Home Care Policy Manual - Microsoft
Home Care Policy ManualSeptember 2015
PURPOSE OF THE SASKATCHEWAN MINISTRY OF HEALTH HOME CAREPOLICY MANUALAs the Home Care Program is administered and delivered by the Regional HealthAuthorities and funded by the Saskatchewan Ministry of Health, this manual is designedto ensure consistency of home care services and home care standards throughout theprovince.The program expectations in the delivery of home care are addressed in thisSaskatchewan Ministry of Health Home Care Policy Manual.This manual provides direction and guidance to regional health authorities. The policiesrepresent a statement of required course of action. Guidelines, on the other hand, areprovided as recommendations to assist in meeting the expectations of policies.Adherence to the policies is one of the conditions under which funding is provided to theRegional Health Authorities by the Minister of Health.It should be noted that this manual does not address in any detail, requirements whichhome care programs must meet as established by other legislation.Home Care is an integral part of the continuum of care that includes both community andinstitutional services necessary to ensure the best possible quality of life for people withvarying degrees of short and long-term illness or disability and support needs. Aneffective continuum of care requires strong community and institutional support sectorsso that appropriate services can be accessed when and where they are needed.The Board of each Regional Health Authority is vested with full legal authority andresponsibility for the home care program. Though not limited to the following, the boardis responsible for the observance of, and compliance with, The Regional Health ServicesAct and Regulations and provincial policy pertaining to the delivery of home care. Theexception to this is the Athabasca Health Authority, which is responsible for theobservance of, and compliance with, the Service Agreement between the AthabascaHealth Authority and the Minister of Health and any policies pertaining to the delivery ofhome care.The Regional Health Authority is accountable:a)through the Minister of Health to the Legislature for the properexpenditure of public funds to provide home care services;b)for planning, administrating and delivering home care services in theregion; andc)for adhering to program policies established by the Community CareBranch of the Saskatchewan Ministry of Health.
The Saskatchewan Ministry of Health provides global funding to the Regional HealthAuthorities for the day-to-day delivery of health programs and services, including homecare services.The regions have the flexibility to use the global funds to provide a full range of homecare services to help people remain healthy and independent. The regions strive to ensurethat appropriate care is provided to clients in their regions. However, when consideringthe delivery of health care services, the Regional Health Authority must take intoconsideration the needs of the entire region, within available resources.The Saskatchewan Ministry of Health would like to acknowledge the contribution to themanual by the staff of the Regional Health Authorities.September 2006(Updated October 2007)(Updated September 2009)(Updated November 2010)(Updated November 2012)(Updated March 2013)(Updated September 2013)(Updated December 2015)
Home Care Policy Manual1.INTRODUCTION1.1Purpose of Home Care1.2Objectives1.3Philosophy1.4Board Responsibilities2.CONTINUUM OF CARE2.1Maintaining Continuity of Service3.CLIENT ACCESS TO SERVICE3.1Coordinated Access3.2Eligibility Criteria3.3Acceptance Criteria3.4Restrictions on Acceptance to the Home Care Program3.5Priorities3.6Accessing Service for Unpredicted Needs after Hours3.7Referrals to Other Agencies if Unable to Meet T RIGHTS AND RESPONSIBILITIES5.1Client Rights5.2Client Abuse5.3Client Responsibilities6.ASSESSMENT PROCESS6.1Assessment Tool6.2Assessment Requirements6.3Clients’ Rights Regarding Assessments6.4Assessment and Approval Process6.5Clients’ Right to Appeal6.6Appeal Process7.CASE COORDINATION/MANAGEMENT7.1Case Coordination/Management8.CARE PLAN8.1Development of Care Plans8.2Care Plan Participants8.3Implementation of Service8.4Reassessment/Revision of Care Plans8.5Authority and Requirements for Discharge8.6Re-admissionSeptember 2015Page 1 of 4
