The Home Care Team

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What is home care nursing?

Home care nursing is a specialized area of nursing practice in which the nurse provides care in the client’s home, school or workplace or other community settings. Individuals who receive nursing care today often have more acute and complex needs and an increasing amount of their care is provided in the home.

What services does a home care nurse provide?

In the home setting, the nurse brings caring activities that generate trust and collaboration for both the care of the client and the maintenance of health of the other family members. The nursing process applied to home care includes assessment, nursing diagnosis, planning for care, intervention and evaluation. These processes are often more complex given the nature of the setting, the additional variables influencing the client and the family, and the need for integration of community health nursing concepts.

What should we look for in a home care nurse?

Home care nursing practice is complex requiring independent decision making, a diverse knowledge base in order to manage the care of patients with a broad array of diagnoses across the lifespan and the health-illness continuum. The home care nurse requires:

  • Advanced assessment and evaluation skills
  • Effective communication skills
  • Sound judgment
  • Effective documentation skills
  • Flexibility
  • Critical/creative thinking
  • Self-direction
  • Competency in technology
  • The maturity to work confidently and autonomously

Personal Support

What is personal support?

Personal Support Workers (PSWs) are the largest class of workers in the home care system. PSWs complete a standardized training program enabling them to provide care and assistance to clients of all ages, and their families/caregivers, with tasks of daily living, personal care and hygiene, restorative/activation activities and home management activities.

What do personal support workers (PSWs) do?

Typically, PSWs provide care that clients could be expected to perform by themselves if  they were physically and/or cognitively able. Their activities are supportive and non-medical in nature.

PSWs provide for the comfort, safety and well-being of their clients, and also demonstrate sensitivity and respect for those in their care. The PSW’s positive attitude, abilities and approach are critical to the health of the people they support.

Why are personal support workers (PSWs) important?

PSWs spend the greatest amount of time, as compared to the other members of the health team, with the client. They are often the first to alert the health care team to subtle changes in a client’s condition and through their close relationship with the client have insight into their needs.


What is Dietetics?

Within home care in Ontario, dietitian services are grouped with the therapies. Registered Dietitians (RD) are regulated health professionals who are “expert in food and human nutrition”.

What services do Registered Dietitians provide?

Registered Dietitians work individually with people of all ages focusing their skills, professional knowledge and expertise on optimizing client nutrition intake; individualizing food intake to meet specific nutrition, dietary and/or functional needs; promoting overall health and well-being; and maintaining client independence.

The Registered Dietitians’ knowledge of nutrition, sources of funding reimbursement, and support technologies positions them to improve client care in a cost-effective manner. RDs are important members of the home care.


What is physiotherapy?

Physiotherapy is a primary care, autonomous, client-focused health profession dedicated to improving quality of life by:

  • Promoting optimal mobility, physical activity and overall health and wellness;
  • Preventing disease, injury, and disability;
  • Managing acute and chronic conditions, activity limitations, and participation restrictions;
  • Improving and maintaining optimal functional independence and physical performance;
  • Rehabilitating injury and the effects of disease or disability with therapeutic exercise programs and other interventions; and
  • Educating and planning maintenance and support programs to prevent re-occurrence, re-injury or functional decline.


Physiotherapists are primary health care professionals with a significant role in health promotion and treatment of injury and disease. They combine their in-depth knowledge of the body and how it works with specialized hands-on clinical skills to assess, diagnose and treat symptoms of illness, injury or disability. Physiotherapists encourage clients to assume responsibility for their health and participate in team approaches to health service delivery.

Physiotherapy Assistants

A PTA is someone who provides care under the direction and supervision of a physiotherapist. They may have been trained in a college program or learned on-the-job. PTAs are not regulated and they do not have a protected title. PTAs may also be called rehab assistants, therapist assistants, support personnel. An individual is only a PTA when a physiotherapist is accountable for treatment (a physiotherapist is assigning and supervising care).

Occupational Therapists

Occupational Therapists (OTs) provide assessment, treatment and education to enable clients to safely participate in daily activities of self care, work and leisure in their homes and community. OTs services include:

  • Recommendation of adaptive equipment to promote safe functioning (e.g. bathroom safety)
  • Mobility, seating and ambulation aids
  • Environmental modifications to promote safety in homes, workplaces or school settings
  • Education on strategies to live with physical, cognitive and/or emotional challenges
  • Consultation on healthy aging strategies in the home

Occupational Therapist Assistants (OTAs)

OTAs may work under the supervision of the Occupational Therapist to support the client in achieving their goals.

