facilitating improved accessibility to home care clients and nurses

Running head: FACILITATING IMPROVED ACCESSIBILITY 1

Facilitating Improved Accessibility to Home Care Clients and Nurses

Rosa Tiberia

ParaMed Home Health Care

Clinical Nursing Experience

Professor Hali Sitarz

St. Clair College in Collaboration with the University of Windsor

March 29, 2015

FACILITATING IMPROVED ACCESSIBILITY 2

Acknowledgments

I would like to thank my preceptor Kateri McGuire, the acceptance and understanding of

my clients, those at ParaMed, and Professor Hali Sitarz at St. Clair College who had an impact

on my continued learning of community health nursing.


Facilitating Improved Accessibility to Home Care Clients and Nurses

Introduction

In the final semester of my nursing program, I was assigned a community placement at

ParaMed Home Health Care. At this placement, I was paired with a community health nurse

who worked primarily in rural areas of Windsor/Essex County. Together, we performed a

variety of different nursing skills such as health teaching, wound care, and IV rehydration. My

nurse and I worked with different kinds of clients including palliative, diabetics, and those with

cancer. During my time, I noticed a lack of accessibility with both the client side and the nursing

side of this agency.

For clients, I saw a lack of accessible information for those who required more services

for their health care needs. Although an accessibility act is in place for Ontarians with

disabilities, a clear and definite resource is not available ParaMed’s clients which meet the same

standards. Continuing care in the home is a priority for ParaMed clients to prevent unnecessary

trips to the emergency room. Using a multitude of services, such as personal support workers or

hospice, may be required based on the client’s needs. I noticed how there was not a more

practical and identifiable document which assisted in this.

Having access to continuing education is essential for ParaMed’s nurses. While ParaMed

offers in-services to its nurses for practicing skills, these do not happen very often. In the

meantime, there may be nurses who feel uncomfortable performing skills in the community

without sufficient practice. Creating access to a more effective resource or program can greatly

influence the way nurses perform their duties.

This paper is meant to analyze the community through the eyes of the home health care

system and determine ways in which both clients and nurses can improve their access to reliable


information. A combination of an environmental scan, a needs assessment, and a resource

evaluation was completed to assess the ways in which ParaMed can improve its accessibility to

both clients and nurses.

With these observations, I have formulated the following PICO (population, intervention,

setting, and outcome):

PICO

P: Patients receiving home care services and nurses that provide home health care.

I: Developing informative resources for patients; creating a way to continue education for nurses.

C: Accessibility to information.

O: Improved accessibility and communication to clients and nurses; evaluation of implemented

resources.

Community Assessment

For the purpose of this paper, I will evaluate current information on the level of

accessibility in the region of Essex County. A community assessment was completed using

Stamler and Yiu’s Community Health Promotion Model (2012). The community assessment

incorporates the following topics: physical and socioeconomic environments, health and social

services, culture and religion, government and politics, law and safety, education and health

child development, transportation, and communication. These topics help to identify gaps in the

health care system which may impact the way clients and nurses access information.

Physical Environments

The term ‘Essex County’ implies the town of Essex as well as the surrounding

municipalities which include: LaSalle, Kingsville, Harrow, Leamington, Lakeshore,

Amherstburg, and Tecumseh. Essex County does not include the City of Windsor, Chatham-


Kent, or Pelee Island. Essex County consists of a total population of 177,720 as of 2011 and is

the southernmost county and census division of Canada (Census Canada, 2011).

Essex County is considered to be a rural area of Ontario. This status of rurality may lead to

poor health services because of geographic isolation. According to the Ontario Ministry of

Health and Long Term Care (2011), “Access to quality health care in rural, remote and northern

communities is a long standing issue in Ontario. The challenges of providing appropriate access

to health care in these communities stem from multiple factors: geographic remoteness, long

distances, low population densities, less availability of other providers and inclement weather

conditions”. This lack of access can subsequently lead to inequitable health statuses among its

residents.

ParaMed is responsible for the delivery of care to populations either in the home,

workplace, or school (ParaMed Home Health Care, 2013). It may be difficult for rural nurses to

be able to provide care for clients who live in these areas. In the past, ParaMed has had staffing

issues related to its availability of county-specific nurses. Many nurses live in the city of

Windsor and would like to work within those boundaries; however, this leaves a nursing deficit

in the county areas. It has been my experience working with these populations that many feel as

though their needs are not being met, mainly due to distance and lack of resources.

It is important to consider the amount of elderly populations because they make up most

of the clients who access home care services. There are more than 83,000 people over the age of

60 living in Essex County (Census Canada, 2011). With the added stress of distance, lack of

mobility, and increasing health needs, it is essential that these populations receive the care that is

needed. A report in the Canadian Medical Association identifies 78% of people entering their

retirement years are concerned about access to high quality home care (Ontario Association of


Community Care Access Centres, 2014). Many of those (especially aging baby boomers) who

are accessing home care services feel as though they are not receiving enough care for their

growing needs.

Socioeconomic Environments

It is important for a health care agency like ParaMed to consider the economic factors

associated with this area that may affect health inequalities. In terms of economic

considerations, the following table illustrates a variety of characteristics of Essex County that

may impact the accessibility of health care as per the National Household Survey (2011):

Table 1:

Characteristic Total Male Female

Canadian Citizens 363,520 179,520 184,005

Not Canadian Citizens 17,825 7,790 10,035

Immigrants 81,730 38,755 42,975

Non-Immigrants 295,980 146,585 149,400

Visible Minority 57,795 28,690 29,110

Aboriginal Identity 7,495 3,525 3,975

Education: Total population aged 15 years and over by location of study compared with province or territory of

residence: No postsecondary certificate, diploma or degree

159,565 76,765 82,800

Education: Total population aged 15 years and over by location of study compared with province or territory of

residence: With postsecondary certificate, diploma or degree

153,145 75,000 78,145

Employed 168,375 87,100 81,280

Unemployed 18,180 10,080 8,100

Employment Rate 53.8 57.4 50.5

Unemployment Rate 9.7 10.4 9.1

Mode of Transportation:

Car, truck or van - as a driver

133,045 69,605 63,445

Mode of Transportation: 8,855 3,700 5,160


Car, truck or van - as a passenger


Public transit

3,885 1,530 2,355


Walked

5,920 2,815 3,105


Bicycle

1,505 1,180 325


Other methods

1,350 575 780

Household Characteristics: Suitable 144,455

Household Characteristics:

Non-Suitable

7,835

Shelter Costs: Spending 30% to less than 100% of household total income on shelter costs

28,715

Without Income 18,685 7,705 10,985

With Income 294,020 144,060 149, 960

Average Income ($) 37,652 44,942 30, 649

Canada/Quebec Pension Plan benefits (%) 4.2 3.7 5.0

Old Age Security pensions and Guaranteed Income Supplement (%)

3.5 2.5 4.9

Income: In low income in 2010 based on after-tax low-income measure (LIM-AT)

66, 645 30, 905 35, 735

Income: Prevalence of low income in 2010 based on after-tax low-income measure (%)

17.5 16.5 18.4

Health inequities continue to be an issue with those who live in rural areas. Socioeconomic

determinants strongly have an implication on how people access health care (Public Health

Agency of Canada, 2008). The characteristics that were pulled from the NHS resemble the

Social Determinants of Health. Some characteristics that are worth mentioning are: the high

unemployment rate, those without income, and those who spend between 30% - 100% of their

income on shelter costs. The amount of people with low education is very high as well. Average

income is on the lower side with a high rate of immigrants and visible minorities. Diversity and


multiple inequities have negative implications on the delivery and accessibility of health care

services. It is essential that health care organizations realize the gaps that are present in their

local populations and have services to help bridge these gaps.

Health and Social Services

In Essex County, there is currently one major hospital. Leamington District Memorial

Hospital is a rural, community hospital servicing people in the south east portion of Essex

County (County of Essex, 2014). This hospital’s vision statement is, “A leading rural community

hospital delivering compassionate care”, and its mission statement is, “Dedicated to improving

the health of the communities we serve” (Leamington Hospital, 2011). Essex County will be the

home of a new acute care hospital in the near future. This hospital will be updated, offer patient

and family-centered care, and will include modern hospital features that are built to the highest

standards (County of Essex, 2014). A date and location have not been confirmed. A site

selection process has been implemented to carefully consider the location of this new facility.

In terms of home care, Essex County is in partnership with CCAC (Community Care

Access Centre) who is crucial to the delivery of home health care services. In general, CCAC

helps to connect people with local health information and referrals to services in their community

(County of Essex, 2014). ParaMed Home Health Care works under the umbrella of CCAC as

well as a variety of service providers including: Bayshore Healthcare Ltd, ParaMed Home Health

Care, Revera Health Services Inc, Saint Elizabeth Health Care, and Victorian Order of Nurses

(Community Care Access Centre, 2014).

As of recently, ParaMed has partnered with Revera Health Services Inc to create an

integrated approach to delivering health care services. The merging of these two organizations

aims to increase the quality of care that is given to those in Windsor and Essex County.


ParaMed remains in the final stages of this merging as of date. No further information is

currently available to the public and to the staff on its specific implications.

ParaMed has had its share of home care service interruptions this year. On January 30th

2015, CCAC announced a labour strike on the basis of home care staff feeling under-valued by

the Ontario Nurses Association. This strike lasted 17 days and staff went back to work on

February 17th, 2015. About 260 nurses work for Erie St. Clair CCAC which serves both Windsor

and Essex County. The strike was not expected to have a significant impact on the delivery of

home care services (Windsor Star, 2015). ParaMed is in close contact with CCAC for the

delivery and accessibility of home care services. During this strike, it was difficult to get in

contact with care coordinators for specific patient information with limited staff working. This

strike impacted the care coordinators of Erie St. Clair and newly discharged patients from local

hospitals. These patients were to be assessed in order of priority which slowed the referral

process during the strike. Many clients asked my preceptor and I if we were on strike during this

time. Some assumed that we would not be making home visits during the strike. My nurse

informed our clients of exactly who was on strike and that the individual care of clients in the

home would not be affected. At the beginning of March 2015, a letter was sent to those who

receive CCAC services by Lori Marshall, Chief Executive Officer, who apologized for any

inconveniences and gave a phone number if the public wished to voice any questions or

concerns.

This strike had the most impact on seniors who were made to wait longer in the hospital for

home care services. Seniors’ health is an important aspect in the health care of Essex County.

The elderly make up 58% of CCAC’s clientele in Ontario alone (Home Care Ontario, 2014). In

addition to the home care services CCAC provides, other services available in Essex County are:


assisted living, housing with supports (retirement home subsidy), and long term care (County of

Essex, 2014). Accessibility to health services for seniors is crucial to maintain a healthy and

dignified life. Those living in rural counties have greater disparities and therefore require the

most assistance.

The Ontario Association of Community Care Access Centres reported a more growing,

aging, and diverse population in the near future. It indicates the themes that are seen in people in

hospice palliative care, and seniors and children with complex needs. Some themes include:

(1) A demand for services has been growing and will continue to grow;

(2) More demand for home and community care will also evolve what people need and their

expectations;

(3) Technology will continue to enable more effective home and community care; and

(4) There is a need for greater clarity about what we should expect from our health care system

and how we will pay for health services (OACCAC, 2014).

OACCAC’s approach to responding to health care changes is reported in their paper

Health Comes Home: Part 4: Launching the Conversation. “People with chronic conditions and

children with complex needs are living longer and choosing to live in their own homes for as

long as possible. That means we need more care and services in the community” (OACCAC,

2014). Addressing individual needs and providing custom care plans is needed to maintain the

health status of this growing population. Finding ways to facilitate these needs are what health

care organizations need to be part of in order to fully respond to the delivery of care.

Culture and Religion

Many residents of Essex County take pride in living amongst areas of rich history and


influence. More notably, Essex County is the home of many First Nation tribes. These cultures

strive to preserve their heritages by having their own methods of treatment for illnesses as well

as practices for everyday life. Many of these minority groups have disadvantages when it comes

to accessing health care because of treaties and jurisdiction ambiguities. With all of the

complexities surrounding the access to health care services, First Nation populations still remain

strong in sustaining their beloved culture.

Together, culture and religion can have an impact on how clients require their health care

services to be delivered. During ParaMed’s initial visit when opening a new case, it is a

formality to ask clients if they have any religious affiliation that would impact the delivery of

health care. Asking these questions during the first clinical visit allows the nurse to demonstrate

culture sensitivity and awareness to one’s ethnic background in relation to their religious

affiliation. The following table shows the most reported religions in Essex County according to

the National Household Survey (2011):

Table 2:

Religion Total Male Female

Christian 284, 520 135, 800 148, 720

Muslim 15, 995 8, 105 7, 890

No Religious Affiliation

70, 665 38, 150 32, 520

Respondents who reported as being ‘Christian’ encompasses a variety of sub-religions

including: Anglican, Baptist, Catholic, Christian Orthodox, Lutheran, Pentecostal, Presbyterian,

United Church, and Other. ‘Catholic’ was reported as being the highest amount out of this

group.