Home Care Policy Manual9.CLIENT RECORDS9.1Client Records9.2Documentation Requirements9.3Incident Reports and Investigation9.4Reportable Critical Incident Review9.5Retention of Client Records10.TYPES OF CARE10.1 Types of Care10.2 Acute Care10.3 Long Term Supportive Care10.4 Rehabilitation10.5 Maintenance10.6 Palliative Care/End of Life10.7 References11.HOME CARE SERVICES11.1 Home Care Services11.2 Primary Home Care Services11.2.1Assessment11.2.2Case Management and Care Coordination11.2.3Nursing Services11.2.4Homemaking Services11.2.5Meal Service11.3 Additional Home Care Services11.3.1Home Maintenance Services11.3.2Volunteer Service11.3.3Therapy Services12.SERVICE PROVIDERS12.1 Assessor/Case Manager/Care Coordinator12.2 Nursing Service Providers12.3 Home Care Aide/Continuing Care Assistant Service Providers12.4 Meal Service/Restaurant and Institutional Providers12.4.1Private Meal Service Providers12.5 Home Maintenance Service Providers12.6 Volunteers12.7 Occupational Therapy and Physiotherapy Providers12.8 Family Care Providers13.SPECIAL PROGRAMS13.1 Individualized Funding13.1.1Collective Funding13.2 Children with Highly Complex Care NeedsSeptember 2015Page 2 of 4
Home Care Policy ManualSeptember 201514.NURSING PRACTICE14.1 Nursing Practice14.2 Nursing Procedures by Transfer of Medical Functions14.3 Special Nursing Procedures14.4 Licensure of Nurses14.5 Delegation of Nursing Procedures14.6 Evidence-Based Practices and Outcomes15.HOME CARE CLIENT FEES AND CHARGES15.1 Basic Home Care Client Fee Policy15.1.1 Short-term Acute Home Care15.2 Calculation of Client Fees for Regional Health Authorities15.3 Charges to Temporary Residents15.4 Third Party Payers15.5 Home Care Nursing Supplies15.6 Home Parenteral Medication Program Coverage15.7 Programs Covering Drug and Supply Costs15.8 Palliative Care Supplies and Charges15.9 Benefits/Payment Policy for Saskatchewan Residents Out of Province (OOP)16.QUALITY MONITORING AND IMPROVEMENT16.0 Quality Monitoring and Improvement16.1 Assessment and Care Coordination Standards16.1.1Assessment and Care Coordination: Structure Standards16.1.2Assessment and Care Coordination: Process Standards16.1.3Assessment and Care Coordination: Outcome Standards16.2 Nursing Service Standards16.2.1Nursing Service: Structure Standards16.2.2Nursing Service: Process Standards16.2.3Nursing Service: Outcome Standards16.3 Homemaking Service Standards16.3.1Home Care Aide/Continuing Care Assistant: Structure Standards16.3.2Home Care Aide/Continuing Care Assistant: Process Standards16.3.3Home Care Aide/Continuing Care Assistant: Outcome Standards16.4 Meal Service Standards16.4.1Meal Service: Structure Standards16.4.2Meal Service: Process Standards16.4.3Meal Service: Outcome Standards16.5 Home Maintenance Service Standards16.5.1Home Maintenance Service: Structure Standards16.5.2Home Maintenance Service: Process Standards16.5.3Home Maintenance Service: Outcome StandardsPage 3 of 4
Home Care Policy Manual16.616.7September 2015Volunteer Service Standards16.6.1Volunteer Service Standards: Structure Standards16.6.2Volunteer Service Standards: Process Standards16.6.3Volunteer Service Standards: Outcome StandardsHome Care Standards16.7.1Home Care Outcome Standards17.REPORTING REQUIREMENTS17.1 Reporting Requirements for Regional Health Authorities18.OCCUPATIONAL HEALTH and SAFETY18.0 Occupational Health and Safety18.1 Safety Hazards18.2 Infection Control18.3 Lifting and Moving18.4 Client TransportationPage 4 of 4
Community CareHome Care PolicySection:Index Ref: 1.1IntroductionPage 1Date of Issue:September 2006Revised September 2015Subject:Purpose of Home Care1.1PURPOSE OF HOME CAREHome care helps people who need acute, end-of-life, rehabilitation, maintenance and long-termcare to remain independent at home. Home care encourages and supports assistance provided bythe family and/or community.
Community CareHome Care PolicySection:Index Ref: 1.2IntroductionPage 1Date of Issue:September 2006Revised September 2015Subject:Objectives1.2OBJECTIVES1.To help people maintain independence and well being at home by:a)determining needs and abilities, developing and coordinating plans of care;b)teaching self-care and coping skills;c)improving, maintaining or delaying loss of functional abilities;d)promoting and supporting family and community responsibility for care; and,e)supporting acute, end-of-life, rehabilitation, maintenance and long-term careprovided by family, friends and neighbours.2.To facilitate appropriate use of health and community services by:a)preventing or delaying the need for admission to long-term care facilities andassisting on discharge;b)supporting people waiting for long-term care admission;c)preventing the need for hospital admission, making earlier discharge fromhospital possible, and reducing the frequency of re-admission;d)helping individuals and families access needed services;e)promoting volunteer participation;f)educating the public about home care; and,g)participating in local service planning and coordination.3.To make the best use of home care resources by:a)serving people with the greatest need first; and,b)operating economically and efficiently.4.To meet client needs and optimize client independence within available home carefinancial resources while working cooperatively with other community agencies,organizations and individuals.
