Program Service Delivery
Carrying Out Client Assessment
Any person may request home and community care services. The request
for service may come to the Home Care Nurse Coordinator from any
number of sources, such as the person requesting the service, a
family member, a community member, the doctor, community health
or social service agencies, or outside agencies.
The decision to "admit" or "not to admit" may
be an obvious one, however, most referrals will result in the need
for a home visit and a detailed client assessment to determine
the care needs and the most appropriate program or agency to care
for those needs. It is important to complete the assessment in
the home as many factors of the person's home environment can influence
his or her home care needs, e.g. is the home wheelchair accessible.
Preparations Prior to Home Visit
Prior to visiting the client, it is recommended that the Home
Care Nurse Coordinator(For purposes of this Handbook, the title
Home Care Nurse Coordinator refers to a registered nurse with training
in client assessment and case management responsible for the management
and coordination of the Home and Community Care Program. Titles
and roles / responsibilities may vary between communities.) (or
the person in your community who will be responsible for carrying
out client assessments) carry out the following preparatory work:
- Obtain relevant information about the referral such as doctor's/other
designated professional orders, acute care discharge summary,
concerns from individuals, other professionals or community members.
- Initiate client record forms by completing the basic information
known from the referral. This may include: name, address, name
of doctor, referral source, diagnosis, problems, etc. It is recommended
that only the forms necessary to complete the client assessment
process be taken to the client's home in order to reduce the
amount of paperwork that is completed during the home visit.
Examples of such forms may be the assessment form/tool, the care
plan or home care contract, the client consent to treatment and
sharing of information form, and the client
rights form.
- Record the time and date of the referral and home visit in
a log book or on referral sheets (refer to Appendix B for
a sample), kept in the office. It is recommended that a
record/file of all referrals be kept for legal purposes, whether
the referral resulted in service provision or not, and the reason
for non-admission to the program. Potential reasons for non-admission
may include: individual referred to another (more appropriate)
program; insufficient or untrained staff available to provide
the service; or services cannot safely or adequately be provided
in the home. This information will be useful for analytical purposes
when looking at the need to increase staff, provide additional
training, and/or to illustrate the number of admissions/nonadmissions
to the program.
- Contact the person requesting the service and/or a family member
to arrange a convenient time for a home visit and to determine
if there is a need for an interpreter or translation of documents.
A family member or an informal care giver, such as a family friend
or another community member, may need to be present at the home
visit, particularly if the person will require long term and/or
complex care. If the person is admitted to the program, the family
member or informal care giver may be asked to assume certain
responsibilities on behalf of the client such as assisting them
with their care needs and acting as their advocate. The family
member or informal care giver will also ensure that someone other
than the Home and Community Care staff are available to assist
the client or respond to emergency needs since home care services
will not be available 24 hours/day, 7 days/week in most areas.
Ensure that the nursing bag has all the necessary
supplies in order to carry out a physical assessment of the client
in the home. A recommended list of basic and supplementary medical
supplies and equipment for home and community care is available
in Appendix C.
The Home and Community Care Program will assist the client with
things they cannot do themselves while promoting client independence
and family involvement.
Conducting the Assessment Interview
While conducting the assessment interview, it is important to
be aware of the cultural and traditionally accepted communication
practices in each community. Any staff member who is not familiar
with these practices should be provided with an orientation to
the community and be encouraged to attend cultural awareness workshops.
It is important to listen and learn the community's lines of communication
and traditions.
A good rapport can be developed at this early time by conveying
a sense of support and trust. The use of non-verbal cues may be
another way to communicate respect and caring in a way that is
more culturally appropriate. The body language of the client and
the informal care giver can also tell you if they are comfortable
with what is being said or asked. Experience and judgement will
guide you on whether more time needs to be spent on establishing
rapport and trust. What is important is that the client feels that
they are respected and that the Home Care staff accepts
them as they are.