Government & Politics

The overseeing government in Essex County is responsible for services and financial

obligations. Such services include: transportation on county roads, libraries, long term care, land

ambulance, emergency preparedness, and planning services. Essex County is also a funding

partner in services that include: child care, social services, public health, and social housing

(County of Essex, 2014).

Nationally, Canada’s health care operates as a publicly-funded system under the Canada

Health Act. This act is responsible for the universal delivery of health insurance plans for

federal cash transfers. Each province and territory must provide reasonable access to hospitals

and services without subjecting Canadians to extra-billing and user fees. Five principles of the

Canada Health Act are: universality, public administration, accessibility, comprehensiveness,

and portability (Health Canada, 2012).

Provincially, Ontario operates under the Ontario Health Insurance Plan (OHIP).

Provincial roles include: administration of health insurance plans, planning and funding of care

in hospitals and other health facilities, planning and implementation of health promotion and

public health initiatives, and negotiation of fee schedules with health professionals (Health

Canada, 2012). The Commitment to the Future of Medicare Act, 2004 is an act that works in part

with the CHA which solidifies Ontario’s commitment to insured access to health care services.

This act allows the Ministry of Health and Long-Term Care to ensure that all Ontarians with a

valid health card have ongoing equitable access to health care.

Every Ontarian has equal rights to access health care services, yet, inequalities are still a

factor. The Canadian government has stated that they are anticipating future problems with the


way health care is delivered. Some trends that the government has noticed are: the progressive

aging of baby boomers, the high cost of new technology, and fiscal constraints. The ways in

which health care services are to be accessed in the future should be re-evaluated amongst

leading health care service providers, such as ParaMed.

Law and Safety

Residents in Essex County grow and prosper in very safe communities. Crime statistics

(2011) reported in The Windsor Star that the safest community in Canada is Amherstburg

followed by LaSalle. Other municipalities in Essex County that made the list are Tecumseh and

Lakeshore which ranked fourth and fifth, respectively. Kingsville was also mentioned and was

ranked at tenth (Wolfson, M, 2012).

What potentially make Essex County safe are the emergency services which include EMS,

fire, and police services. The Ontario Provincial Police (OPP) serves the towns of Leamington,

Tecumseh, Kingsville, Lakeshore, and Essex. (County of Essex, 2014).

While Essex County may be the safest place to live, other factors that influence safety are

the laws that are put in place. It is now the law to have accessible customer service as of January

1, 2008. This law requires businesses and organizations allow their operations to become

accessible to those with disabilities. The Accessibility for Ontarians with Disabilities Act 2005

creates provincial accessibility standards for those accessing goods and services (County of

Essex, 2014). This act is the first in a series of standards that will allow Ontarians to have

complete accessibility by 2025.

Education & Healthy Child Development

Healthy child development starts at the Windsor-Essex County Health Unit. Here, they

provide classes and programs for pregnancy and parenting. Such classes include: prenatal


classes, feeding your baby, home visiting programs, immunizations, and nutrition (County of

Essex, 2014). It is important to educate expecting parents on healthy behaviours. Poor childhood

developmental characteristics (low birth weight or poor nutrition) can compromise brain

development that will extend through adulthood (Stamler & Yiu, 2012). It is also essential for

community health nurses to teach parents about other issues which may impact health and social

needs such as social assistance. Low-income or disadvantaged children are at a greater risk for

poor health and tend to not do well in school.

Learning to adopt healthy behaviours and societal norms are ideally set in schools. Both

elementary and secondary schools are operated by the following 4 school boards: Greater Essex

County District School Board, Windsor Essex Catholic District School Board, French Catholic

School Board, and French Public Board (County of Essex, 2014).

Transportation

A dependable transportation system is necessary to ensure that the community has access to

health care services. Currently, there is no public transit system for of Essex County. In lieu of

public transit, Essex County provides a program called the County Wide Active Transportation

System which encourages the use of human power to get around (County of Essex, 2014). ‘Self-

propelled’ transportation includes biking, walking, running, and in-line skating. (County Wide

Active Transportation System, 2014).

Many residents of Essex County do not participate in this kind of transportation system,

especially those who require home care services. Table 1 shows a variety of methods of

transportation as reported by the National Household Survey. While most people have access to

a vehicle, a good portion of the population uses other methods to get around. This can have a

negative impact on accessing health care if clients need to get to a doctor’s appointment or


perhaps visit a local clinic.

Some clients rely on their own method of transportation or a family member/caregiver to

drive them to appointments, clinics, or drugstores. Other clients rely solely on health care staff

to visit them at home to provide care. Home health care organizations such as ParaMed are

dependent on their nursing staff to have their own vehicle in order to provide equitable health

care.

Communication

Communication is crucial for building relationships that can subsequently assist in the

delivery of quality health care services. CCAC is the main communication center between

communities and local health care service providers. “CCACs work together, and with

physicians, hospital teams and other health care providers to enhance access and co-ordination

for people who need care in their own homes in the community, in supportive housing, or in a

Long-Term Care Home” (Ontario Ministry of Health and Long Term Care, 2008). CCAC’s

Service Provider Relations Framework outlines the ways in which CCAC integrates its health

services to meet the needs of the public. The framework promotes interdependency to works as

an ongoing dialogue between CCAC and its service providers. It works to promote:

High quality, resource effective services to CCAC clients;

Successful and sustainable CCAC-Service Provider partnerships;

Consistent contract management practices within and across CCACs related to:

o Support of contract principles at all levels of the CCAC and Service Provider

organizations;

o Interpretation of contract language;

o Use of contract tools for performance measurement and monitoring; and


Collaboration in the pursuit of innovations in practice and service delivery (Community

Care Access Centre, 2009).

Along with CCAC, ParaMed can communicate with their clients by providing a clear

directory of phone numbers and extensions that clients can call during regular office hours as

well as after hours. Effective and efficient communication sets the foundation for clear, concise

messages that can assist in the equitable access of health care services. Other services should

further be incorporated into the care of these clients to meet other health care needs. Some

clients may not be aware of services and organizations that could assist in their individual needs.