Community CareHome Care PolicySection:Index Ref: 1.3IntroductionPage 1Date of Issue:September 2006Revised September 2015Subject:Philosophy1.3PHILOSOPHYHome care is guided by the following ple can usually retain greater independence and control over their lives in their ownhomes;Most people prefer to remain at home and receive required services at home;Support provided by families and friends should be encouraged and preserved and, ifnecessary, supplemented;Service should assist individuals and families to retain maximum independence and avoidunnecessary dependencies;Home care should assist people to access needed health and community services;Home care should preserve and promote volunteer involvement;Service decisions in home care should be based on assessed client need and the risk to theclient if service is not provided;Individuals and their supporters should help identify their needs, establish goals, anddevelop plans to meet goals;People with the greatest need for home care should receive priority for service;Individuals have the right to be treated with kindness, dignity and respect;A person’s right to live at risk to one’s self and to accept or refuse services is respected;Home care services should be provided respecting the client’s cultural values and,whenever possible, by staff who are of the client’s language and culture;Regional Health Authorities should have significant responsibility for planning anddelivering home care services;Home care involves the planning and coordinating of local health and communityservices; and,Home care does not usually provide services to allow caregivers to work at a long-termjob. Home care is not normally provided to relieve parents from routine childcare.
Community CareHome Care PolicySection:Index Ref: 1.4IntroductionPage 1Date of Issue:September 2006Revised September 2015Subject:Board Responsibilities1.4BOARD RESPONSIBILITIES1.The Regional Health Authority is the governing body of the health region, which includesthe home care program. The board is vested with full legal authority and responsibilityfor the home care program. Though not limited to the following, the board is responsiblefor the observance of, and compliance with, The Regional Health Services Act andRegulations and provincial policy pertaining to the delivery of home care 1.2.The Regional Health Authority is accountable:a)through the Minister of Health to the Legislature for the proper expenditure ofpublic funds to provide home care services;b)for planning, administrating and delivering home care services in the region; and,c)for adhering to program policies established by the Community Care Branch ofthe Saskatchewan Ministry of Health.1The exception to this is the Athabasca Health Authority, which is responsible for the observance of, andcompliance with, the Service Agreement between the Athabasca Health Authority and the Minister of Healthand any policies pertaining to the delivery of home care.
Community CareSection:Index Ref: 2.1Page 1Date of IssueHome Care PolicyContinuum of CareSeptember 2006Revised September 2015Subject:Maintaining Continuity of Service2.1MAINTAINING CONTINUITY OF SERVICEGUIDELINESMaintaining continuity of service includes:a)b)c)d)e)f)g)h)i)providing the same home care service providers to clients where feasible;educating organizations and providers about home care services;identifying major referral sources and establishing communication links;liaising with other organizations or Regional Health Authority services involved withclients (e.g. adult day program);developing an awareness of and integrating complementary services provided by otherorganizations and agencies;working collaboratively with other organizations providing service;referring appropriately to other organizations;ensuring relevant information is communicated in a timely manner; and,working with families/supporters to achieve continuity of service.
Community CareHome Care PolicySection:Client Access to ServiceIndex Ref: 3.1Page 1Date of Issue:September 2006Revised September 2015Subject:Coordinated Access3.1COORDINATED ACCESSPOLICYRegional Health Authorities, as a minimum, will provide coordinated access to long-term care,respite, adult day programs and home care. Other services may be included, as appropriate.GUIDELINES1.Coordinated access to long-term care, home care, adult day programs and respite servicesensures that clients are prioritized based on greatest need.2.Coordinated access enables the Regional Health Authority to identify gaps inprogramming and the need for new initiatives, and to effectively use resources within theregion.3.Coordinated access includes a case management approach, avoids duplication of serviceand ensures that appropriate service is provided.