Some time may
need to be spent on explaining the philosophy, values and mission
of the Home and Community Care Program of encouraging independence
and involving family or others in the care plan. This will be
especially important in areas where home care has traditionally
been seen as a homemaking service and where services have been
provided based on historical practice rather than on assessed
need.
Time should be taken to explain the purpose of the client assessment,
whether or not writing will be done during the assessment, and
how the care plan will be jointly agreed upon. During this time,
the client should be informed of his/her "rights" (refer
to the Client Care Section of the Policies Template Manual for
examples on Client Rights) and should be encouraged to ask
questions at any time during the assessment process to ensure that
what has been explained has, in fact, been understood. Using language
that is easily understood and avoiding, where possible, the use
of medical terms is a good idea. The services of an interpreter
may be necessary in some cases.
The home care
assessment is the key to successful home care services. This
process sets the foundation for a positive and effective relationship
between the client and informal care giver and the Home and Community
Care staff. The average assessment visit will take between 60
and 90 minutes. It will take at least the same amount of time
to do the preparatory work, charting, follow up visit and any
referrals that may be necessary.
Completing the assessment tool should only be done after a good
rapport has been established between the client/informal care giver
and the Home Care Nurse Coordinator. Each Home Care Program should
have an assessment tool that has been adopted for use by the Program. Sample
assessment tools are available in Handbook 4.
Questions should be understandable and open-ended whenever possible.
A good way to ask a question is to start by saying "please
tell me about ..."
The assessment tool should begin with all the relevant information
about the client, such as name, address, next of kin, health number,
band number or NIHB number (the latter is Inuit specific), language
preference, doctor's name, name of pharmacy, diagnosis, medications
and treatments, medical history as well as the client's ability
to understand written instructions.
The tool should also identify the physical and functional conditions
and needs, the living conditions of the client's home environment,
the supports available to the client, the current problem(s) and
any services being received. Information on completing a physical
and functional assessment follows on page 10.
The Home Care Nurse Coordinator will need to do more than complete
a form during this initial home visit. She will also need to observe
the environment (e.g. access to home, stairs, running water, mold),
examine relevant conditions (e.g. wounds, skin conditions, breathing
problems), and review all medications currently taken by the client.
In order to do a complete medication review, the Home Care Nurse
Coordinator should ask the client to show all the medications (e.g.
pills, creams, sleeping aids, liquid medication) that they are
currently taking. Specifically, ask about any medications that
the client might be "borrowing" from someone else as
well as any non-prescription medications, vitamins and traditional
remedies. When all medications have been gathered, the Home Care
Nurse Coordinator should ask the client to tell her about when
they take them. This may be a good time to check reading ability
by asking them to read the instructions on the
medication container.
A suggested acronym for a complete Physical Assessment is
"M.O.R.E. S.E.N.S.E."
M Mobility/Physical
Abilities
This will identify any movement or walking difficulty
as well as any limited strength or transportation problems. You
may ask "Do you go to church, to the community centre, hall,
etc.? Do you own/drive a ski-doo or 4-wheeler? "
O Oral/Dental
Health
Note dentures, if any and discuss any problems
with chewing. Identify the client's dentist and the date of the
last examination.
R Respiration
Determine any breathing difficulties or persistent
cough. You may ask "Can you walk the distance equal to one
block without trouble breathing? "
E Eyes/Ears
Ask client to describe what they have trouble
seeing, e.g. numbers (at Bingo or on telephone). Identify their
Eye Doctor and the date of their last examination. Ask if they
wear glasses. Ask and observe any hearing difficulties and ask
about whether or not client has/uses a hearing aid and how long
they have had it. Also determine if the client understands how
and when to obtain/change batteries.
S Skin
and Circulation
Use questions and observation. Does the client
identify any problems? Do you see any conditions, e.g. poor color,
dryness, ulcers, etc.?
E Elimination
This can be a very sensitive area for clients
to talk about so phrase the questions very carefully, e.g. "Would
you say that you have any problem with your ....bladder or bowels? " (Use
language that the client would understand).
