where they want to be. Yet all of the teams are seeing increasing demand.

“Redesigning our work will help us work smarter, and make the best use of our resources, so that we’ll have the capacity to be there for our clients,” says Laura. “We already have excellent staff in the community who are best equipped with the skills to care for these clients. Now it’s time for them to drive the change they want to see with care management.”

Program leadership

The Regional Home Health Program is led by Laurie Leith and medical director Dr. Peter Edmunds, under the executive sponsorship of Laura Case. The mandate is to set priorities for VCH and to ensure quality and standardization is maintained or enhanced across our various Home Health teams.