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Team-based care at the centre of the FSSP role - Part 2


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

In last week’s issue of VCH News, you met Ms. Maple and her daughter, Simi. They are composite clients of a number of different situations and clients that the Family and Social Support Practitioner (FSSP) might have to deal with. The situations are real, but Ms. Maple and her daughter are not. If you didn’t read the article last week, check it out here before finding out what the FSSP did to help our clients and our staff​ navigate the health care system.

After meeting with other VC team members and the clients, the FSSP and Case Manager (CM) consult about this case including the risks for Ms. Maple, her daughter and staff. 

​​​The FSSP works with the Case Manager to break down the situation:

  • Risks – both tolerable and intolerable and possible mitigation strategies
  • Issues & Barriers to service
  • Legislation and implications 
  • Consideration of Ms. Maple’s values, wishes, beliefs and strengths as the primary focus of intervention
  • Determining priorities in order of importance and time urgency – short, medium and long term 
  • Ethical considerations including avoiding unintended consequences and ensuring the response is least intrusive 

The following risks and care planning strategies are considered:

Risk #1: Ms. Maple and Simi lack insight and safety awareness / reluctance for change.


  • Establish and maintain trust and rapport between staff and Ms. Maple and Simi. 
  • Paced interventions, considering readiness for change with urgency / safety.
  • Further team-based medical and cognitive assessment (team based approach with family physician and mental health partners).

Risk #2: poor hygiene, nutrition and hydration leading to illness, increasing frailty, hospital presentation, residential care placement


  • Daily home support to encourage personal hygiene, nutritional intake and hydration. 
  • Referral to a community dietician. 
  • Daily delivery of prepared meals, weekly grocery delivery.  

Risk #3: The Home environment presents health and safety risks (falls, infections) to Ms. Maple, her daughter and staff.


  • Clutter removal, pest control and cleaning including garbage removal.
  • Ongoing cleaning services.
  • Repair to the porch and other pertinent repairs. 
  • Occupational Therapy safety assessment, including bathroom safety equipment.
  • Lifeline-call bell system.

Risk #4: The financial situation is unclear and it seems the hydro will soon be turned off. Care plans require financial resources and  appropriate financial management. 


  • Financial capability assessments for Ms. Maple and her daughter. 
  • Work with the duo on getting their finances in order.
  • Possible referral to Public Guardian and Trustee office for consideration of Statutory Property Guardianship. 

Risk #5: Ms. Maple and her daughter lack any informal support system. 


  • Respite and caregiver support for Simi (Adult Day Program for Ms. Maple).
  • Assessment and care plans for daughter (Community Living B.C.).

​Summing up the role of the FSSP in working with staff and clients

The FSSP is integral in supporting staff to ensure least intrusive, most effective support and assistance for this vulnerable duo. If the strategies above are implemented too quickly and without focus on the values and wishes of Ms. Maple and Simi, the plans may backfire and staff may be blocked from any involvement. If some of the strategies are not implemented urgently, the two will remain at intolerable risk. In either situation, more intrusive measures may be required and may lead to unintended consequences. The FSSP works with staff to balance client autonomy with safety, while navigating a complex system. 

SOURCE: Team-based care at the centre of the FSSP role - Part 2 ( )
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