A hospital discharges you and your Case Manager (a nurse) doesn't necessarily speak to the care providers after initial contact.
In the city, 'Home Care' can be provided at a clinic, where specialists (e.g., wound specialist, palliative care nurses) need not spend time travelling to various patient's homes.
In my mother's case, Home Care meant 4 hours per day, by a nurse, in rural Ontario, who was replacing her regular nurse in a staff shortage. Mom died the next day. We are short nurses in the province by about 17 - 20%, I've heard told.
No one talked to me about how close the end was. Her physician visited and asked me if she wanted to die at home. I told him she did. He did not tell me that the end was nigh. I had no idea that she would die within 24 hours. he wasn't a geriatrician. He ordered oxygen and left. There was no coordination, explanation, nor information provided to me, the primary caregiver.
Dad was suffering from a urinary tract infection. It went undiagnosed, even after an ER visit. He missed Mom's funeral. We (my brother and I) were desperately trying to figure out why Dad clearly had delirium, thinking it was dementia .
I believe that the Home Care movement is a good one, but there are risks for those not on an equal footing. The * Compassionate Care Benefits Program (EI benefits) has an impact on caregiver (read women's) pensions. Doctors are reluctant to predict longevity for terminal, palliative care patients.
Disparities and barriers to receiving good health care
Caregivers (primarily women) suffer financially. Even with the government's program
Caregivers need Patient Navigators , and a Navigation System , much like the Altzeimer's First Link program . (See First Link Presentation ; in PDF)
*However, to be eligible for compassionate care benefits, a medical doctor or practitioner must issue a certificate stating that the family member has a serious medical condition with significant risk of death within 26 weeks and that he/she requires the care or support of one or more other family members.