HomeWise Health (HWH) is committed to ensuring that the highest quality of care is delivered to its clients and that their experience is “Living Well at Home”. 

To achieve this outcome, particularly for those requiring higher levels of care, this service must be closely monitored and tightly coordinated, especially with care being delivered by a team of carers with input from time to time by allied health professionals.

The following Case Study has been written to help give some insight into the care of a notional client, Betty Smith and how it is delivered to her on a day-to-day basis using our Client Management System - BaseCamp. 

Holistic Care
We achieve high-quality care on a comprehensive basis through the application of a well-designed Care Management program, including a Care Plan (and suitable resources to support its execution), a schedule of care (to ensure the team knows when and where they are to be available), Case Notes for overall care management issues, both of an environmental and health nature and Shift Notes (giving real-time insight into Betty’s day to day activity and well-being). It is accessed through her portal.

Betty’s care starts with its Documentation.

The Document’s folder contains all information relevant to Betty’s care and well-being. The Carers have access to the relevant resources through mobile devices (phones and tablets) at all times and to Betty’s Clinical Care Manager (CCM).

Betty’s CCM is supported by other clinical managers and a further higher level of managerial support, all of whom are highly experienced Nurses.

Care Instructions

The Care Instructions are “living, breathing documents” updated as Betty’s condition changes. These instructions are not “set and forget”, as her condition can change rapidly and frequently, and different care regimes will be implemented to meet her current needs. 

Reading the Shift Notes and Case Notes demonstrate how rapidly her condition changes and the fluctuations, whether it be what she wishes to eat, her sleeping patterns or issues of personal care. We will take a longer-term problem - her reluctance to shower or be showered, a common occurrence for people living with dementia as an example of how it is monitored and managed. 

On many occasions, a creative approach will be required as Betty’s willingness to shower can change from minute to minute as on some days and times she is disoriented and on others, alert and aware.

Following are just some of the Instructions to the carers to help manage Betty’s care.

To communicate Betty’s reluctance to shower should a new carer have some concerns, she has access to the relevant details under Personal Care.

Here we can see these instructions point out that Betty can resist showering. Full showering occurs when two staff are on duty before outings. Daily sponge baths occur while sitting on a shower stool in the bathroom, usually mid-morning. Preparation for all tasks is required (heating the bathroom, organising clothing, setting up equipment) to ensure their uninterrupted execution.

We also have visibility into the currency of the instructions and can see that the document was last updated by Caroline on Sept 27th. 

We can also track who did what and when to any document through a detailed changelog.

Importantly, our clients and their families can access this information and monitor the care in real-time should they wish.

While the documents are living and breathing, there is a significant amount of day-to-day discussion, planning and scheduling required to manage the care delivery environment. At the same time, the carers give real-time attention to Betty’s every need. 

We use Schedules and To-Do lists and develop the plans through Case Notes and related comments, allowing us to have a collaborative and team approach.

Briefly looking at some of these tools will give insight into how they fit into Betty’s overall care regime.

For recording future events, the system Schedule is used. Events, meetings, appointments and birthdays are entered to ensure nothing is overlooked. Each scheduled event allows the attendees to be notified and added to individuals’ calendars.

While events are planned and noted on the schedule and calendar, many other issues require careful planning and a series of tasks to be completed. The recent “de-cluttering” and mould works are such issues. 

For this, we use To-Do lists.

Consider the current issue with Hazards that arose after a Work Health and Safety (WHS) inspection (a requirement legislated by the government).

This inspection uncovered various trip hazards, electrical faults, mould and issues related to surplus materials and personal effects around the home.

While managing care delivery is like managing a small project, and the task lists in To-Dos provide the appropriate mechanism, health issues require a less structured, more collaborative “real-time” approach. 

Take, for example, a case in late August where Betty was having difficulty eating, and some food may have, in layman’s language, “gone down the wrong way”. The following Case Note recorded the response with possible causes and outcomes.

After receiving a call from the carer, Cath organised an ambulance to attend to Betty. Note that 3 people were initially involved, with five supporting comments.

