Home Community-Based Care

The Integrated Health and Wellness Package in the Community is a comprehensive and integrated one which includes Community Based Services (CBS) and Wellness Services.

The package includes health and wellness interventions (ranging from prevention, promotion, cure, rehabilitation, and palliation), aiming to empower clients and primary caregivers to look after their health at home.  The Health and Wellness Package helps to reduce the demand on healthcare facilities by avoiding admission, providing home-based care for minor health problems/ailments and long-term conditions, and achieving and maintaining optimal functioning.

Rather than individuals or groups being supported simultaneously by many different health workers from a range of vertical programmes (e.g., HIV, TB, nutrition, family planning, etc.), the Integrated Health and Wellness Package holistically sees community members with a variety of needs and provides a person-centred service to meet those needs. This might include one health worker providing HIV and TB-related services, along with nutrition advice and family planning methods to each person/group.

Patients receive Community-Based Services in their  homes, an alternate living environment, work, learning, or social settings. A health worker will provide the primary service in the community; however, supplementary services may be provided at a Western Cape Government Health (WCGH)  facility as determined by sub-structure/sub-district management.

Service components include:

• Community entry and engagement
• Maternal and newborn health
• Child and adolescent health
• Healthy adults and ageing
• Sexual and Reproductive Health

A Professional Nurse will supervise the services primarily provided by Community Health Workers (CHWs), including screening and referral (where applicable), assessment, care planning, interventions/treatments, and monitoring and review are among the services provided.

There are multiple entry points to the service – for example, entry could be health worker-initiated, person-initiated, or initiated by the referring Primary Health Care Facility.

Wellness Services  is a comprehensive package of care provided in the living, learning, social and working spaces. The Department strives to promote wellness by expanding the current service and establishing wellness hubs. The Wellness Service might be fixed or mobile and offered within spaces, depending on the circumstances in the area and space /venues that are available. It delivers different types of services in different settings (e.g. adherence support in a local community or school hall, screening and testing next to the taxi rank, health education sessions in the grounds of a sports club, or using a mobile unit to reach a hard-to-reach community).  

Who can benefit from this service?

The provision of services will follow a life course approach with focused interventions based on the assessed health needs in a defined geographic area. Including differentiated interventions for target groups across the life course:

• Children: birth to 12 years (maternal, perinatal and neonatal services, children under 5 years
• Adolescents: 13 to 19 years (youth and adolescent services)
• Adults: 20 to 59 years (adult services)
• Elderly: over 60 years (healthy ageing)

We provide services across the spectrum of health needs (from wellness to illness)

• Mostly healthy (mainly preventative and health promotion)
• Defined episode of care (single episode of illness/ailment)
• Long-term conditions (care over a prolonged period)
• Complex disabling conditions (extended and specialist care)

Specific interventions will also be planned and delivered for:

• Key populations in the community
• Vulnerable people in the community