Home & Community Care
The Home & Community Care Program (HCC), formerly the Home Care/Home Support Program, provides in-home nursing care visits for clients who are referred by a physician with specific needs and for post-operative patients who require continued care when released from hospitals. Medical nursing treatments require a physician’s order. The nursing medical treatment provide a range of services from Intravenous therapy, wound management, palliative care, etc. Nursing visits per client can range from monthly to twice daily, according to the needs assessed. HCC assists people whose capabilities are diminished due to acute or chronic conditions. Program personnel assist with activities of daily living such as personal care, meal preparation, grocery shopping, housekeeping, and assist with medical appointments. Family support and the promotion of independence are strongly encouraged.
The Home & Community Care Program’s office is located on Kawehno:ke (Cornwall Island) at 24B Frank Benedict Memorial Lane, Akwesasne, ON K6H 5R7.
Our Mission
The Home & Community Care Program provides a therapeutic and supportive services to our community members, as well as ensuring that staff are qualified and receive ongoing training to support our clientele.
Objectives:
- To provide high quality therapeutic and supportive services to our eligible community members.
- To support community members to remain in their home environment for as long as, ensuring health and safety to both client and employee.
- To maintain and build strong internal and external relationships to assist with hospital discharges.
- To manage all resources to ensure program sustainability within service standards
- To maintain accreditation certification standards.
Criteria for Services:
- No age requirement must be registered with the Mohawks of Akwesasne band.
- Must reside within the Three Districts of Akwesasne under the Mohawk Council of Akwesasne jurisdiction.
- Must have a written Physician or Nurse Practitioner referral for all client specific care and treatment.
- Upon receipt of the referral an appointment is made for an in-home assessment to determine need and services requirements.
- Consent for Treatment/Services plans must be signed.
The Home Care and Support Program is building and maintaining a strong and sustainable system of seamless community support services that meets the needs of Akwesasne. The Electronic Medical Record (EMR) is now being used by the Home Care Nursing team, facilitating equitable access to and navigation within the community health sector. This process helps with client transitions between health service providers within the Department of Health (DOH). Health care is ever-evolving at a fast pace, with an aim of putting clients at the center of proper care, at the right time, and in the right place. The Home Care and Support Program are serving an increasing numbers of people and families in their homes, and providing increasingly more complex care over a longer period of times. The program is constantly met with challenges within the needs of our clientele that require networking and new ideas to help with a seamless care service across all health care providers.
Health Services contracted:
- Physicians: 1
- Message Therapy
- Chiropodist
- Lab Work provided by Life Labs
Nursing Care Services:
Our nursing team, are licensed in both Ontario and Quebec. We strive to provide all aspects of nursing services to eligible clients and their families, within their own homes. We collaborate with the hospital Discharge Planners, Physicians and Nurse Practitioners regarding eligible clients who are released from hospital, and provide medical referrals for wound management, cancer care, infection control, intravenous therapy and in-home palliative care services.
Personal Support Worker (PSW) Services:
Our PSWs provide in-home care to eligible clients in all three (3) districts, services include the following; personal care, monitoring vital signs and blood sugars, assists with activities of daily living, meal preparation, respite care, light housekeeping, local transportation and in-home palliative care (end of life-shifts).
Medical Social Liaison Worker:
Our Medical Social Liaison Worker provides assistance to clients in need of advocacy for financial, legal concerns, environmental and housing deficiencies. Provide assistance with long-term care placement, case conferencing and referrals for clients and families. Actively participates in community outreach programs, multidisciplinary committees and provides presentations on program services to Elders at various facilities.
Home Maintenance Services:
Ensuring client’s homes are free from hazards is of prime concern to our Home Maintenance Services. We complete home assessments and provide referrals to appropriate agencies should a safety concern be evident emphasizing a safe living environment especially for our chronic care clients. They have excelled in meeting clients requests and work orders, on many cases were emergency based. We also provide minor home maintenance services, delivery and installation of medical equipment, grass cutting, and snow removal to those who meet the criteria.
Physiotherapist Assistant (PTA) Services:
Our PTA provides in-home designed physiotherapy treatment plan that is initially develop by the Physiotherapists in the Outpatient Physio Clinics at Tsiionkwanonhso:te. The individual physio treatment plans are communicated from the Physiotherapists to our PTA to be continued to eligible clients in all three (3) districts for continued care, support, and advocacy.
CONTACT INFORMATION
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Name
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Position
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Ext./Email
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Contact for Dept.
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Chelsy Plante, |
Program Manager |
613-575-2341 ext. 1067 Located at HCC Management |
HCC program management; Service complaints/concerns; Unique circumstances; Contracts/agreements |
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Sabrina Jacobs |
Administrative Assistant |
613-575-2341 ext. 1618 |
Accepts, processes, and dispatches all referrals; Contacts referral sources for proper demographics; Bill payment; Deliveries |
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Referrals |
Nursing Care; PSS Services; HME; Fall Alert |
Fax: 613-745-6984 |
Must have a MD or NP signature; HME can accept MD, NP, OT, or PT; Health card & status # are required |
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Referrals |
Lawn Maintenance; |
Fax: 613-932-7503 |
Must be a HCC client with no family assistance & a completed application |
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Referrals |
Social Transportation |
Fax: 613-932-7503 |
Must be a HCC client with no family support or access to a vehicle. HCC does not transport for medical appointments |