N Nutrition
Ask the client "what" they eat. Determine
if they have ever been advised to be on a "special" diet,
what kind, etc. Discuss how groceries are obtained and any difficulties
cooking. You may ask "Can you get to the store? Do you have
enough to eat? Do you have access to traditional foods? "
S Social
Activities
Ask client about visitors and their frequency
- Who? When? What activities they do with them? What role do they
play with children/grandchildren? Are children present in their
home? How often? Determine activities that the client enjoys as
well as any difficulty performing these activities or getting to
them. Also enquire about skills/interests that the client may be
willing to share.
E Emotional
Health
Another very sensitive area. Ask client to share
their feelings about a variety of things, e.g. their illness (ask
what is the hardest thing about their illness), their family, their
environment, sleeping, etc.
A complete Functional Assessment looks at all activities of daily
living. An easy acronym for this may be "H.E.L.P.".
H Homemaking
Identify any difficulties with housework, making
meals, shopping and/or laundry.
E Environment
Look at/enquire about home renovations that
are needed or ones that impact on the safety of the client or the
care givers. Is there sewer and running water? Is wood required
to heat?
L Living
Activities/Lifestyle
Enquire about financial management, transportation.
Is the client able to manage these activities or does she/he need
help? Questions related to lifestyle issues such as addictions
are relevant to ask in an assessment, however, direct questioning
may or may not be appropriate. Each case should be looked at individually.
P Personal
Hygiene
Ask client to describe their bathing/shampooing
practices. Is help needed? Do they have difficulty dressing or
undressing? Do they have difficulty getting in/out of the tub?
After carefully doing the Physical and Functional Assessments,
summarize:
- the areas where assistance is required (client needs);
- the type of assistance required;
- who will do the assisting; and
- when the help will be given.
Admission
A person is admitted as a client to the Program when:
- the client assessment has been completed; and
- it has been determined that the person has a physical and/or
functional need that is greater than what the family/informal
care giver can meet; and
- the need can be met in a safe and affordable manner through
the Home and Community Care Program.
Since the spiritual
aspect of a person's life affects many areas, it is important
to be sensitive to the client's beliefs during the entire assessment
process. Both cultural and traditional customs and beliefs will
influence how they will accept and comply with the proposed plan
of care.
Non-Admission
A person should not be admitted to the Program when following
the client assessment:
- it has been determined that the person and/or family can provide
the needed services themselves (your Program Philosophy and Mission
Statement of client independence and family involvement will
help guide you in this decision); or
- it has been determined that the person's needs can best be
met by another program or agency; or
- it has been determined that the person's needs cannot safely
be provided in the home.
In the event of the latter two, the person should be referred
to the appropriate agency/program and told that "if the needs
change" the Home Care Nurse Coordinator should be contacted
again and asked to reassess the situation. If there is no other
appropriate service in or outside the community, this should be
noted.
Prior to ending the assessment visit:
- inform the client whether he or she will be admitted or not
admitted to the Home and Community Care Program. If further research
needs to be carried out, inform the client when a decision will
be made;
- review the identified needs/problems with the client and the
informal care giver/family;
- clearly state the goals of care and tasks to be carried out
(refer to the following section for more information on developing
a care plan);
- agree on what the informal care giver is able to do in meeting
the goals of care;
- agree on what the client can do;
- agree on what the Home and Community Care staff will do for
the client;
- inform the client and the informal care giver/family when the
service will begin, the duration of the service, and when the
reassessment will occur;
- review any relevant policies and procedures related to the
goals of care, e.g. care will only be provided with the client
present and within a safe environment for the client and care
provider;
- ask the client to sign a consent form for treatment and sharing
of information, as needed with other professionals (refer
to Client Care Section of Policies Template Manual for examples)
as well as any other client forms (e.g. client contract, client
bill of rights, worker bill of rights) if applicable; and
- ensure that the client and informal care giver know how to
contact the Home Care Nurse Coordinator if needs change.
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