The essential elements  provided by this program are client assessment, case management, home care nursing services, home support services, in home respite services, establishing linkages with other professionals and community services, managing the delivery of the Home Care Program, record keeping and data collection.

• Client assessments are completed by an RN to determine need and allocation of services for community members that are eligible for services.   These assessments are a wholistic look at a person (emotional, social, physical and spiritual).  The assessment form is taken from the First Nations and Inuit Home & Community Care planning resource kit.
• Case management refers to referring and linkage of clients to appropriate services both on and off reserve.  For example, an RN may determine that an OT/PT assessment is required for a client for equipment/exercise and would make a referral to VIHA for this assessment on the client’s behalf.  Other recommendations for linkages could include podiatrists, orthotics, or diabetic education clinic.  Case management also involves follow up for a client with such things as medications, monitoring vitals, or advocating on behalf of the client to other professional services.
• Home care nursing services are determined by the RN based on the ongoing assessments of clients.  These services may include wound care, foot care, palliative assessments/services or respite services.  If there is no nurse available for these services, VIHA will provide wound care and respite services may be allocated through the Nanaimo Association for Community Living if the client has a developmental disability.
• Home support services include the provision of personal care (grooming, bathing, toileting), transferring, meal preparation,  medication reminders, assistance with blood glucose monitoring and general surveys re well being of the client. Home support services may be long or short term depending on the need of the client and are not to duplicate services provided by the Department of Indian  Affair s and Northern Development- Homemaking services.  There were two full time personal care aides for the Chemainus First Nations with one casual worker.  The LPN also provided services to Chemainus First Nations such as simple dressing changes and foot care.  Eleven community members received services from personal care aides . New assessments were completed by an RN for current community members on home care services as well as several other assessments for community members who were not eligible for home care services.
  Kuper Island (Penelakut) has one full time personal care aide who provided services to six home care clients at various time though out the year.  Nursing services were provided to 2 community members (palliative) who did not wish to receive personal care services.  Assessments were completed for community members at Halalt.  Home Care was unable to connect with members of the Malahat band in order to complete full assessments.
• In home respite provides care for a client to give the main, unpaid care giver support so that they may continue to support the client in their home.  This service is being provided by Nanaimo Association for Community Living as arranged by home care nursing.
• Establishing linkages with other professional and community services includes clients’ physicians, hospital liaison nurse, NIHB, ITHA, VIHA RNs, H&CC case managers and diabetic educators, occupational therapists, physiotherapists and podiatrists.
• Managing the delivery of home care services essentially ensures that safe and effective care and case management is provided to community members.  One part time home care RN worked from April until the end of August on Kuper Island.  In September, a full time home care RN was hired to provide services for H’ulh-etun Health and a part time manager was hired at the same time.  The full time nurse left her position after approximately 6 weeks and several casual RNs were hired to complete/update assessments and provide case management as needed.  Two RNs were hired February 23/09 to job share for full time home care nursing hours.
• Record keeping and date collection is currently being done on paper (Charting/record keeping).  RNs and personal care aides are expected to chart on client after every encounter.  There are some challenges with this system as paperwork is not always fled and accurate records are not always kept on paper. Data collection is done with  Health Canada through a program called eSDRT monthly statistics are compiled and submitted in a confidential manner and uploaded to a program so Health Canada can track hours and type of service provided for community members.  Initially this responsibility fell to the LPN but was taken over by the Home & Community Manager in September.  There was some computer difficulty and the uploading of this information fell behind by several months.