It is essential that a home care agency such as ParaMed facilitates in the holistic care of their

clients by calling upon other services within the community.

Literature Review

The literature explains the benefits to increasing and improving nurse/client education for

the purpose of accessing effective health information. Client-centered interventions have been

shown to be more focused on facilitating proper use of Telemedicine and Telehealth whereas

nursing-centered interventions are focused on how nurses can access information to improve

their knowledge when working in the community. I am looking to create a resource for clients

that can facilitate optimal usage of local services which can be incorporated into ParaMed’s

orientation documents and given upon the first visit. For nurses, I want to create a resource that

can enhance their knowledge on procedures that are not commonly seen in their day to day. This

would benefit the clients by providing quality care nursing services and would decrease any risk

of harm. The literature review reflects both concepts.

Nurses

A study done by Fowler (2012) looked at how knowledgeable community nurses were on


the topic of heart failure. Some of the nurse’s patients were having repeated visits and

readmissions to the hospital because of their illnesses related to heart failure. The study noted

how coaching interventions need to be tailored to the patient when promoting self-management.

“Nurses need to possess a strong understanding of the pathophysiology of heart failure because

this knowledge is key to understanding drug therapy and self-management principles” (Fowler,

2012). The results concluded that in order to improve nurses’ knowledge on heart failure, an

educational and communication-based intervention would be effective. This study is informative

for me because it explains how community nurses had a deficit in a specific topic and an

educational tool was implemented to improve their knowledge. The educational resource I

would create to improve nurses’ knowledge would be focused on a concept like this by utilizing

ParaMed’s existing protocols. This resource would be used by community nurses the way

hospital nurses can access pamphlets and flyers to improve their knowledge.

A suggestion made by RNAO to further improve accessing health care in communities is

to secure the continuity of care and continuity of caregiver. Current models of delivering nursing

care reflect best practice guidelines and continuing the use of the best evidence available

continues to optimize nursing care. Another suggestion is to expand the role of the RN by

maximizing knowledge, skills, and experience so that the nurse can practice within their full

scope. Lastly, addressing educational needs, recruiting and retention of health care professional,

and expanding the role of the RN is needed by developing a health-related human resource

intervention (RNAO, 2011). The goal for my nursing-based intervention is to maximize the

knowledge of community nurses so that they can continue to deliver high quality health care

services to their clients. I can do this by creating resources for them in the form of an


educational tool that is standardized and meets specific criterion according to ParaMed’s current

policies.

Jefferies & Shah (2011) looked at how implementing different educational tools for

clinicians can be successful when providing information to patients. Their study suggested that

using pocket cards are preferred amongst clinicians because these tools are simple and easy to

access. The study also explains how multifaceted learning strategies are the most effective

intervention when implementing change. The study further explains how educational tools are

used more often because they are simple and easily accessible, and the simplest tools are the

most effective when leading practice change. My intervention for community nurses would be

to create an educational tool such as a pocket card or pamphlet that they can keep either in their

nursing bag or in the glove compartment of their car. It would meet quality standards by using

ParaMed’s existing procedural protocols.

A very informative piece done by Clark (2009) elaborates on patient educational

materials. She explains, “If used properly, a handout can be used to facilitate communication

between the provider and patient, and guide the patient education part of the visit, as well as give

a patient a document to use at home to refresh his/her memory and enhance understanding of

his/her condition and treatment plan” (Clark, 2009). Reasons to have educational handouts for

patients are: memory, anxiety, hearing, demand management, communication, and complexity.

The handouts should also be customized to include contact information for the clinic or hospital.

These handouts do not have to be patient-specific. Other things to consider for appropriateness

are: reading level, language, design, illustrations, content, demand-management value, ethnicity,

and source (Clark, 2009). The author provides helpful web links that meet health care standards

for patients to access such as Familydoctor.org and Healthfinder.gov. I can incorporate this


valuable information when creating my educational resources for both nurses and clients. This

outlines specific topics to be aware of such as readability, content, and language which are

essential when trying to create a successful, useful resource.

Clients

According to the Registered Nurses Association of Ontario (2011), Ontario would need

to hire close to 15,000 more registered nurses to align the province’s nurse-to-patient ratio with

the rest of Canada. Accessing nursing care is an essential part of creating vibrant communities

and facilitating optimal health outcomes. “Full-time RNs, as compared with part-time and casual

employees, are closely associated with lower mortality rates, continuity of care and continuity of

caregiver for patients, and better morale” (RNAO, 2011). It is clear that there are not enough

nurses available to deliver face-to-face health care to those in Ontario. As of 2013, 15.6% of all

Ontario is having difficulty accessing health information or advice (Statistics Canada, 2015).

These statistics show that there is a deficit in the availability of nurses compared to the needs of

patients. Statistics also show that patients are trying to access appropriate health care but have

having difficulty doing so. ParaMed reaches a large portion of the population who access health

care services. Enhancing the way clients access health care by organizing phone numbers and

informing them about local services can bridge these gaps that are being seen, yet a resource

currently does not exist.

A study conducted by Moffat & Eley (2010) researched the use of Telehealth in rural

Australia. The report showed benefits to using Telehealth and Telemedicine for both patients

and professionals. The report claims to have improved access and quality of health care services

amongst those living in rural areas. The authors explain that patients have benefitted from:

“Lower costs and reduced inconvenience while accessing specialist health services; improved


access to services and improved quality of clinical services” while health care professionals

benefitted from, “Access to continuing education and professional development; provision of

enhanced local services; experiential learning, networking and collaboration” (Moffat & Eley,

2010). The findings of this study suggest the increased use of Telehealth has the potential to

decrease inequitable access to health care. The findings also suggest using Telehealth to address

on-going problems of recruiting and keeping rural health care staff.

Telehealth Ontario is available to those living in Essex County. 211 is another service

which links the public with information and referrals for community, social health, and

government services. People who use ParaMed may not access these services and may not know

its value and benefits. Perhaps if clients were informed of this added service in times when

ParaMed cannot be reached, clients would have a better sense of health care accessibility.

