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Who are the people on your Home Care team and what do they do?
You may be surprised by the sheer number of people who are part of your home care team. It can be very overwhelming, especially at first, since there can be a dozen or more people calling you on the phone and meeting you at your home. It can also be confusing to remember the differences between each person’s role and what to expect from them. Keeping contact information straight is difficult, as is knowing who to call for what. The chart below is my attempt to make these issues clearer. It is not exhaustive, but it is meant to be practical and easy to use.
I recommend that you print out this chart and fill it in with the help from the team members you meet or speak with.
Team member table
For printer-friendly version click here
| Home Care Team Member | Role |
|---|---|
| Primary Palliative Physician | Oversees overall medical care |
| Home and Community Care Support Services Care Coordinator | Quarterback for all services listed as *HCCSS |
| Nursing (RN/RPN) *HCCSS | Provides direct care and support, including symptom assessment and management suggestions, monitoring overall condition, wound care, medication management. |
| Personal Support Worker (PSW) *HCCSS | Assists with activities of daily living such as bathing and dressing |
| Occupational Therapist (OT) *HCCSS | Helps with activities related to daily living, such as mobility, home safety, equipment such as walkers, hospital beds. |
| Physiotherapist (PT) *HCCSS | Assists with improving movement, strength, and balance |
| Social Worker (SW) *HCCSS | Assists with financial, legal, and emotional issues |
| Dietitian (RD) *HCCSS | Assists with nutrition advice |
| Speech-Language Pathologist (SLP) *HCCSS | Assists with communication and swallowing problems |
| Oxygen Supplier | Provides home oxygen |
| Respiratory Therapist (RT) (usually via Oxygen Supplier) | Assists with breathing problems and equipment such as home oxygen, BiPAP machines. |
| Palliative Paramedic Program | Can respond in case of urgent need to help manage acute symptoms in the home |
| Private Service Provider | Supplemental nursing and PSW services (paid privately or via insurance) |
| MAID Assessor/Provider (If specifically requested) | Assesses if patient meets criteria for MAID and provides MAID |
Who to call when:
| Problem/Issue | Who to call |
|---|---|
| For symptoms not under control | Call the doctor |
| For equipment issues, wounds, injectable medications | Call the nursing agency |
| For oxygen equipment issues | Call the oxygen supplier |
| For care coordination issues (staff did not show up for a planned visit, need to change frequency of visits, expected delivery did not occur) | Call the Care Coordinator |
| For new equipment needs | Call Occupational Therapist or Care Coordinator |
| For immediate and urgent issues | Call the doctor |
| If the person has died | See the article: “What to do when the person dies” |
If you are calling after regular business hours:
- For the CPMA doctor on-call, press “1” once you hear the message. You will be connected to the doctor’s cell phone or voice mail.
- For Home Care, just keep pressing zero until you are connected to a person.
- For nursing/PSW agencies, you will often have to leave a voicemail. Please leave a message with the person’s name and your phone number. Response times vary.
- For Paramedics, make sure you inform the dispatcher that the patient is being cared for by palliative care team.