Community CareHome Care PolicySection:Client Access to ServiceIndex Ref: 3.2Page 1Date of Issue:September 2006Revised September 2015Subject:Eligibility Criteria3.2ELIGIBILITY CRITERIAPOLICY1.Applicants for home care must meet one of the following eligibility criteria in order tohave their applications considered:a)hold a valid Saskatchewan Health Services card;b)be in the process of establishing permanent residence in Saskatchewan and haveapplied for a Saskatchewan Health Services card; or,c)be a resident of Manitoba or Alberta in a border area where contractualarrangements have been approved by the Saskatchewan Ministry of Health.2.Regional Health Authorities must consider applications for home care from anySaskatchewan resident. Indian Bands may enter into contractual service agreements withRegional Health Authorities to request services for Registered Status Indians living onreserve.3.Non-residents must apply for a Saskatchewan Health Services card in order to receivesubsidized home care services beyond three months. This three-month periodcorresponds with the waiting period for coverage under Saskatchewan hospital, medical,and other health plans.Non-residents who are not required to apply for a Saskatchewan Health Services card inorder to access home care services include:a)students (who are in the province for less than 12 consecutive months);b)individuals who have employment contracts for a maximum of 12 months;c)interim refugees who are covered by Health Canada;d)refugees intending to remain in Saskatchewan who receive coverage uponapplication for a Saskatchewan Health Services card;e)RCMP who are covered under Health Canada; and,f)individuals of Military and Corrections Canada.4.Saskatchewan residents who are out of province and are eligible for home care servicesmay receive services in another province. The Saskatchewan Ministry of Health will payfor this service based on the fee structure established by the Ministry. Prior approvalfrom the Saskatchewan Ministry of Health is required.
Community CareHome Care PolicySection:Client Access to ServiceIndex Ref: 3.2Page 2Date of Issue:September 2006Revised September 2015Subject:Eligibility CriteriaGUIDELINES1.Saskatchewan home care programs may accept applications from non-Saskatchewanresidents staying temporarily in the province. Non-residents are liable for the full costsof all services provided, including assessment and coordination costs, but notadministration costs.2.In exceptional circumstances, where the charge for services provided imposes a seriousfinancial hardship for the non-resident client, the Regional Health Authority may chargeless than the full cost of service defined above. The Regional Health Authority shouldnot charge less than the amount a Saskatchewan resident with the same income would becharged for the same service if she/he applied for an income-tested subsidy.
Community CareHome Care PolicySection:Client Access to ServiceIndex Ref: 3.3Page 1Date of Issue:September 2006Revised September 2015Subject:Acceptance Criteria3.3ACCEPTANCE CRITERIAPOLICY1.The Regional Health Authority shall set acceptance priorities based on assessed need andlevel of risk.2.Individuals requiring a single service shall be assessed to determine need and risk if theservice is not provided.3.The provision of a single service shall not be linked to the requirement of an additionalservice (e.g. Regional Health Authorities are not to link homemaking to another service).4.When an applicant is accepted to the program and there are serious reservations aboutsafety, either for the individual requiring care or the home care provider, home care must:a)set any conditions it believes are necessary to make service arrangementsworkable;b)ensure that any conditions for admission are clearly explained to the applicant andto involved family members and supporters;c)ensure ongoing documentation of client needs and circumstances, factorsaffecting service arrangements, and all discussions and agreements with clientsand supporters regarding service arrangements; and,d)ensure that the service arrangements are reviewed at least once a month.GUIDELINES1.Home care services may be provided to any person based on assessed need where:a)the person requires care and support while living in the community; and,b)the services to be provided do not replace the assistance usually provided by thefamily or community, unless necessary.2.Home care services may be provided to:a)determine a person’s needs and develop appropriate plans for care;b)improve a person’s ability to function independently by teaching self-care;c)prevent or delay the functional deterioration of a person;d)provide needed assistance and relief to the family and others who are providingcare to a person;e)assist a person with a disability to function as independently as possible;f)eliminate or delay the need for a person’s admission to a special-care home,hospital or other care-giving institution;
Community CareHome Care PolicySection:Client Access to ServiceIndex Ref: 3.3Page 2Date of Issue:September 2006Revised September 2015Subject:Acceptance Criteriag)h)i)3.maintain a person in the community pending placement in a special-care home orother care-giving institution;allow a terminally ill person to remain at home as long as possible; and,permit earlier discharge of a person from hospital or reducing the frequency
POLICY MANUAL . As the Home Care Program is administered and delivered by the Regional Health Authorities and funded by the Saskatchewan Ministry of Health, this manual is designed to ensure consistency of home care services and home care standards throughout the province. The program expectations in the delivery of home care are addressed in this
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