Home Care Services and Early Detection & (Risk)Signaling: An Indispensable Link in Integrated Primary Care

Abstract

Summary: Funded by the city of Antwerp, this project wants to optimize the preventive role and position of Home Care Services (HCS) in primary care by (1) improving the early detection en (risk)signaling of the home care professionals, (2) and elaborating the bridging function between HCS and the different primary care disciplines and sectors through shared vision and goals, suitable tools, communication systems and clear procedures in information sharing.
 Short description: HCS provide essential (non-medical) support that a person or a family in need of care requires in order to continue to live independently at home. Typical for Home Care Services is that employees spend many hours in close contact to the person or family in need of care. As a confidant to the client they quickly pick up on behavior changes, evolution in illness or condition. They are often the “eyes and ears” to a multidisciplinary team of care providers surrounding a client or patient. Or at least: they could be. All too often this indispensable role of HCS is insufficiently recognized by welfare organizations and medical care providers.
 The confidant position and early detection role of HCS professionals can bridge gaps between other professional care givers and a (psychologically or mentally vulnerable) client/patient, via signalization and referral to best placed (mental) health care or welfare actors.
 Several conditions need to be fulfilled for HCS to being able to effectively play this part in an integrated care system, like shared vision and goals, suitable tools, clear procedures in information sharing, recognition of HCS professionals as equal partners in primary care. All these conditions are being addressed in this project.
 Target group: All independent living persons in need of care and their care givers. In the first phase the project focusses on people with a psychological or mental vulnerability. 
 Project design
 * Involved actors:
 All HCS active in the City of Antwerp, in intense collaboration with a network of mental health care organizations, the social health services of the City of Antwerp. A sounding board is established to ensure the involvement of all relevant parties (project intervision, monitoring, adjustment).
 
 * Co –design approach: the target groups are therefore being involved via focus groups and quality surveys, throughout the project.
 * Possible restrictions:
 
 Legal restrictions on information sharing (e.g. GDPR, professional secrecy)
 Diversity in ways of financing of organizations.
 A broad and diverse set of (online) communication tools and ways of information sharing between health care sectors
 
 Next steps:
 
 Roll out of training programs to add to the competences of HCS professionals.
 Adjustment of internal and external communication protocols.
 Development and testing of uniform and shared (digital) communication tools.
 Application of uniformized methods concerning early detection, signalization and guidance in all vulnerable client situations.
 
 Learning for the international audience:
 
 Insights regarding the project's approach
 Importance of the role and contribution of a home care service (with lower-skilled staff) compared to the (highly-skilled) GP or home care nurse.