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Team-based care at the centre of the FSSP role - Part 1


Team photo (Left to right): Lou DeMaeyer, Bev Nolan, Rachael Best, Amy Schuster, Ivy Lee, Melanie Griffiths, and Matt Scott.

​If I tell you I’m a nurse or a doctor, you have a pretty good idea what it is that I do. If I define it further and say I’m an Emergency Department doctor or nurse, that makes it even clearer. What if I tell you I’m a Family and Social Support Practitioner (FSSP)? Not quite so clear?

The FSSP role is unique to the Vancouver Community Home Health and Home Hospice programs and is key in managing transitions between acute and community. That’s the elevator pitch. It makes it a bit clearer, but it doesn’t cover the depth of this role or the impact it has on our clients. 

The best way to do that is to show you through a client journey. In this case, the FSSP team has created a composite of a number of different clients and situations that they might have to deal with. The situations are real, but Ms. Maple and her daughter are not.  

​Meet Ms. Maple and her daughter Simi

Ms. Maple is an 87 year old widowed woman living in her self-owned house in Vancouver with her daughter, Simi who has a developmental disability and has never left home. Recently, there has been somewhat of a role shift in that Ms. Maple was always her daughter’s caregiver, but was recently diagnosed with vascular dementia. Simi has had to take on more responsibility such as prompting her mom for daily activities and going with her on the bus to doctor’s appointments. 

Over the past few years the home has becomes less well-maintained. There is garbage piled up, the home is cluttered with many falls hazards and the front porch is in disrepair and unsafe. Ms. Maple has had several falls. Recently, she fell at home and could not get up. Simi didn’t know what to do and Ms. Maple was left on the floor for over 24 hours. When Simi was out at the corner store, a neighbour could hear Ms. Maple calling out. The neighbour found Ms. Maple on the floor in her living room and called 911. 

In the emergency room, an X-ray showed no fractures, but Ms. Maple has painful bruising and has some pain. She is also mildly undernourished and dehydrated, but is otherwise medically stable. She is given acetaminophen for the pain and cleared for discharge home. The social worker in the ER calls Simi to discuss what has been happening at home and becomes concerned that Simi seems overwhelmed and has limited insight into her mother’s health needs. 

The Transition Services Team (TST) contacts the FSSP expressing concern as Ms. Maple will be discharged home today. Ms. Maple is declining home support services, but is grateful to be sent home with enough prepared food to last 24 hours. The FSSP asks TST to refer for a Home Health social work case manager (CM) to investigate adult protection concerns and care needs at home. 

The FSSP and the CM discuss the situation and review a geriatrician consultation report in Care Connect. They contact the family doctor who expresses concern about both Ms. Maple and Simi, noting that they both appear dishevelled and with long fingernails, tangled hair and dirty clothes. Ms. Maple and her daughter do not have any known family or friends. 

The CM calls Simi who sounds suspicious but reluctantly agrees to a home visit the next morning. On arrival the FSSP and CM note the porch is unsafe and access the home around the back, carefully avoiding abandoned household items and piles of garbage. The FSSP interviews Simi, while the CM interviews Ms. Maple. 

The FSSP finds Simi disorganized, overwhelmed and somewhat mistrustful. The CM finds Ms. Maple has some cognitive impairment which is contributing to her lack of understanding of the risks and safety hazards in the home. The FSSP and CM are concerned about the state of the home. Not only is it dirty, cluttered and in disrepair, there are mice droppings in the kitchen and bed bug bites on Simi and Ms. Maple’s skin. The kitchen isn’t functional and the bathroom needs cleaning and safety equipment. 

Neither Simi nor Ms. Maple are able to explain their financial situation, but the CM sees a late payment notice from BC Hydro stating the power will be shut off at the end of the month. After establishing rapport, Ms. Maple and Simi reluctantly agree to a weekly visit from a Community Health Worker (CHW).

The FSSP and CM consult about this case including the risks for Ms. Maple, her daughter and staff. 

Check in next week to find out what happens.

SOURCE: Team-based care at the centre of the FSSP role - Part 1 ( )
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