As soon as the patient is admitted within the HHC structure, his/her therapeutic project is established so that the types and number of human and material resources required for the
care delivery can be determined. This therapeutic project is defined by the French health decree of 2nd October 1992 as being a project which “formalizes all the clinical, psychological and social care necessary for the state of the patient”. More precisely, the information mentioned in this project are: the types of care givers necessary to deliver the care, the drugs to administrate, the frequency and average duration of visits, the additional home helps that the patients needs as well as the modalities of exit from the HHC structure. This project is defined for a limited and reviewed period and can be changed if the patient’s conditions necessitate it. It ends when the therapeutic objectives fixed at the admission of the patient are reached or when the patient is dead.
The diversity of human resources involved in the care delivery process explains the necessity of assigning to each patient a reference care giver whose role is to manage care, communicate the therapeutic project’s modifications to the other care givers and ensure the delivery of all the services needed by patients. It also explains the necessity to communicate on time the information related to patients’ conditions, coordinate all these resources during the patient stay within the HHC structure. However, the human resources do not work in the same unit, do not meet and possibly do not know each other. Consequently, the communication of the information related to the patients is complicated in the HHC context which would conduct to heterogeneous points of view and decisions related to the therapeutic projects of the patients. Furthermore, the variety of these resources coupled with the uncertainty of demand complicates the adjustment of the capacity to demand. In order to remedy to this, most of HHC structures work more with external care givers, develop the multi-disciplinarity of the internal care givers, use more new technologies such as telemedicine, nanotechnology, etc. Furthermore, as detailed below, different types of material resources requires the organization of their supply chain by selecting material and equipments’ suppliers, defining inventory management policies related to the consumable material resources, organizing resources’ delivery to the patient home, planning the medical and paramedical equipments’ maintenance procedures, etc.
4.2.1 Types of human resources
The care delivered by HHC structures is performed by a multidisciplinary team composed of medical and paramedical care givers among whom we can distinguish:
• The nurses who represent the largest group of HHC employees. They evaluate the conditions of the patients who receive HHC services, provide the necessary care, make sure that the physicians’ prescriptions are carried out, coordinate the visits of all care givers, update the patient’ file by mentioning the activities performed and the changes of his/her conditions, take care of the medical equipment and have an educational role with patients and their families.
• The therapists such as physical, occupational and speech therapists who consider therapy needs, develop care and rehabilitation plans and have oversight for any assistants involved in providing therapy.
• The nutritionists who can also participate in the delivery of care to the patients.
• The social workers who support the patients and their families in accessing to community assistance, overcoming their financial and social problems that can influence the delivery of care by determining their needs in terms of additional helps (house cleaning, meal preparation, etc.).
• The home care assistants and the home health aides who “are the foundation of the home care workforce because of the wide variety of services they provide” [Tarricone and Tsouro, 2008]. The home care assistants are responsible for the assistance with therapy while the home health aides are responsible for house keeping, meal preparation, eating, transfer, displacement inside home, grooming, toileting, dressing, etc.
• The psychologists responsible for the psychological support of patients.
• The pharmacists providing prescribed medicines.
• The informal careers i.e. the patient’s family, friends or neighbors whose participation in the care delivery process and the patient supervision is very important. Since HHC relies on the permanent availability of the informal care givers who cannot be always guaranteed, the organization of the care delivery is complicated. According to [Tarricone and Tsouro, 2008], the balance between informal and formal care givers depends on political, economic, demographic and cultural factors.
These care givers are either multi-disciplinary, able to treat all patients whatever the care needed, or specialized in one or some specific pathology(ies) so that they can deliver care to one or some patients’ categories. Care givers can be full-time employees (internal resources of the HHC structure) or part-time employees (external resources). According to [Chahed et al., 2006], it is necessary to combine these two categories of care givers in order to satisfy the
patients’ demand. Indeed, the internal resources allow the service quality improvement thanks to the diversification of their skills while the external resources cost less to the HHC structure and enable the expansion of the area of the HHC intervention particularly in rural areas, the enhancement of the flexibility and reactivity of the structure when an emergency occurs. Additionally, the external resources allow the coordination of the activities all over the care process, before, during and after the stay within the HHC structure and thus the guarantee of the care continuity.
Note that we can also distinguish between these various care givers according to their experience level which influences their performance but also according to their degrees which would condition the types of activities assigned to them. For example, [Hertz and Lahrichi, 2006] differentiate between case manager nurses who obtained a Bachelor’s degree and nurse technicians who hold a community college degree. These degrees enable to identify the types of activities assigned to them.
4.2.2 Types of material resources
Material resources can be consumable (drugs, single-use material, dietetic products, single- use equipments, etc.) or non consumable (fleet vehicles, medical and paramedical equipments, information system, etc.). The non consumable material resources can be, depending on the size of the HHC structure, rented or bought. The consumable material resources can be managed either by the Pharmacy for Internal Use (PIU) of the HHC structure or by a private pharmacy agreed by the HHC structure. According to the FNEHAD (Fédération Nationale des Etablissements d’Hospitalisation A Domicile), among the 208 HHC structures existing in 2007, 118 have PIU and 90 work with private pharmacies. The HHC structures that have a PIU must use secure transport (available 24h/24, adapted vehicles, etc.), implement strict procedures related to the transmission of information between the care givers and the HHC structure. The use of a PIU can however generate important costs and complex operations especially when it is necessary to deliver consumable products to patients living in rural areas.