Shortened hospital lengths of stay, and a growing number of people living with chronic diseases has meant that more Ontarians than ever are receiving health care services in their homes.
In 2010, the Ontario Auditor General raised concerns about the quality and value of home care services, some of which remain outstanding.
Resolving these issues is important because the recently released Drummond Report suggests directing more resources towards home care.
‘Delores’ is a fictional home care client in Ontario. She is 85 years of age, and lives alone in a bedroom community west of Toronto. She has mild dementia, diabetes, high blood pressure and heart failure. Delores needs help to take her medication and with activities around the home including bathing, meal preparation and grocery shopping. Delores has needed support for many years in order to live independently in her home, and over time has seen many nurses, rehabilitation therapists, personal support workers and other providers come and go. Currently, Delores has providers from four different agencies delivering care, all coordinated through the local Community Care Access Centre.
What kinds of services are delivered by Community Care Access Centres?
The 14 Community Care Access Centres (CCACs) in Ontario coordinate the delivery of a range of services in the home and community including highly complex medical care provided by nurses, rehabilitation services, personal support and homemaking services like food preparation, and community service supports such as transportation.
55% of CCAC clients are aged 65 and above. Although many are the frail elderly, CCAC clients also include those receiving end of life care, children living with chronic diseases or complex disabilities, and those recently discharged from hospital who receive medical treatment or rehabilitation in the community.
Who pays for home care?
Unlike physician services and hospital care, home care is not included in the Canada Health Act. However, in some provinces like Ontario, there is a long history of paying for some forms of home care with public dollars. For example, skilled nursing services and providers have been publicly funded in Ontario for decades. Compared to other provinces, Ontario has a relatively well-resourced home and community care sector.
CCACs received $1.9 billion in funding from the Ministry of Health and Long-Term Care in 2009, with which they served 600,000 Ontarians. However, the demand for home care often outstrips the resources available. In order to balance budgets, CCACs manage the volume of services provided to clients by restricting the number of hours of care per week, or placing patients on wait lists for services. Clients can also purchase additional services from service provider agencies directly.
Who delivers home care?
CCAC staff do virtually all the the care coordination and case management for home care services. But most care – representing more than 70% of CCAC budgets – is provided by external, private sector agencies which can be either for-profit or non-profit.
How are external providers chosen?
Traditionally home care were delivered through a patchwork of for-profit and non-profit agencies and organizations associated with different regions, ethnicities, religions and voluntary groups. When CCAC’s were established in 1997, the government determined that the service provider agencies would compete for contracts to provide home care services through a competitive bidding, or procurement, process. It was felt that the competitive process would lead to the selection of agencies which provided the best value for money. George Smitherman, Ontario’s Minister of Health from 2003 to 2008 says “the theory behind procurement is that the competitive tension can be a pathway to both improve quality and control costs.”
The competitive bidding process, however, has been modified over time. In 2003, motivated by concerns about the quality of home care services, the government froze procurement processes. Procurement was restarted in 2005 following a two-year review with longer terms for providers, and a greater focus on measuring quality of care. However, in 2008 the procurement process was frozen again, after a controversy broke out in Hamilton, Ontario when two large non-profit agencies were disqualified from the competitive bidding process. The procurement process remains frozen today.
The Auditor General’s report
In 2010, the Auditor General of Ontario conducted a review to assess whether CCACs were meeting home care needs in an equitable, consistent and high quality way across the province.
The major findings of this review were that:
- Funding to CCACs was based on the financial support they received historically, rather than on the needs of patients in their regions. This had led to substantial variation in the amount of services provided by CCACs across the province.
- There were major differences in how much providers were paid, with CCACs indicating that they could not obtain the best cost and service value because of the procurement freeze.
- There was a great deal of variation among CCACs on patient guidelines for services, as well as around how the quality of services and providers was measured.
What has been the response to the Auditor General’s report?
The Auditor General’s report made five recommendations, which included making services delivered across Ontario more consistent, obtaining cost savings from procurement and improving the measurement of quality and performance of CCAC services and providers.
Nevertheless, the procurement freeze put in place in 2008 remains today.
CCACs have been working to improve their ability to measure the quality of home care. Developing quality measures and standardizing data collection is a complex, time consuming undertaking. Margaret Mottershead, CEO of the Ontario Association of CCAC’s says that her organization has been working with Health Quality Ontario on “…testing ways to improve the approach to procuring services.” In addition, Mottershead indicated that “there has been a lot of progress made in the measurement and reporting of quality, beginning before the release of the Auditor’s Report and since, including working with Health Quality Ontario in development of performance indicators and with the LHINs on a common set of indicators based on our service accountability agreements.”
The future of home care in Ontario
We have heard from a number of health care professionals that the quality and continuity of home care in Ontario is insufficient to meet the needs of some of their patients. They attribute this to the increasing number of patients with complex needs, the lack of an organized care delivery model that allows for routine measurement and reporting on quality, and their perception that increases in funding have not kept pace with the number and complexity of patients being served.
The Minister of Health and Long-Term Care, Deb Matthews, announced Ontario’s Action Plan for Health Care last month, which includes a commitment to provide seniors with “better quality care at home.” Matthews also argues that Ontario’s health care system requires increased efficiency, and a “shift of spending to where we get the highest value.”
The importance of care in the community has been echoed in the Commission on Reform in Ontario’s Public Services, led by Don Drummond, and released on February 15, 2012. While this report suggests reducing funding to many sectors of the health system, it recommends that Ontario “increase the focus on home care, supported by required resources, particularly at the community level”. The Auditor General’s Report and recommendations provides insights about how to improve the value and quality in home care services.