The Case Notes allow us to track daily issues and concerns and collaboratively observe unfolding stories, permitting the team to engage with Betty’s care and her Care Team effectively. 

These allow us to harness the team’s experience to resolve concerns such as Betty’s showering. Here we learnt from Eunice's success with showering to prepare everything so that they could move quickly to a warm shower when Betty went to the bathroom. The path of least resistance.

You will note that the Carers are invited into some of these conversations. Other notes are for Team management only to protect privacy etc. Family members can also join these conversations and make comments should they wish. In Betty's refusal of her medication in early September, there were 8 different comments around a strategy to address this issue, providing a powerful opportunity to reach the appropriate solution. 

We were alerted to this by the Shift Notes recorded throughout the day as carers registered them on their phones. We are notified as the note for each client is received, allowing us to be quickly responsive. Cath observed the following note in this case and was the first to respond.

The Shift Notes have become crucial to delivering Betty’s care, allowing us to get previously unavailable insights. The content, in the form of a message thread, is conversational, informative and, importantly, searchable.

Following is some insight into a day in Betty’s life as provided by Eunice, one of her long-term carers. 

While this may seem like too much information, the team can glean some valuable insights from this. 

From this, we see that the Carers are already alert to issues around showering, as was noted in the Care Plan, and we see here that, as commented, Betty is regularly refusing a shower. Today Eunice, having failed earlier, will try again later. Note that Betty was also reluctant to change her clothes. We also observed how often Betty wakes during the night and worked on mitigation strategies, as Betty and her carers must get adequate sleep for their health’s sake. 

Betty had been going to bed earlier and earlier, mainly as it got dark early in winter, and then waking very early the next morning, but with CCM assistance, the carers were able to change Betty’s routine to stay up till after 7 pm so that she could get a full night of uninterrupted sleep.

Searching the Shift Notes

By examining the Shift Notes for relevant terms, we can observe trends that may reflect problems, and if so, the team can intervene by either changing the Care Plan for the long term or documenting shorter-term solutions. Consider our example where Betty is reluctant to shower. In this case, the Care Plan allows for two people to assist and where Betty is reluctant (typical behaviour of a person living with dementia, some of whom do not shower for weeks or months at a time), then provide a sponge bath and the Betty’s daily or more frequent peritoneal washing.

By looking at the Shift Notes search results, we can see the times Betty will shower or can be convinced to shower if she is reluctant and those occasions where the carers are unsuccessful. We can see that Betty won’t want to shower if she is settled and warm, but there is more success around 9 am after breakfast and coffee when she wishes to go to the bathroom. In cases such as this, carers have been successful.

The search on the word Shower in the Shift Notes gives the following results (a subset) and provides insight into the power of such a tool to help us discover the best solutions to such a problem. 

Rosters
The final and essential piece of the Care Jigsaw is scheduling the carers and for HWH to ensure that the team is well informed about who is going where and when, as unplanned events such as illness and misadventure occur. There are significant logistical problems involved in ensuring these issues are resolved.

The following will give some insight into Betty’s roster to ensure the essential continuity of service.

Note that HWH, where possible, schedule services a month in advance, and each carer has the information relevant to them on their phone and are automatically notified when their shifts are planned and when they need to “Clock On”. When they don’t “clock on” as scheduled, the CCMs are notified in cases of accidents or other issues so that they can take corrective actions.

HomeWise Health’s purpose is to deliver the highest levels of care so that their clients live the best they can at home and, if possible, stay in good health and in good spirits.

For clients requiring higher levels of care, this is impossible to deliver without the dedication of the carers, nurses and allied health professionals working in a well-informed collaborative environment. HWH strongly desires to make a difference in its clients’ lives and the people, processes and systems to make this a reality. 

We hope that this brief insight into some of the tools applied to care delivery, our processes and our dedication to the task, taken from real life, will give you sufficient insight into what makes HWH “stand out” and give you the level of comfort you require to select HomeWise Health as your care provider.