THINGS HAVE CHANGED — WHAT DO WE DO NOW?

Start here

You already have Home & Community Care, but something has changed.

Maybe the person needs more help. Maybe they are recovering and need less help. Maybe their health, abilities, family support or day-to-day situation is different from before.

When that happens, the current care plan may no longer match what is happening at home.

Your case manager is the main person to contact if you already receive publicly funded Home & Community Care and your needs or circumstances have changed.

A professional review or reassessment may be appropriate. The care plan or services may be reviewed or revised through the Home & Community Care process.

What does “needs have changed” mean?

A change can mean that daily life is different from when the current care plan was made.

Changes can include:

• the person is having more difficulty doing things they could do before;
• the person has improved or recovered and can do more than before;
• there is a new illness or another health change;
• walking, transferring, dressing, bathing, eating or other day-to-day abilities have changed;
• the person was in hospital and came home with different needs;
• family, friends or community members who were helping are now less available or more available;
• the current care plan no longer seems to fit what is happening day to day.

You do not have to decide whether the change meets a technical Home & Community Care threshold. Your job is to notice and describe what has changed. The appropriate professional decides what the change means for assessment and care planning.

Who should I contact?

If you already receive publicly funded Home & Community Care, contact your case manager.

You can keep the first message simple:

What may happen after I report a change?

What happens next depends on the situation.

A professional may review the information and decide whether further review or reassessment is appropriate. Where reassessment occurs, the care plan and services may be reviewed and revised as required.

For Home & Community Care providers covered by Alberta’s Continuing Care Health Service Standards, reassessment occurs annually and when a regulated health professional determines that a formal Significant Change in Health Status has occurred.

“Significant Change in Health Status” is a technical term. You do not need to decide whether your situation meets that definition before contacting your case manager.

After review or reassessment, different outcomes are possible. The Home & Community Care process determines what is authorized.

What should I prepare?

Before you speak with your case manager, it may help to write down:

• what has changed;
• when you first noticed the change;
• what the person could do before compared with what they can do now;
• whether the change is improvement, decline or another change;
• what help is currently available from family, friends or community;
• whether that family or community help has changed;
• which parts of the current care plan no longer seem to match daily reality;
• what questions you want to ask.

Use your own words. You do not need to use medical or government terminology to explain what you are seeing.

Recovery and decline can both matter

Core 4 is not only for situations where things are getting worse.

If the person is recovering or functioning better, that can also matter for care planning.

For example, a person may need to discuss whether the current care plan still reflects their present abilities and needs.

KYR does not decide what should be added, reduced or changed. The learner describes the change; the appropriate professional assesses what it means.

What if family or caregiver help has changed?

Family, friends and community support can be relevant when Home & Community Care is considering unmet need.

If a person who used to help is no longer available, tell the case manager. If more support is now available, that can also be useful information.

But a change in family or caregiver availability does not automatically mean:

• the formal Significant Change threshold has been met;
• services will increase;
• hours will increase;
• funding will increase.

It is information for the Home & Community Care process to consider.

What if the person was in hospital?

Hospitalization can matter in Core 4 when a person already had Home & Community Care and their needs are different after returning home.

If the old care plan no longer seems to fit, tell the case manager what changed.

This section is not a general hospital-discharge guide. For hospital-to-home planning, use the separate KYR resource for coming home from hospital.

Could the care plan, services or arrangement change?

They may.

Depending on the professional review and program circumstances, the care plan, services, amount or frequency of service, referrals, supports or delivery arrangement may be reviewed.

If the current delivery arrangement no longer seems to fit, you can ask whether it should be discussed.

Do not assume that another arrangement is available or that a change will be approved.

If you need to understand Home & Community Care arrangements such as Type 1, Type 2 or Type 3, use KYR’s separate Core 3 resource, Understanding Your Home Care Options.

When this may be a different problem

Sometimes both situations can happen one after the other. For example, needs may change first and the care plan may be reviewed; later, a separate care-delivery problem may arise. They should not be treated as the same issue.

Questions I may want to ask

You can use questions like these:

• Our needs have changed. Should the care plan be reviewed?
• Do we need a reassessment?
• What information would help you understand what has changed?
• Can I participate in the care-plan review?
• Can I have someone I trust participate with me?
• Can I access the current care plan?
• What happens after the reassessment?
• Could the services or delivery arrangement change?
• Who decides what services or hours are authorized?
• If the current arrangement no longer seems to fit, what can we discuss?

You do not need to ask every question. Choose the ones that fit what you need to understand.

Discuss / decide

KYR helps you notice the issue, understand the process and prepare useful questions.

KYR does not decide:

• whether the technical Significant Change threshold is met;
• whether you are eligible for a particular service or arrangement;
• what services should be authorized;
• how many hours should be funded;
• what clinical care is required;
• what the new care plan should contain.

Print / Take-With-Me

The following content is suitable for later adaptation into a simple question sheet or take-with-me handout.