Telehealth is a great way to bridge inequitable gaps; however, if clients want to access

health care information over the internet, they need to be more technologically savvy. There are

more than 700, 000 websites that offer health information and more than 50 million people who

seek this kind of information online as Cline & Haynes (2001) explains. Public health

professionals need to be concerned about this because clients can access the wrong kind of

information from a website that does not meet certain health care standards. Access can become

inequitable and could cause consequences for the health care system because of inaccuracy of

information. Clients can encounter navigational challenges because of numerous website design

flaws such as disorganization, technical language, and lack of permanence (Cline & Haynes,

2001). The authors suggest reinforcement is needed to evaluate quality standards and

information for websites offering health care information. Having a resource to present to clients

that is government officiated and meets quality standards can direct clients to the right kind of


health care information and services. I can use this kind of information to formulate my own

resource to present to ParaMed that would allow for easier access to health care services.

The use of technology and education can greatly affect a client’s access and quality to

health care services. A small town called Brazos Valley in Texas composed of 7 counties

developed a regional community solution to combat the issues rural populations were facing. A

2002 study revealed poorer health conditions and fragmented health care systems which were not

seen in urban parts of Texas. This localized strategy gave way to a “one-stop shop” where a

multidisciplinary team of health care professionals can deliver services to those in rural areas

(Garney, Drake, Wendel, McLeroy, Clark, & Ryder, B., 2013). Reduced overhead costs allowed

service providers to deliver services such as transportation, information and referral, and case

management to rural areas. Local oversight bodies evaluated the effectiveness of the solution by

collaborating with local entities which led to continuing the expansion of rural health care

services. Services like these and much more are already available in Essex County but there are

still people who do not make use of them or do not know how to contact them. A useful

resource should be the “one stop shop” by including local services that would be most frequently

used. Some services that I can add to my resource are: Poison Control, Canadian Mental Health

Association, Heart and Stroke Foundation, and Windsor/Essex County Health Unit.

Nursing Diagnoses

In order of priority:

1. Readiness for enhanced knowledge as evidenced by clients and nurses seeking new

resources.


2. Deficient access to community health care services and educational tools related to rural

home care delivery as evidenced by clients and nurses requesting a standardized resource

to accommodate health care needs.

3. Ineffective continuation of nursing knowledge related to a lack of in-service education as

evidenced by nurses expressing a need to have more frequent continuing education

opportunities.

4. Risk for compromised health outcomes as evidenced by inequitable access to health care

services by living in rural communities.

Nursing Care Plan

Refer to Appendix A for a detailed nursing care plan for both clients and nurses.

Discussion

During my time at ParaMed Home Health Care, there were many barriers set in place that

created an overall challenging experience for me. Deciding what to focus my attention on was

difficult because there was a perceived lack of options. What eventually led to the idea of

improved accessibility came from emerging themes that I had noticed while visiting clients in the

rural areas of Essex County. Thus began the idea for my client-centered intervention on creating

a standardized resource that largely met the needs of clients. Creating a resource that only met

client-centered needs did not seem as though it would be a worthy project; which led to the

introduction of a nursing-centered intervention. The idea of creating a resource to improve

accessibility for both clients and nurses helped generate a holistic approach to my project.

While in the planning stages of my resources, I encountered several obstacles within the

organizational culture of ParaMed. First, the agency was experiencing a reduction in supervising

staff. This created barriers for obtaining permission to send out a survey to the nurses through


their work phones. Eventually, the concept of my project was explained to a supervisor and the

survey was successfully sent. Another obstacle was the combination of the CCAC strike and the

merging with Revera Health Services. This, along with staffing shortages, demonstrated an

increased level of difficulty as I attempted to implement my resources.

Within a relatively small amount of time, the black cloud of obstacles had lifted and the

culture of ParaMed was sent back into motion. The strike ended rather quickly and new nurses

were recruited to fill the vacant supervising positions. I was able to speak to an appropriate

nursing supervisor about my project which resulted in their approval for my intended

interventions.

For clients, a standardized, laminated tool was created that included a directory of phone

numbers and government-officiated websites of local services on one side. On the other side,

space is allotted for clients to input their own phone numbers for family doctors, nurses, and

drugstores. This tool is meant to be placed in a convenient location, such as the refrigerator, so

that clients have easy access to health care information. A dry-erase marker is meant to

accompany this tool at the agency’s expense. A preview of this prototype is available in

Appendix E. This intervention is appropriate because it applies to seniors which make up the

majority of CCAC home care users. Furthermore, the font is large enough for clients to read, it

is attention-grabbing, and provides government-officiated websites for easy use as well as

emergency/referral phone numbers.

For nurses, compact, visually appealing educational pamphlets were created using input

from the survey presented in Appendix D. These pamphlets are meant to be replicated for each

nurse and kept with them in their car for easy access. They may also be used as educational tools

for clients when doing health teaching. The topics were chosen based on the skills that were


most commonly requested. The responses generated from the survey reported 85.71% of nurses

requesting a need for improved education on ostomy and tracheostomy care. The finalized

prototypes are available for preview in Appendix F. To assist in those requesting other types of

resources, a suggestion is made for nurses to advocate to their head office for the supply of

newly implemented protocols as evidenced by the research provided in Appendix D.

Since the nursing-centered interventions were solely based on existing protocols, a

quality assurance check was performed to evaluate the consistency of information. The original

protocols that were used are available for preview in Appendix B. Each protocol identifies its

implementation date, a copy written date, and references.

The protocol entitled, “Application of Ostomy Appliance” (p. 33-35) was implemented in

March 1997 and its references include information from Potter & Perry (n.d). This document

was crossed-referenced with Kozier & Erb (2009, p. 1255-1277). The information provided in

Kozier & Erb resembles that in ParaMed’s protocol which establishes consistency between the

documents. The only difference between the two documents is that Kozier & Erb provides

rationale for most steps in order to assist the reader’s learning. Kozier & Erb also provide visuals

whereas ParaMed’s protocols do not.

For the tracheostomy care procedures, the protocols are divided into three different

documents: Cleaning Outer Cannula and Faceplate, Suctioning, and Tie Change. The documents

entitled, “Suctioning” and “Tie Change” were both implemented in March 1997. Their

references are from British Columbia Children’s Hospital, Children’s Hospital of Eastern

Ontario, and the Royal Ottawa Regional Rehabilitation Centre. While these were both

implemented in 1997, “Cleaning Outer Cannula and Faceplate” was carried out in March 2009.

References include that of Potter & Perry (2007), Robin Rice (1995), and St. Joseph’s Healthcare


(2005). When comparing these documents to that of Kozier & Erb (2009), there is not much

difference in the information. Both provide a purpose for each intervention, a list of equipment,

and a detailed list on how to perform the procedures. Kozier & Erb may be the more superior

document of the two because it contains more detail, rationales, and pictures to facilitate visual

learning. One must note that while Kozier & Erb provides a more visually appealing skill

explanation, it is meant as a teaching aid for nursing students.

