Top 3 Complex Care Challenges Facing Home Care Providers

The demand for home care is rising quickly. So is the number of patients with complex care needs. If you operate, manage, or work for a home care agency, you’re aware that these two trends are coming together to create some serious challenges.

In the years ahead, the business of caring for people at home will become more complicated. How will agencies continue to provide high-quality care? Is technology part of the answer, or an overhyped solution?

This post will look at three of the biggest complex care challenges facing home care providers right now.

1)  Coordinating Practitioners in Different Disciplines

Communication between care providers poses difficulties in many Canadian health care settings. In home care, it can be especially challenging.

Of course, when it comes to clients with complex care needs, things get even more complicated. You know from experience that care never exists in a vacuum. When several practitioners and caregivers deal with the same client, each one is likely to have information that will be useful to the others.

Unfortunately, information doesn’t always make it to all of the right professionals.

For people who need care, navigating a patchwork of policies, agencies, and service providers can be both physically and emotionally difficult. It isn’t easy for those on the provider side, either.

Do you have complex care clients who are only entitled to a few hours of service per week? Perhaps some of these clients can afford to pay for services, but not nearly as many as they’re seeking.

Either way, in a perfect world, your team would have the means and the manpower to provide them with absolutely outstanding care.

In complex care, this would mean starting with a complete understanding of a client’s conditions and how they’re interacting. It would mean ensuring that everyone providing care understands this information – and tracks how changes over time.

Canadian governments – including Ontario’s ruling Liberals – are working to help make home care better. But change takes time. While providers wait, there are things they can do to streamline their processes. We’ll discuss these later on in the post.

2)  Keeping Complex Care Clients and their Families Informed

It’s not just caregivers and health care professionals who need to know what’s going on. The best home care agencies are those run and staffed by professionals who know the value of an empowered client.

Of course, some complex care clients can exercise more autonomy than others. Whether a person is able to make all of their own decisions or not, their family members may play a very significant role in their care.

Home care agencies need to find ways of ensuring that everyone within a client’s circle of care understands relevant symptoms, treatments, and medications.

If you’re a nurse or retired nurse, you’ve almost certainly dealt with people who are able to provide some of their own day-to-day care. Still, it’s not uncommon for clients to forget to do things like take their medication, or make appointment-related phone calls.

These mistakes may be more likely to occur in clients with complex care needs, since they usually undergo more treatment, see more specialists, and take more medications than those with just one chronic condition.

In these cases, sharing timely health information with clients – in the form of explanations, instructions, and reminders – is critical. It can also be difficult – no worker can be with one individual all of the time.

Family caregivers, as well as family members who have established the right to access their loved one’s health information, should hear about relevant developments in easy-to-understand language.

Of course, this sounds simple enough. It sounds like common sense. But, as we all know, there’s a big difference between theory and practice.

First, there are the regular coordination challenges. If family members aren’t present when caregivers visit, how are they supposed to receive critical updates? In some cases, the conditions of people with complex care needs change frequently. This makes it even harder pass along all new information.

The bottom line? The hectic and fractured nature of at-home care makes communication a challenge. This is true even in the most well-organized agencies. As governments begin to provide better home care funding, resources, and guidelines, this issue should improve.

For now, agencies face serious difficulties when it comes to communicating with clients and their families.

3)  Keeping Up With Demand

It’s no secret that the demand for home care services is growing fast. People want to retain their independence by receiving care in their own homes. Governments want to curtail the aging population’s reliance on hospital and care facility beds.

And home care providers? You’re seeing these ongoing shifts much more clearly than those on the outside.

Chances are, there are some needs your agency just can’t meet. As massive change occurs in Canada’s health care sector, providers may be forced to say “no” to more clients than ever before.

Of course, government agencies involved in allocating care, such as Ontario’s CCACs, will likely face the brunt of the public’s criticism. But as demand increases, many successful home care providers will face new challenges.

Increasing regulation. Calls for greater proof of transparency. The need to find a new batch of qualified staff members. These are good changes. They signify a huge increase in the number of people who are about to receive care where they want it most – at home.

The problem is, these changes are coming on quickly. In the short term, adapting will be difficult for some.

What Can Providers Do?

What do the three challenges listed in this post have in common? They all relate to the need for home care agencies to become more efficient in the face of increasing demand.

And how can agencies do that? One word. Technology.

It doesn’t always live up to the hype, in part because of poor implementation. Trying to adopt any type of electronic system without extensive planning can actually slow down existing processes.

Still, technology has huge potential to change the face of home care – especially as more patients with complex care needs are being treated at home.

Here’s a question. What if more providers thought not just in terms of transferring data, but of communicating the wellbeing of clients?

It’s extremely important that home care workers across disciplines connect and understand one another. Health records are just one piece of the puzzle. Conversations add a whole new dimension, especially when specialists are involved.

Technologies that allow health care practitioners to share, collaborate, and coach one another in real-time can be extraordinarily useful in complex care. To improve team adoption rates, managers should consider technology that can be used on familiar devices, such as cellphones and tablets.

What about communicating with clients and family members?

Try starting from a client-centred point of view. What if you provided consistent updates through technology so simple, even people with no professional background in health care or caregiving could use it? Think, user-friendly.

As for the many new challenges that will pop up as demand increases, there’s a lot of uncertainty. Providers will have to be ready to adapt, just as they’ll have to be ready to adapt to an influx of complex care clients. One of the best ways to do this is to streamline existing processes.

The bottom line? In home care, the expectations of clients and needs of practitioners are changing. In the years ahead, the most successful agencies may be those willing to research and explore new solutions.

Feature Image: sergio santos

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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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