1.0 PREAMBLE 

Health care access remains one of the barriers to achieving a  healthy world population. The cost of seeking health care also  remains high in many areas of the world necessitating a need for  cost-effective delivery of health services. Poor health outcomes are  traceable to the lack of access, poor health seeking behavior, lack  of information, late diagnosis and poor management of cases.  Home based care is one of the means of mitigating this.  

The World Health Organization (2002) defines Home Based Care  (HBC) as any form of care given to ill people in their homes,  including physical, psychosocial, palliative and spiritual activities.  Home based Care increases efficiency of health systems by  increasing accessibility to healthcare, reducing cost of care and  burden on hospitals while delivering care in convenient and  familiar environments to patients. Through this model of health  care, more people receive the highest quality of care with reduced  barriers to healthcare.  

Different health professionals, lay community health workers and  home based care volunteers deliver home based care. The use of  technology is an asset to the delivery of home based care. E-TIBA  is keen to employ different telemedicine strategies in delivery of  home based care. Telemedicine offers an avenue to achieve the 

universal health coverage goal by increasing access to health care,  reducing costs of care for both the patient, caregivers and healthcare workers, and helping to achieve better health outcomes.  Through various technological means employed in telemedicine,  early diagnosis, convenient follow-ups for patients is achieved.  Telemedicine also helps to provide linkage to hospitals helping in  healthcare agency-hospital collaborations, increasing health care  capacity for different hospitals and reducing transportation costs  for both patients, caregivers and health care workers. 

2.0 PURPOSE/OBJECTIVE 

To provide Home Based Care that helps people who need acute,  end-of-life, rehabilitation, maintenance and long-term care to  remain independent at home. Home Based Care encourages and  supports assistance provided by the family and/or community and  provides monitoring of low-risk patients in the home setting.  

3.0 POLICY STATEMENTS 

1. Home care should preserve and promote volunteer  involvement; ii. Service decisions in home care should be based  on assessed client needs and the risk to the client if service is not  provided; 

iii. Individuals have the right to be treated with kindness,  dignity and respect; iv. A person’s right to live at risk to one’s  self and to accept or refuse services is respected;

1. Home Based Care services should be provided respecting the  client’s cultural values and, whenever possible, by staff who  are of the client’s language and culture; 
2. Regional Health Authorities should have significant  responsibility for planning and delivering home care services; vii. Home Based Care involves the planning and coordinating of  local health and community services; and, 

viii. Home Based Care does not provide services to allow  caregivers to work at a long-term job. Home Based Care is not  provided to relieve parents from routine childcare. 

4.0 DEFINITIONS, ABBREVIATIONS AND  ACRONYMS 

A & E: Accident & Emergency 

BP: Blood Pressure  

HBC: Home Based Care 

WHO: World Health  Organization

DEFINITIONS OF TERMS 

Guardian: Another person authorized to give informed  consent or make decisions on behalf of the patient, when the  patient is incompetent or otherwise unable to make decisions  

Clinician: Qualified consultant, medical officer, nurse or clinical  officer 

5.0 RESPONSIBILITIES OF KEY ACTORS 

1. Home Based Care Coordinator 
2. Implement, manage and evaluate current operational  processes and procedures in accordance with the standards  and procedures set out by MOH. 
3. Oversee core functions including Caregiver staffing and  recruitment, customer services and  

Caregiver credentialing 

1. Assist in developing strategies and implementation plans to  improve and standardize all aspects of operations
2. Develop, write and implement policies and procedures of  home based care 
3. Establish metrics for key areas of measurement within  operations and hold teams accountable to achieve or exceed  these goals 
4. Establish a climate that encourages teamwork and promotes  collegial collaboration among all team members 
5. Consultant Physician 
6. Give expert medical advice when needed during patient  reviews 
7. Provide new interventions, assess medication compliance, and  recommend environmental modifications. 
8. Examine patients, conduct diagnostic tests, prescribe  medications, and educate patients, families, and caregivers  about management of chronic diseases where necessary 
9. Perform some procedures in the home as well as refer patients  for other testing and services 

III. Medical Officer/Clinical Officer 

1. Assess patient eligibility for home based care in liaison with a  Social Worker 
2. Enroll patients into the home based care program c. Clerk and manage patients 
3. Conduct daily telemedicine consultations 
4. Conduct home visits when required

1. Perform venipunctures and other specimen collection  procedures 
2. Refer patients to consultant if need be 
3. Discharge patients from home based care 
4. Nursing Officer 
5. Educate the patient and caregiver on how to give care at home b. Educate the patient and caregiver on how to take vital signs  at home 
6. Monitor and record patients’ daily vital signs as reported by  the caregiver 
7. Conduct home visits when required 
8. Conduct nursing care at the homes of the patients when need  arises 
9. Nutritionist 
10. Conducting nutrition assessment that involves acquiring  client’s diet and lifestyles, evaluating dietary related laboratory  values, medical-surgical history 
11. Provision of nutritional education and counseling. c. Offering explanations on nutritional curative and preventative  measures along with individual nutrition needs-both  macronutrient/micronutrients based on biochemical values,  gender, physiological conditions, age and diagnosis.
12. Setting up SMART nutritional goals on healthy diets and  lifestyle such as body weight, Exercises, dietary habits,  laboratory values including blood sugar, lipid/cholesterol, and  blood pressure among others. 
13. Physiotherapist 
14. Provide physiotherapy sessions for patients at least once a  week  
15. Assess, diagnose and provide rehabilitation of physical  problems or conditions resulting from illness, injury, disability  or aging 
16. Assist patients to develop, maintain and restore movement  and functional abilities that have been impaired 
17. Promote wellness and health by educating patients and  caregivers on exercise and movement 

VII. Psychologist 

1. Provide counseling for patients at least once a week. b. Provide guidance and counseling services for patients,  caregivers and family members if need be. 
2. Assess, diagnose and treat psychological, physical and  behavioral problems by providing appropriate interventions  and advice 
3. Promote personal and social wellbeing and in turn improve  the patients’ quality of life
4. Refer patients for psychiatric further professional review if  need be. 

