In Home Care, What Do We Really Mean By Circle of Care?

In Home Care, What Do We Really Mean By Circle of Care?

Most healthcare providers have dealt with a tricky “circle of care” issue at one time or another.

Perhaps you’ve found yourself confused about the boundaries of implied consent, or had trouble navigating a situation where a patient’s decision-making capacity was in question.

Adding to the confusion is how the term is sometimes used in healthcare legislation. Consider PHIPA (Ontario’s Personal Health Information Protection Act). “Circle of care” isn’t defined in the act, but the concept is central to understanding it.

In home care, there’s plenty of room for confusion. Changing industry regulations are part of it. But environment also plays a role.

Often, those on the front lines work alone; they may have trouble communicating with other practitioners due to distance. Understanding a patient’s circle of care is difficult when its members are hard to get in touch with.

If you’re a home care agency operator or director, you well know that at-home care is unlike traditional healthcare in more ways than one. It’s not just about working in different locations – it’s about having different attitudes. There’s something special about caring for people where they’re most comfortable and independent.

Home care providers get to know their clients; they want to see them flourish. This attitude informs how those in the field think about circles of care, which are just as much about providing support as they are about maintaining patient privacy.

This post will look at some of the unique circle of care challenges and opportunities home care providers face.

Expanding the Circle of Care

For many physicians and healthcare practitioners, understanding a client’s circle of care is first and foremost about adhering to regulations. In some ways, this makes perfect sense. Avoiding legal repercussions is obviously a good thing.

But more than that, complying with legislation means protecting the patients for whom it was designed. Though it may cause some confusion, PHIPA strikes a strong balance between protection and supportive care.

That said, the term “circle of care” is about more than who has the right to assume implied consent over a patient’s personal health information. Over time, the term has come to signify the strong, compassionate support network that forms around a person undergoing medical treatment or care.

For most patients, this support and compassion will come from healthcare practitioners, professional and unofficial caregivers, and close family members who are involved in their care.

A recent study from Genworth Financial indicates that family is playing an increasingly important role in many circles of care. According to the research, when it comes to caregiving in long-term care environments, “more family members, and younger family members are getting involved”.

Some broader conceptions of the circle of care even include members of a patient’s community, especially volunteers.

It would, of course, be unusual for a volunteer to be privy to the personal health information of a person she was helping. What the term really suggests in this these situations is a move toward a more holistic, cooperative, and inclusive approach to care.

It’s a move that most home care providers are very much aware of and involved in.

The Circle of Care in the Home: Challenges

It’s certainly true that care provided in hospitals and traditional healthcare facilities can become fragmented. Communication breakdowns can occur, even when all or most of the healthcare professionals working to help a patient are working in the same building.

Unfortunately, as the distance between people providing care grows, so do the chances that a piece of information will be lost, misused (due to incomplete or misremembered instructions), or sent to the wrong healthcare professional.

In home care, where vast city blocks and long stretches of highway often separate the caregivers within a client’s circle of care, serious precautions have to be taken to avoid the suffering that miscommunication can cause.

Miscommunication – or too little communication – creates some of the biggest circle of care challenges in at-home care. Issues can also occur in situations where caregivers feel unsure about their responsibilities, which may cause them to under or overestimate their qualifications. This can happen even in agencies with watchful managers and coordinators.

A recent study conducted in Ontario found that 78% of students enrolled in a personal support worker (PSW) program were aware of “role drift” in their field.

In some cases, confusion may cause a caregiver to carry out a task he’s not trained for. In others, it may be a desire to help a patient when nobody else is there to do so.

On the flip side, there are times when nurses and caregivers believe they’re unqualified to do important work that could relieve client suffering, even when instruction from a specialist would allow them to carry that work out.

While the expanding role of family members within the circle of care is a good thing for clients, it can lead to more complicated situations for caregivers. It’s natural for a nurse or PSW to assume that a family member they see a lot of is actively involved in their client’s care.

In contrast, the absence of a family member may be incorrectly interpreted by a home care worker as emotional distance. The point is, assumptions about someone’s awareness of a client’s personal health information should never be made.

Navigating the boundaries of family relationships in the home is just one of many circle of care challenges home care agencies should be thinking about.

Communication: Turning Challenges into Opportunities

As a rule, circle of care challenges are communication challenges. When handled correctly, they can be not only overcome, but used to make the care provided by an agency better and more client centred.

If you are directly involved in the operation of a home care agency, you know there’s always room for improvement. You can avoid many of the potential problems associated with poor or disorganized communication by developing internal policies and staff education measures that clearly address these issues.

Implementing systems that make communications quicker and more efficient can also go a long way. Any technology that makes it easier for the members of a client’s circle of care to connect to one another will ultimately improve that client’s care.

Easy video conferencing can have a huge impact on the coordination of care between staff members, as well as communication with the client, with the client’s family members – even with healthcare specialists. Alerting systems that notify those within the circle of care of emergencies can also help caregivers sync up to respond in the most appropriate way possible.

