Updated: Aug 2
***Disclaimer: This article is for informational purposes only and does not provide medical, legal, or health advice and is not a substitute for mental health services
***Please note I do not work for the Ontario Ministry of Health and Long Term Care or related associations. I am simply presenting a perspective about navigating home care services based on my past social work experience helping many patients and their families as they prepared for discharge from hospital.
If you are a person in Ontario, Canada who needs help with basic care tasks, more complex care tasks, or cannot manage in your home any longer and may need institutionalized care, then this article may be beneficial for you to read to develop your understanding of how home and community care works in the province of Ontario.
Publicly - funded care services in Ontario are provided by Home and Community Care Support Services, which consists of organizations across the province of Ontario that coordinate services to help people live well in their homes, the community, and as well as in long-term care homes.
For more information about Home and Community Care Support Services, you can go to their website or call 310-2222 (no area code needed) to find your local organization and request help with your personal care needs. More information about how to navigate home care services is outlined below.
1. Understanding the home care referral process
If you are currently in hospital, your health care team will make the referral for you as they will have a great deal of medical information they will want to provide for additional context. This gives greater depth to your referral and helps clarify exactly what services you will need when you are discharged home.
For example, if you require support from a nurse for wound care, intravenous medication, or other types of specialized tasks, the hospital doctor will sign off on the referral as this is required for receiving home-based nursing services.
If you are living at home and are struggling with basic personal care tasks (e.g. toileting, bathing, dressing, feeding, getting in and out of the shower or bed, etc.), then you may be able to refer yourself for home care services. Your family may also refer you although home care will assess you directly to determine your eligibility for services.
Once your referral has been submitted, you will be contacted shortly by a home care coordinator. If your family has done a referral on your behalf, they may be contacted by the coordinator to discuss the referral and arrange a date/time for you to be assessed for service eligibility (unless they listed you as the main contact in the referral, in which case you will be contacted).
2. Accurate home care referral information is key
It is very important that the information in the home care referral is accurate. If details such as your name, phone number, address, and personal health information are wrong, it can contribute to misunderstandings regarding the services you need, confusion between you and your caregivers, and might even lead to a delay in receiving care services while your file is being corrected.
Ensuring your referral is accurate from the start will hopefully help the whole process go smoothly.
You can inform the home care coordinator who assesses you for services about any information you feel needs to be corrected and you can also share any other details you think would be helpful for them or your future caregivers to know.
3. Find out your next step in the home care referral process
You can ask your health care team what to expect in terms of when you will be assessed for home care services prior to discharge. The hospital Home and Community Care coordinator will assess you before discharge depending on the extent of services you require and/or they may direct your local home care office to connect with you for an assessment once you return home.
Given that Home and Community Care policies and procedures can change over time, it is best to inquire about the assessment process and next steps shortly after a referral has been made.
4. Have a support person with you for your home care assessment (if needed)
You will be assessed by a service coordinator to determine your eligibility for care services and you will need to consent to care services before they are provided. (This article assumes the client is cognitively capable to provide consent – if this is not the case, then the power of attorney for personal care for the client may provide consent for services).
When you receive an update as to what date and time your assessment will be, you can ask that a loved one be part of the assessment, particularly if English is not your first language and you need help with communicating, if you have memory or cognitive issues and need assistance with navigating the conversation, and/or if you feel you will not be able to describe your care needs sufficiently and need help advocating for yourself.
You may also want to think about asking this trusted person to make some notes for you so you have something to refer back to following the meeting. You can make notes yourself if you feel able to do that during the assessment.
5. Keep the contact information for your care coordinator and care providers in an easy–to–find place
Once you have the contact information for the care coordinator who will be assessing you, put it in a place that you will be able to see it easily (e.g. your fridge, a contacts book, etc.) and add their details into your cell phone as well.
If you are re-assigned to a new care coordinator after the assessment, obtain their information as that will be who you contact moving forward. Similarly, make note of the contact information for your care providers and/or the main phone line to call if your caregiver is running late or if they missed your appointment due to illness so that you can make alternate arrangements.
6. Understanding what types of home care services are available
Health care consumers require a range of services depending on their needs. Perhaps you are a senior who needs help with bathing, dressing, or feeding. Or perhaps you have an acquired physical disability and need an occupational therapist to assess your home for safety and make accessibility and medical equipment recommendations.