VIII. Nurse 

1. Educate patients and caregivers on the appropriate cleaning  and disinfection methods 
2. Disinfection of patients’ homes when required c. Handling waste management if need be 
3. Liaise with Agency staff to carry out regular home visits for  patients 
4. Emergency Medical Services 
5. Provide urgent prehospital treatment, stabilization for serious  illness and transportation of patients to definitive care 
6. Health Records Officer 
7. Monitoring, evaluating and maintaining health records of  patients and information systems and ensuring the  information is up to date on a daily basis 
8. Provision of weekly statistics to the HBC Committee 
9. Billing Officer 
10. Determine patient invoice by capturing services noted on  patient’s charts and facilitate the delivery of effective billing  services

XII. Community liaison Officer 

1. Communication link between the Agency (HBC) workers and  the Insurance or Hospital and the households for the duration  of the home based Isolation and care through performing  regular home visits and supervision. 
2. Identify special populations such as disabled and/or the elderly  people and create specific opportunities for engagement with  them through the HBC staff. 
3. Facilitate conflict resolution with community members by  addressing issues that could occur between members of the  community and the patient recuperating at home.  

XIII. Customer Care Representative 

1. Enroll patients into HBC from various departments with the aid  of Nurses on the ground 
2. Ensure regular training to the HBC team on PR and  Communication skills  
3. Answer any HBC related queries. 

XIV. ICT Officer 

1. Provide overall ICT support to the HBC program. b. Help install and support all ICT hardware and software; c. Maintain and troubleshoot all network and computer related  issues; 
2. Integrate security, physical control solutions for all confidential  data and systems;
3. Monitor performance and manage parameters to provide fast  responses to front-end users; 
4. Integrate and configure computer networking for best  performance; 
5. Troubleshoot and repair of hardware, operating systems and  applications; 
6. Monitor and maintain computer systems and networks; i. Identify security gaps and provide relevant solutions in  consultation with the Operations manager; 
7. Conduct electrical safety checks on computer equipment; 

6.0 KEY PERFORMANCE INDICATORS  (KPI) 

1. Number of patients recruited monthly. 
2. Inquiry to admission ratio. 
3. Client satisfaction: Filled forms on Consumer Assessment of  Healthcare Providers and Systems (CAHPS). 
4. Number of scheduled appointments done on time: Allowable  delay time 10 minutes.

7.0 PROCEDURE STEPS 

7.1 Online applicant 

1. Patients who apply for the Home Based Care program through  the E-TIBA Forms, Website and APP shall be contacted by the  Customer Care Team within 1 hour of receipt of expression of  interest.  

7.2 Assessing feasibility of Home-Based Care 7.2.1 A Nurse or clinician shall use the Home Based Assessment  Form to conduct an assessment to verify whether the residential  setting is suitable for providing care to confirm if: 

1. The patient is stable enough to receive care at home; 2. Appropriate caregivers are available at home; 
2. There is a separate bedroom or isolation space where  the patient can recover without sharing immediate space  with others; 
3. Resources for access to food and other basic necessities  are available; 
4. There is capability to adhere to precautions  recommended as part of home based and care (e.g.  good personal hygiene, face-mask wear, separate meals,  good hand sanitation); 
5. Availability of a thermometer and a person able to read  and record the temperature are available; and

7.3 Assessment of patients 

1. Patient assessment shall include at the minimum: clinical  history; physical examination; taking of vital signs and  diagnostic testing.  

7.4 Discharge from the Home Based Care 

1. Discharge from the program shall be done through an  online system with the patient being provided with a  discharge summary.  
2. The patients will be requested to fill in a client satisfaction  form upon discharge.  

xii. Patients who complicate before the period of home care is  experienced shall be advised to seek care in the nearest  identified facility. An offer to continue with care after  seeking medical attention shall be made to the patients.  Applicable addition costs shall be considered before an offer  is made to continue with care in cases where the Home  Based Care is repeated. 

7.5 Addressing Barriers to Care 

1. Common barriers to access of care include language barriers  and physical barriers. These shall be identified and  documented at triage, admission and at discharge. 
2. Provision shall be made to avail translators to address  language barriers.

7.5 Monitoring and Evaluation 

iii. The Home Based Care program shall be monitored by the  Nurse and challenges shall be addressed immediately. If  there is a need for consultation, the home based care  coordinator shall advise. The challenges and barriers shall  be communicated during the HBC meeting.  

1. The program shall be evaluated during Home Based Care  meetings which shall be held once every month. Changes  to this procedure can only be made during a HBC meeting.  
2. All documents shall be maintained in the system for ease of  evaluation and monitoring. 
3. The committee shall be required to submit quarterly reports  through the Home Based Care coordinator office to the  Management.