Any online tool that makes it easy to record, organize, and share client updates and details can go a long way in coordinating care. Better coordination means improved treatment accuracy in less time. Ultimately, home care providers are more efficient and able to help more clients.

In many hospitals, hierarchies and standard (often outdated) ways of doing things can act as barriers to true collaboration. Moving forward, the most organized and communicative home care teams will excel by learning from one another to build skills and capacity and provide more comprehensive care for each individual client.

Efficient home care can help family relationships thrive by reducing the stress of familial caregiving. The quality of time spent with family at home is far higher than that spent in a hospital, where strict visiting hours and the continuous proximity of hospital employees can get in the way.

The right technology can improve communication not only between caregivers, but amongst a patient’s entire circle of care – including family.

Keeping the Circle Connecting

In a profile piece for Ontario’s CCACs (Community Care Access Centres), social worker Marlene Howard sums up the joy of working in home care. Howard describes bringing a student to a client’s house, and the student’s surprise at how open the conversation became.

“I remember explaining to the student that this was the advantage of seeing people in their home environment”, says Howard. “They feel safe and are more willing to open up about their personal lives.

This is the power of expanding circles of care inside client homes. As the demand for at-home care grows, providers will continue to improve team communication so that clients receive these valuable experiences.

Feature Image Courtesy: Ken

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COPD Education – Onboarding


To complete a thorough needs assessment / initial evaluation for a COPD patient of an outpatient clinic

Patient, Educator (Nurse, RT, the Physician could also be the educator)

One 60-90 min session with the Educator

  • This protocol should be established for all COPD patients from a given clinic, independently of whether they are new patients or they are known to the clinic. This protocol is the basis to engage the patient into other protocols such as education, exacerbation follow-up, etc.
  • We need to identify patient goals/concerns to guide the interventions
  • A thorough evaluation is carried on, with the objective of understanding where the patient is on their disease journey and follow-up treatable traits: dyspnea, exacerbation or dyspnea and exacerbation.
  • It includes the use of objective questionnaires such as the mMRC, CAT, HADS, Frailty Scale, etc.
  • Identify if the patient needs to be referred to other resources (e.g. Physiotherapist, social worker, occupational therapist)
  • Once Onboarding is completed, the patient continues to the COPD Education workflow
COPD Education – Continuous Maintenance


To cover in depth all the necessary elements of self-management education as per the LWWCOPD, with priorities based on patient goals and identified treatable traits

Patient, Educator (Nurse, RT or Physician)

A number of “Core” educational modules have been identified which cover the basic COPD education from the LWWCOPD program. Additionally, optional modules can be used to respond to patient needs. The timeline (frequency, number of modules to be covered at a given education session) is fully customizable, although we recommend to have education sessions every 2-weeks during the “active” phase of education. Once this is completed, the patient continues to the Maintenance Mode (see below).

  • Launched at the onboarding protocol
  • Provide basic overview of COPD self-management based on LWWCOPD (medication adherence, inhaler techniques, PLB technique & energy conservation) up to the development of an Action plan for early exacerbation recognition and management.
  • Prioritize self-learning by the patient (e.g. watching videos, reading educational materials, completing homework) in addition to live sessions with the Educator. Educational materials are sent to the patient directly via the platform, and become the patient’s own library. The Educator can customize which “homework” the patient receives.
  • Educators have access to “User guides” to standardise their educational intervention. These user guides include: objectives, interventions, suggested questions, evaluation of self-efficacy, and learning contracts for each module.
  • Once the core education is completed, the patient can continue to the Respiratory Status Follow-up Workflow (run in parallel)

The Maintenance Mode
  • As soon as the maintenance mode is engaged, the frequency of visits Educator/Patient is reduced to once every 6 months.
  • During the Maintenance Mode sessions, the educator has access to all the education modules and can choose any piece of content that needs to covered with the patient. 
  • A streamlined evaluation (similar to the initial eval.) is done during each “maintenance” visit to identify any substantial changes on the patient’s needs that will require some adjustment. The patient could come back to an “active” education mode (more frequent education sessions, e.g. every 2 weeks).
COPD Respiratory Status Follow-up


Monitoring of stable patients from a clinic in order to identify early any aggravation of symptoms (exacerbation) and implement an action plan

Patient, Educator (Nurse, RT or Physician)

Scheduled regular automated follow-up to the patient symptoms. Intensity/Frequency can be adjusted by the Educator depending on patient needs (e.g. daily, every week, etc.). Ongoing through the year.

  • Launch: Patients who have completed the Core Educational including setting-up an action plan.
  • Regular automated questions allow to identify any change in patient’s symptoms and severity.
  • If an exacerbation is detected the patient gets a reminder to engage their self-management strategies while waiting for the Educator to call back.
  • An alarm is generated for the Educator, so they immediately call back the patient. At this call they will evaluate any further intervention required and schedule additional follow-up.
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