Speech Language Pathologist

Speech Language Pathologists (SLPs) provide comprehensive assessment, education and a functional, life participation approach to home-based community therapy for adults with communication and swallowing disorders.  SLPs services include:

  • Language (expressive and receptive)
  • Speech
  • Swallowing

Social Work

What is home care social work?

Within home care in Ontario, social work services are grouped with the therapies.  Social work is a regulated profession “concerned with helping individuals, families, groups and communities to enhance their individual and collective well-being.  It aims to help people develop their skills and their ability to use their own resources and those of the community to resolve problems.”

What do social workers do?

Social workers specialize in working with people, families and communities whose needs are high and whose resources to meet those needs are compromised or depleted.   At the individual level, social workers assist with the management of issues ranging from depression, dealing with marriage problems or family breakdown, living with chronic or debilitating health conditions, recovering from trauma, or facing a life issues.

What are the goals of social workers?

  • Restore, maintain and enhance functioning by mobilizing strengths.
  • Provide psychosocial education to facilitate independence and informed decision making.
  • Optimize coping capacity and safety.
  • Modify dysfunctional patterns of relating and acting.
  • Link people to necessary resources.
  • Alleviate environmental stressors.

Mediate and facilitate multicultural environments and diversity. 

Infusion Pharmacy

What is home care infusion pharmacy?

Home care infusion pharmacy is a specialized area of pharmacy practice where patients are able to receive infusion administered medications in the client’s home, school, workplace or other community settings such as clinics. Individuals who receive infusion pharmacy medications administered by nurses often have more acute and complex needs, and an increasing amount of their care is provided in the home and in community.

What services does an infusion pharmacy provide?

A physician from hospital or in community will provide the pharmacy with a medical order or prescription for a patient to receive infusion medication.  HCCSS – Home & Community Care Support Services (formerly the LHIN) will arrange for the pharmacy to deliver the medication, infusion equipment and related medical supplies to be delivered to the patient’s home, work or to a clinic setting for administration by a home care nurse.  The pharmacy coordinates with the home care nurse to ensure all required medication and supplies for infusion to be administered safely.  Patients receive education about who to contact in case of questions regarding medication, or administration process.

What should you look for in a home care pharmacy?

Infusion pharmacies approved under government-funded programs must meet NAPRA standards for dispensing highly complex medications safely in a clean room environment.  The pharmacy must be licensed for dispensing complex medications, infusion equipment and supplies and pre-qualified for servicing through HCCSS – Home & Community Care Support Services (formerly the LHIN) in Ontario.

Respiratory Therapy

What is Respiratory Therapist?

A Respiratory Therapist is a regulated health professional who monitors/assesses and treats individuals with breathing difficulties. Respiratory Therapists are experts in:

  • Ventilation and airway management;
  • Oxygen and aerosol therapy;
  • Treatments for obstructive sleep apnea syndrome; and,
  • Cardiopulmonary resuscitation.

They provide care in hospitals, long term care and home care settings; they must be registered with the College of Respiratory Therapists of Ontario.

What services does a home care Respiratory Therapist provide?

Respiratory therapists provide many services to patients in their home including:

  • Perform respiratory assessments;
  • Perform pulse oximetry assessments;
  • Initiate and titrate oxygen therapy;
  • Manage airways;
  • Manage invasive and non-invasive ventilation;
  • Review and recommend medications;
  • Evaluate therapy effectiveness;
  • Develop care plans and review goals achievement;
  • Educate and train clients, care givers, and family members on care routines;
  • Offer their expertise as part of the community multidisciplinary care team;
  • Address client or caregiver concerns; and,
  • Assess equipment performance.

Complementary Services

An efficient and effective home care system appropriately utilizes and collaborates with all members of the broader health care team to achieve value and to assist Ontarians who wish to receive care at home and remain independent. These include:

Family Physicians & Home Care

Family physicians are integral members of the health care team and are critical for the medical support they provide to all clinicians in the home. The strong linkage between family physicians and home care practitioners enhances the ability for individuals to remain independent at home for as long as possible.

Pharmacists & Home Care

Pharmacists have unique expertise in medication management. They are responsible not only for the procurement and dispensing of medications, but also for their safe and effective use in the prevention of disease and the promotion of health and wellness.  As a medication expert, the pharmacist makes an important contribution to the home care team by serving as a resource for the increasing numbers of medications prescribed to seniors in particular.