Specialized Services

Ontario Health atHome provides a wide range of care options within the community. Referrals can be made by patients, family and caregivers, as well as other health care providers and programs. Accessing community services begins with an assessment completed by a Care Coordinator in order to determine eligibility and what would be most beneficial based on individual patient care needs. Many of the services offered in a community setting include various therapies, which are outlined below. 

Social Work 

If you are experiencing an acute or chronic illness, coping with disability or living with the effects of aging and loneliness, you may also be struggling mentally and emotionally. Families and caregivers can be equally affected. Our social workers are regulated health professionals who offer much more than simply someone to talk to – they play a key role in a patient’s circle of care and can assist with accessing other supports such as housing or transportation. 

If your care coordinator feels that you might benefit from meeting with a social worker, you will be contacted for an assessment. Together, you and your social worker will develop therapeutic treatment goals specific to your needs, as well as a counselling schedule. Your social worker will also monitor and assess your progress and provide education to you, your family members and caregivers. 

Social work is typically a short-term service. If necessary, social workers will refer you to other support services in your community upon discharge from their care. 

Dietitian or Nutrition Services  

Nutrition is very important to getting well and feeling better and many people with different health conditions will need information about nutrition to help them manage. A dietitian can help you meet these needs and manage your nutrition through food and supplements.

Dietitians assess individual needs and work with patients to develop a personalized nutrition plan that complements a patient’s health goals, while monitoring and assessing progress. They work with other members of your health care team to help you manage a tube feed, heal wounds and pressure injuries, find foods to eat that are easy to chew and swallow, manage side effects as a result of conditions such as cancer, manage chronic diseases such as diabetes and heart disease and many other conditions. Additionally, dietitians will explain how nutrition affects your specific health condition or disease and will work with you and your caregivers to help you manage at home. 

A dietitian’s role is to help people who are requiring parenteral nutrition (nutrition that goes directly into your blood). They will also work with your doctor to provide recommendations on how much energy, protein, fat, and carbohydrates you need, provide recommendations on how much vitamins, minerals and fluid you need, and monitor your weight and blood work to ensure that you are getting enough nutrition. 

Personal Support Services 

Personal support services are aimed at providing assistance with daily personal care needs as individuals deal with the affects of aging, injury or illness. Managing everyday tasks can be challenging for people who are faced with health-related issues, but having additional support and care can be a solution that enables individuals to stay at home safely and comfortably. 

These services encompass such care as grooming, dressing, bathing, transferring, bed care, medication compliance, simple wound dressings, blood sugar and blood pressure monitoring and respite care. This care is usually performed by a personal care support worker or health care aide. 
 
While some services may vary across the province, agencies that offer personal support may accompany this care with additional homemaking services, such as home management, meal preparation, companionship (live-in, overnight or visiting), light housekeeping, and accompaniment to appointments, shopping and errands.  

Intravenous Therapy

Intravenous (IV) care – which can also refer to infusion or injection therapy – is often available in a clinic setting or in a patient’s home, depending on the nature of the treatment. Ontario Health atHome helps eligible patients by arranging for the delivery of medication, infusion equipment and medical supplies for administration by a nurse.  

Ensuring safe IV treatment with the highest level of comfort and care is a top priority for all care providers involved. If you are a patient receiving IV therapy, it is also important to understand the roles and responsibilities involved in your care.  

The patient’s role

As the most important person on your care team, you need to be an active participant in your care. Remember to: 

• Ask questions if you do not understand the information that has been given to you
• Ensure that you know how to properly store your medications
• Contact your care coordinator to schedule an appointment if your supplies have been delivered and you haven’t been contacted by the clinic
• Bring your IV medication and supplies (including any PICC or port kits and pump) to your clinic appointment (an IV pole is provided). If you forget your medications or supplies, we may need to reschedule your appointment, causing a delay in receiving treatment
• Keep our contact number easily accessible in case you need to rebook your appointment
• Arrive at your clinic appointment on time, as appointments are pre-scheduled for every patient
• Return all equipment (including pumps, battery packs and cords) to the pharmacy when your treatment is complete

The clinic nurse’s role

The clinic nurse will ensure you receive your treatment safely in our clinic by:

• Reviewing your updated list of medications (please bring this with you)
• Helping you understand the medication you are taking and how the IV medications and supplies you brought with you from home will be used in your treatment

• Ensuring you know what symptoms to watch for when receiving IV treatment so that you can contact a nurse if you need to
• Providing you with a contact number in case you need after-hours nursing on-call support

The pharmacist’s role

The pharmacy will provide you with your IV medication, supplies, PICC and/or port kits and anything else you may need, as well as:

• Prepare the IV medication that was ordered by the ordering medical practitioner
• Call you within one or two days of starting therapy to answer any medication-related questions you may have and to collect a list of other medication you may be taking
• Deliver your medication to you
• Call you once your IV therapy is complete, to arrange for the equipment to be returned
• Collect and dispose of any unused medication, supplies and waste
• Arrange a convenient time to conduct a medication review at your home, if you are on long-term IV therapy

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