Performing a quality assurance check was essential to identify gaps within ParaMed’s

protocols. The information contained in these documents is what nurses and supervisors rely on

to provide safe, competent care. Ensuring the consistency of the information as compared to

another recent, reliable resource was needed to further evaluate the accuracy of these documents.

The intention for these educational tools was to take ParaMed’s existing protocols and revitalize

them. The final products are pamphlets that are visually appealing, compact, and contain

accurate information to facilitate continuing education with ParaMed’s nursing staff.

A way in which one would measure the efficacy of these tools is by an evaluation survey

for each intervention which is provided in Appendix G. These evaluation surveys use a Likert

scale which measures the level of user’s satisfaction. The information gathered by these surveys

allows ParaMed to assess the level of the tool’s integrity. A decision can later be made whether

to continue using the proposed tools as is or to find ways to improve them.

Conclusion

To conclude my community health nursing process assignment, the proposed

interventions to improve accessibility appropriately meet the needs for both ParaMed clients and

nurses. Needs were identified by using surveys to create educational tools to facilitate the way in

which clients and nurses access information. This was an appropriate avenue to further explore


because it applied to those accessing health care services in rural areas as well as nurses who

work for a health care agency.

The overall impact of my interventions has generated a well-received response amongst

clients, nurses, and nursing supervisors. I was able to meet with a supervisor at ParaMed who

provided me with feedback on where the future lies with my resources. Budget constraints

continue to be an issue as with any business. It may be possible to start implementing the

nursing-centered educational tools as paper copies to give to staff. For the client-centered

intervention, it may be more difficult to implement this because the resource needs to be

laminated. Cost for lamination may pose as an issue because the resource would also need a

supply of dry-erase markers. Overall, the supervisor showed great enthusiasm for the idea and

was able to foresee an active use in these educational tools. Their feedback provided strong

recognition to the idea of facilitating improved access to health care services and continuing

education amongst ParaMed’s clients and nurses.

The research I gathered elicited other needs that were unknown to ParaMed’s supervising

staff, as addressed in Appendix D. ParaMed can continue to utilize the information I gathered by

advocating to their head office for more, newly implemented strategies to meet these specific

needs.

Home health care agencies like ParaMed do their part by ensuring clients have reasonable

access to optimal health care services while also retaining knowledgeable and competent nurses.

Research has shown that despite these efforts, there are still populations who are receiving

inequitable health care services. Improving the ways in which accessibility is met to all clients

and nurses can bridge the long standing accessibility gaps that are seen within Canada’s health

care system.


References

Census of Canada. (2011). Retrieved February 6, 2015, from http://www12.statcan.gc.ca/census-

recensement/index-eng.cfm.

Clark, N. (2009). Patient education materials. Florida State University College of Medicine.

Cline, R., & Haynes, K. (2001). Consumer health information seeking on the internet: The state

of the art. Health Education Research, 16(6), 671-692.

Community Care Access Centre. (2009). CCAC - Service Provider Relations Framework.

Retrieved February 27, 2015, from

http://healthcareathome.ca/serviceproviders/en/Documents/20131101Appendix

B.PDF#search=communication.

Community Care Access Centre. (2014). Retrieved February 18, 2015, from

http://www.healthcareathome.ca/serviceproviders/en/Service-Provider-Listing/Erie-St-

Clair.

Community Care Access Centre. (2014). How CCAC's care: An update on quality improvements

for patients.

County of Essex. (2014). Retrieved February 7, 2015, from http://www.countyofessex.on.ca.

County Wide Active Transportation System. (2014). Retrieved February 19, 2015, from

http://www.cwats.ca/en/places-to-go/explore-our-area.asp.

CTV Windsor. (2014). Concerns over homecare cuts in Windsor. The Windsor Star. Retrieved

February 27, 2015, from http://windsor.ctvnews.ca/concerns-over-homecare-cuts-in-

windsor-1.2122417.

Fowler, S. (2012). Improving community health nurse's knowledge of heart failure: Education

principles. Home Healthcare Nurses, 30(2), 91-99.


Garney, W., Drake, K., Wendel, M., McLeroy, K., Clark, H., & Ryder, B. (2013). Increasing

access to care for Brazos Valley, Texas: A rural community of solution. The Journal of

the American Board of Family Medicine, 26(3), 246-253.

Health Canada. (2012, October 9). Canada's health care system. Retrieved March 9, 2015, from

http://www.hc-sc.gc.ca/hcs-sss/pubs/system-regime/2011-hcs-sss/index-eng.php.

Home Care Ontario. (2014). Facts & Figures - Publicly Funded Home Care. Retrieved

February 2, 2015, from http://www.homecareontario.ca/home-care-services/facts-

figures/publiclyfundedhomecare.

Jefferies, A., & Shah, V. (2011). Clinicians prefer simple educational tools for implementing

practice change. Simple Educational Tools and Practice Change, 33, 602-606.

Leamington Hospital. (2011). Retrieved February 18, 2015, from

http://www.leamingtonhospital.com/about.php?id=12.

Moffatt, J., & Eley, D. (2010). The reported benefits of telehealth for rural Australia. Australian

Health Review, 34(3), 276-281.

National Household Survey. (2011). NHS Profile, Essex CTY. Retrieved February 26, 2015,

from http://www12.statcan.gc.ca/nhs-enm/2011/dp- pd/prof/details/Page.cfm?

Lang=E&Geo1=CD&Code1=3537&Data=Count&SearchText=

Essex&SearchType=Begins&SearchPR=01&A1=All&B1=All&GeoLevel=PR&GeoCod

e=10#tabs1.

Ontario Association of Community Care Access Centres. (2014). Making way for change:

Transforming home and community care for Ontarians.

Ontario Ministry of Health and Long Term Care. (2008). Community Care Access Centres.

Retrieved February 28, 2015, from http://www.health.gov.on.ca/en/public/contact/ccac/.


Ontario Ministry of Health and Long Term Care. (2011). Rural and northern health report.

Retrieved March 8, 2015, from

http://www.health.gov.on.ca/en/public/programs/ruralnorthern/docs/exec_summary_rural

_northern_EN.pdf.

ParaMed Home Health Care. (2013). Services. Retrieved February 25, 2015, from

http://www.paramed.com/homecare/about/.

