One definition of a health care team is that it is ―composed of the care recipient/family caregiver(s), staff, physicians and other health care practitioners, all of whom collectively and co-operatively assume the responsibility for making, implementing, reviewing and evaluating the plan of care.1
Effective teamwork requires mutual understanding of the roles and responsibilities of each member of the team. Regardless of whether family caregivers live close to the care recipient or at a distance, and regardless of whether the care recipient is at home or in a facility, it is still important to get to know who is who and what each person’s role is, both in relation to their job function (for example, nurse, home support worker) and in terms of their function within the team (for example, team leader, care plan coordinator, chairperson of meetings). Also, it is helpful to clarify the use of certain words so as to reduce confusion and be clear about roles. For example, many people in the health care sector use the term caregiver to refer to themselves. However, in fairness, you are the caregiver and they are the health care providers.
The following are some roles/ people you will probably encounter.
Director of Care
This is the staff person who, in a residential facility, manages each individual resident’s care. The Director of Care typically chairs the case conferences and ensures that the care plans are up to date, in place and reviewed regularly. This person typically has a nursing background.
Family physicians typically focus on and are paid to provide primary care/ acute care. Specialists will be necessary as well, particularly in areas such as psychogeriatrics, dementia, or Alzheimer’s.
Registered nurses generally assume many different roles, depending on the setting (i.e., acute care hospital, residential care facility, community care, private in-home care). Because of their education and training, they provide nursing care directly and may supervise the care team. Nurses can be found in the Liaison and Case Manager roles as well as in a variety of supervisory or administrative/management positions where a knowledge of health care is required.
Social workers are found in hospitals, community care and licensing services, residential facilities and community support agencies. As with nurses, they assume many roles, such as Long Term Care Assessor or Hospital Liaison Worker. Social workers often pay attention to the social/emotional dimensions of care, help problem solve and assist with other non-medical types of concerns which are also key to one’s health.
Community health worker
Also referred to as home support workers, community health workers typically provide assistance of a non-medical type, in the home. They are assigned through a home support agency after an assessment is completed regarding the level of need or care that is required. Community health workers assist with routine tasks such as meal preparation and home cleaning, as well as more personal tasks such as bathing and incontinence care. They are an important part of the care team and often the most visible to the client. Wherever possible, effort should be made by agencies to provide assignment of consistent workers.
Home support scheduler
These are the people who schedule community health workers. They work for home support agencies or the Health Authority and will call to tell you who is coming and when.
Home support supervisor
This person sets the home support care plan, lets you know what tasks the community health workers will be doing, and monitors the quality of care.
Long Term Care Case Manager
This person works for the Health Authority and determines, for example, how many hours of home support the care recipient is eligible to receive, as well as whether this will be subsidized. They provide access to other services such as facility care, rehab, home nursing care, and nutrition services.
Liaison Case Managers
These are case managers in the hospital who organize the community supports necessary to discharge clients safely home or assess for residential facility placement from the hospital.
Resident Care Attendant
This person works in facilities and performs similar types of duties and functions to the community health worker. There are usually several aides assigned to a floor or facility.
Occupational and/or physical therapist
Both occupational therapists and physical therapists are trained and licensed health care professionals. Occupational therapists evaluate the impact of disease on the activities of the patient at home, in facilities and in work situations and then recommend equipment and/or exercises that can assist. Physical therapists provide services that help restore function, improve mobility, relieve pain, and prevent or limit permanent physical disabilities of individuals suffering from injuries or disease.
1. B.C. Rehab. 1996. Team Handbook (Draft), p.12.