You may need help from a nurse to receive intravenous medication or wound care to treat a complex skin issue. Or maybe you have noticed you are not able to manage at home and want to inquire about the possibility of applying for long-term care (this application is also managed by Home and Community Care Support Services).
There are even more services that Home and Community Care Support Services offers beyond what is noted in this article - your referral is a vital first point of entry into the broad home and community care system.
7. Figuring out if extra private care services are needed
It’s important to note that public care services are mostly focused on providing personal care supports as well as assessments to help you live safely at home and in the community. Services also tend to vary by region – some regions may have more challenges securing staff or care hours – you will be informed by your care coordinator if this is an issue.
If the government care services that you are receiving are not able to meet all of your needs, then you may need to supplement with fee-based private care services. For example, if you need transportation to medical appointments, meal preparation, laundry, house cleaning, support going to the grocery store or other outings, or more frequent wellness check-ins throughout the day or the week, then you may need to consider additional private care services.
You can do an online search of private care services in your local area to find out what they offer and to also ask about price points. Most private care companies will do an assessment of your needs – similar to how you are assessed by government home care services.
If you decide to pursue private services, the agency you choose will create a contract for you to sign that outlines the cost of the services and what services you have agreed to as well as the frequency. A more detailed schedule of when to expect these services to take place per week or per month will be provided later.
It’s important to factor in your budget limits as well as the most important tasks you need help with in case you can only secure one or a couple private services based on your other expenses.
8. Learning how to advocate for yourself and direct your care are important skills when receiving services
Perhaps one of the most important tips for understanding home care services is to be able to direct your care and advocate for yourself during your interactions with providers. What this means is that you will want to have a good understanding of all of the tasks you need help with so that you can explain them as needed. You may find that you need to give instructions to new caregivers who are just getting to know you and your preferences for how you prefer these tasks to be done.
Being able to speak up about your needs will help your care team learn how best to support you. Similarly, giving constructive feedback if you would like to see changes in a caregiver’s approach is also a key aspect of self-advocacy. Building a satisfying client-caregiver professional relationship will allow you to receive care in an effective and compassionate way.
If you feel you need help navigating how to direct your care, you can ask your health care team for guidance and/or speak with someone you trust to see if they can help you work on and develop this valuable skill.
9. Raise any questions you have to your health care team and/or your home care coordinator or service providers
If there is something you feel uncertain about or if you have a question, please ask your health care team and also the home and community care coordinator so that you can get the information you need to feel well prepared for accessing care services when you go home. You can also ask questions of your care provider directly as needed once service begins.
Given you are the person who receives care, you need to know more than anyone else what to expect from your care services, when your care services will be received, and how your care services will be delivered. Asking questions as they arise will allow you to feel more comfortable and at ease throughout the process.
10. Record your personal care service details on a calendar
Streamlining the information you receive from your local home care coordinator is important for having a guide or a map of your care plan. Understanding which service provider is coming, what date/time, and what exact service they will be offering will help you keep all of the details clear in your mind.
Noting this information in a calendar can be a good step. Put one on your fridge or somewhere that is easily accessible for you and perhaps others in your family to see if they are supporting you in this process.
If you are technologically savvy, you can also store information in your phone calendar so that you have it at your fingertips, such as when you are at a doctor’s office and are trying to coordinate follow up appointments around your home care services.
Whatever tracking method you use, pick something that makes sense to you and that allows you to have a good grasp of what your week and perhaps your month looks like.
Understanding home care services can be confusing, especially if you are dealing with the additional stress of planning the transition from hospital to home. Ask your health care team (if relevant) for more information about home care services. Also, ask questions to the home care coordinator who assesses you. If you need help from a loved one to help you sort it all out, ask them.
Once you have the information you need, figure out a system that allows you to organize it better so you have an easy reference guide. Reflecting on any gaps in care and reviewing your budget will also help you determine if you need any additional fee-based private care services.
And don’t underestimate the importance of speaking up for yourself – being a well-informed health care consumer is crucial for you to be able maximize your well-being and overall health.
Wishing you well on your journey.
Davina Tiwari MSW, RSW, CSFT
Registered Social Worker and Certified Solution Focused Therapist
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