Public Health Agency of Canada. (2008). Social and economic factors that influence our health

and contribute to health inequalities. Retrieved February 26, 2015, from

http://www.phac-aspc.gc.ca/cphorsphc-respcacsp/2008/fr-rc/cphorsphc-respcacsp07a-

eng.php

Registered Nurses Association of Ontario. (2011). Creating vibrant communities: RNAO's

challenge to Ontario's political parties.

Stamler, L. L., & Yiu, L. (2012). Canadian health nursing: A Canadian perspective. (3 ed.).

Toronto, Ontario: Pearson Canada Inc.

Statistics Canada. (2015). Difficulties accessing health information or advice, among those who

required care at any time of day, household population aged 15 and over, Canada,

provinces and territories. Retrieved February 21, 2015, from

http://www5.statcan.gc.ca/cansim/a47.

The Windsor Star. (2015). Retrieved February 18, 2015, from

http://www.blogs.windsorstar.com/news/thousands-of-ccac-nurses-go-on-strike-in-

windsor-and-across-province.

Wolfson, M. (2012, September 18). Essex County safest place in country. The Windsor Star.

Retrieved March 8, 2015.


Appendix A

Client-Centered:

Goals Nursing Interventions P, N, G Target Date EvaluationParaMed clients will report

improved access to

necessary services as

evidenced by 25% higher

satisfaction scores pre - and

post – intervention.

Poll clients and ask whether they find

difficulty in accessing health care services and

if they would like to have a new resource be

created to facilitate in this.

P January 31,

2015

Out of 10 clients polled, all said yes.

This indicates that there is a need for

a more standardized resource to meet

the needs of the clients.

Create resource according to quality

standards, readability, and appropriateness for

clients as outlined by Clark (2009)

P March 15,

2015

An evaluation tool was created using

a Likert Scale that measures the

tool’s efficacy. A preview is

available in Appendix G

Pilot the new resource to ParaMed

supervisors

P March 29,

2015

I met with a ParaMed supervisor on

March 19, 2015 where I presented a

completed prototype and an

evaluation tool. More detail is


provided under the heading

“Conclusion”.

Nursing-Centered:

Goals Nursing Interventions P, N, G Target Date Evaluation

ParaMed nurses will report

improved access to

continuing education

services as evidenced by

25% higher satisfaction

scores pre - and post –

intervention.

Create a survey for nurses to access on their

work phones that will ask if they require a

new resource and what kinds of information

they would like to see on it.

P January 31,

2015

The survey went live on February

9, 2015 on

www.surveymonkey.com

Nurses were given three questions

to answer. As of date, 7 people

responded. A more in-depth look

on responses is available for

preview in Appendix D.

Assess the responses and formulate a

prototype according the most responded

topics.

P March 29, 2015 According to the survey responses,

85.71% reported an interest in

learning more about the

application of ostomy appliances


and tracheostomy care and

suctioning.

Create resource according to quality

standards, readability, and appropriateness

for nurses as outlined by Clark (2009)

P March 15, 2015 An evaluation tool was created

using a Likert Scale that measures

the tool’s efficacy. A preview is

available in Appendix G

Pilot the resource to supervisors at ParaMed

for evaluation.

P March 29, 2015 I met with a ParaMed supervisor

on March 19, 2015 where I

presented completed prototypes

and an evaluation tool. More

detail is provided under the

heading “Conclusion”.


Appendix B


Appendix C


Appendix D


Appendix E

Phone Numbers and Useful WebsitesAlzheimer Society of Windsor and

Essex County519-974-2220 www.alzheimerwindsor.com

Arthritis Society 800-321-1433 www.arthritis.caCanadian Cancer Society 519-254-5116 www.cancer.ca

Canadian Diabetes Association 800-226-8464 www.diabetes.ca Canadian Mental Health

Association Windsor/Essex519-255-7440 www.cmha-wecb.on.ca/

home/home.aspCentre for Addiction and Mental

Health800-463-6273 http://www.camh.ca/en/

hospital/Pages/home.aspxCCAC 519-258-8211 www.ccac-ont.ca

Elder Abuse Ontario 866-299-1011 www.elderabuseontario.caFamily Services Windsor/Essex 519-966-5010 www.familyserviceswe.caHeart and Stroke Foundation of

Canada519-254-4945 www.heartandstroke.ca

Hospice of Windsor/Essex 519-974-7100 www.thehospice.caPoison Control of Ontario 800-268-9017 www.ontariopoisoncentre.com/

poisoncentre/Senior Safety Line 1-866-299-1011 www.onpea.caTelehealth Ontario 866-797-0000 www.health.gov.on.ca/en/public/

programs/TelehealthWindsor/Essex County Health Unit 800-265-5822 www.wechealthunit.org


My Doctor’s Office:

Ext: My Nurse:

Ext: My Drugstore:

Ext:

Other Important Phone Numbers:

Appendix F

911Police, fire, or medical

emergencies

311For Windsor residents to

request information on non-emergency programs or

eventswww.citywindsor.ca

211For Windsor and Essex

residents to request information for community,

social, health, and governmental services

www.211windsoressex.ca


Application of Ostomy Appliances

Changing a Two Piece Bag

Carefully pull the pouch away from the skin in a downwards direction

Put the soiled bag into a plastic garbage bag

Use a towel and wipe away any access stool from the stoma

Use a wash cloth with warm tap water and mild soap and gently wash the entire ostomy area in a circular

motion

Rinse area well and pat dry with a towel

Let the skin air dry. In the meantime, assess the stoma site the same as in a one piece

Check the size of the stoma with a measuring card and trace the size on the new pouch

Next, cut a hole in the new pouch according to the size of the measuring card

Apply a barrier wipe around the stoma to prevent skin irritation

Fit the flange over the stoma and hold it in place for 30-50 seconds as warmth increases the adhesion to

the skin

Attach the stoma bag to the flange starting from the bottom ensuring alignment

Press the bag to expel air, the reapply the clip or clamp

Wash hands and document

Necessity of Buying Colostomy Bag [Online Image]. (2013). Retrieved March 15, 2015 from https://ostomysupplies23.wordpress.com/2013/05/10/necessity-of-buying-colostomy-bag/ParaMed Home Health Care. (1996). Application of ostomy appliance. Care Procedures.Stoma Bag Guide [Online Image]. (2013). Retrieved March 15, 2015 from http://www.ostomylifestyle.org/content/stoma-bag-guide.

A Quick Reference Guide for Nurses


Procedure

Carefully pull the pouch away from the skin in a downwards direction

Put the soiled bag into a plastic garbage bag

Use a towel and wipe away any access stool from the stoma

Use a wash cloth with warm tap water and mild soap and gently wash the entire ostomy area in a

circular motion

Rinse area well and pat dry with a towel

Let the skin air dry. In the meantime, assess the stoma site for:

Redness and irritation Colour (should be pink) Size (should not be swollen)

Check the size of the stoma with a measuring card and trace the size on the new pouch

Next, cut a hole in the new pouch according to the size of the measuring card

Apply a barrier wipe around the stoma to prevent skin irritation

Remove the sticky side of the pouch and apply it over the stoma

Press the bag to expel air, the reapply the clip or clamp

Wash Hands and document

Changing a One Piece Bag

EquipmentNew collection bag

ScissorsTowels

Wash ClothPlastic garbage bagDisposable glovesMeasuring Card

Barrier Wipe

After gathering supplies, wash hands, don gloves, and explain the procedure to the client

It is best to change the bag in the bathroom so as you can remove the soiled collection in the toilet

before removing the pouch

Depending on the equipment, you may have to unclamp or unclip the bag to remove the soiled

collection

Some pouches can be 1 piece or 2 pieces:


Tracheostomy Care and Suctioning

Changing the Tracheostomy Ties

ParaMed Home Health Care. (1996). Tracheostomy: Cleaning outer cannula and faceplate. Care Procedures. ParaMed Home Health Care. (1996). Tracheostomy: Suctioning. Care Procedures. ParaMed Home Health Care. (1996). Tracheostomy: Tie change. Care Procedures.Tracheostomy Neckband Collar [Online Image]. (2015). Retrieved March 18, 2015 from: http://www.baytownmedicalequipment.com/Catalog/Online-Catalog-Product/423/Disposable-Collection-Jar

A Quick Reference Guide for Nurses

Equipment:New TiesScissors

Clean Cloth and TowelHydrogen Peroxide and Water Solution (½ & ½)

Wash hands and explain procedure to the client

Cut a length of the new ties long enough to go twice around the client’s neck

Turn the client’s head to one side

Cut one end of the tie and clean the exposed skin using a cloth with ½ & ½ hydrogen peroxide

and water. Repeat on the other side

Pat dry. Do not use powders or lotions unless otherwise prescribed

Loop one end of the tie through the faceplate and secure it with a loose knot. Repeat on the

other side

Test for fit. You should be able to fit your index finger between the neck and the tie


Special Considerations:Change the ties after suctioning

Ties should be changed once a day or more often if they are wet or dirty as to prevent rashes or

other skin problems


Cleaning the Outer Cannula Suctioning

Equipment4 x 4 Gauze Squares

Cotton Tip Swabs3% Hydrogen Peroxide

Normal SalineNon-Sterile Gloves

After gathering supplies, wash hands, don gloves, assemble equipment, and explain the

procedure to the client

Position the client either sitting or semi-reclining with the neck slightly hyper-extended

Remove the dressing around the tracheostomy tube and inspect the skin for:

Redness Swelling Ulcers Bleeding

Clean the exposed cannula with a cotton tip swab moistened with 3% hydrogen peroxide, then use a saline soaked cotton swab to rinse

Clean the stoma with a cotton tip swab moistened with hydrogen peroxide in a circular

motion going inward to outward, then use a saline soaked cotton swab to rinse

Pat the skin dry with a dry gauze square and replace the tracheostomy dressing


EquipmentSuction Machine

Clean GlovesSterile Gloves

Sterile CatheterNormal Saline

Sterile Cup

Check physician’s orders, wash hands, and explain the procedure to the client

Don a pair of clean gloves and pour normal saline into a sterile cup

Connect the sterile catheter to the suction machine and test it to make sure it is working. Normal suction

pressure is 80-120 mmHg

Don sterile gloves on your dominant hand only to manipulate the catheter

Lubricate the tip of the catheter with normal saline and then introduce it into the tracheostomy without

applying suction

STOP inserting if resistance is met

Apply intermittent suction when withdrawing the catheter and rotate it from side to side for a maximum of 10-15 seconds. Repeat until

secretions are cleared

Clean the catheter by suctioning normal saline

Make sure the client has a way to breathe in between suctioning

Dispose of gloves and catheter when finished


Suctioning

Appendix G

Client Satisfaction Survey

Dear ParaMed client,

We are asking that you assist us in providing feedback for our newly developed phone number and websites resource. This survey will be used to improve our health care delivery service practices. Your answers will be kept confidential. Please return a completed survey to your nurse. If you have questions, you can contact ParaMed at (519) 972-7760.

Thank you.

Rate our resource tool on a scale of 1-10:

9 – 10 Excellent7 – 8 Very Satisfied5 – 6 Satisfied3 – 4 Not Satisfied1 – 2 Poor

1. How long have you been using our phone number and websites directory tool? Less than a month 1 – 3 months 4 – 6 months Never used

2. How helpful do you find our phone number and website directory tool to be? Please circle your answer.

1 2 3 4 5 6 7 8 9 10

3. How satisfied are you with our directory?

1 2 3 4 5 6 7 8 9 10

4. How likely is it that you will use or continue to use this directory?

1 2 3 4 5 6 7 8 9 10

5. Please provide commentary on what ParaMed Home Health Care can do to improve this product in order to further assist your access to health care services:

Employee Satisfaction Survey

FACILITATING IMPROVED ACCESSIBILITY

62

Dear ParaMed employee,

We are asking that you assist us in providing feedback for our newly developed ostomy and tracheostomy care resources. This survey will be used to improve our commitment to continuing education. Your answers will be kept confidential. Please return a completed survey to your supervisor. If you have questions, you can contact your nursing supervisor.

Thank you.

Rate these resource tool characteristics on a scale of 1-10:

9 – 10 Excellent7 – 8 Very Satisfied5 – 6 Satisfied3 – 4 Not Satisfied1 – 2 Poor

Characteristic Poor Not Satisfied Satisfied Very Satisfied ExcellentHelpfulnessConvenience

Accuracy of InformationUsefulnessReadability

Please provide commentary on what ParaMed Home Health Care can do to improve these products in order to further facilitate your access to educational resources:

facilitating improved accessibility to home care clients and nurses

Documents

home care clients

improved accessibility

paramed clients

home care services

health care needs

home health care system

parameds nurses

way nurses