There are hidden costs of moving care out of hospitals
Connie is a Personal Support Worker (PSW) who cares for seniors and people with dementia in their homes. She is a graduate of George Brown College’s PSW program and has been working in home care for the last 10 years.
She makes $16 per hour, but rarely gets paid for more than four hours a day, because most of her time is spent traveling on subways and buses between clients’ homes, which are spread across the sprawl of North Toronto. She is paid only $1.50 for travel, even though getting between clients’ homes often takes an hour on the TTC. She does not make enough money as a PSW to make ends meet for her family, and so cleans homes when she is not providing home care.
Despite struggling to make ends meet, Connie loves providing home care, and speaks passionately about how she helps her clients live independently. She can’t help but wonder, however, why she has to struggle when her former classmates from George Brown with the same training enjoy higher wages and steady hours working in hospitals and nursing homes.
Moving care out of hospitals
Ontario has joined an international trend in shifting health care out of hospitals and into communities, including a planned expansion of home care. Not all patients who occupy hospital beds need acute care and not all patients in long-term care facilities need to be institutionalized. For some of these patients, care can be provided effectively and efficiently in the home.
Moving care into the home is popular with the public. Studies consistently indicate that patients prefer to be cared for at home when it is safe to do so. There is also evidence that unnecessary hospital stays are bad for patients’ health. Providing care in the home also raises hopes of substantial cost savings for the government, while simultaneously freeing up hospital resources to focus on patients with acute needs.
If done well, moving care out of hospitals could improve patient care, while reducing health care spending. However, there are hidden costs, both financial and human, of moving care into the home that have received little public attention, including lower wages, riskier work environments and greater burdens on family caregivers.
Lower wages in the home care sector
A major source of expected savings from a shift to home care is lower wages – wages in the home care sector are substantially lower than in the hospital or long-term care sector.
Personal support workers in the home care sector can be paid as little as $12.50/hour compared to hourly rates of $18 to $23 for their hospital-based colleagues. Similar disparities have also been observed for other care workers, including registered nurses.
In addition, home care workers often do not get steady hours, compared with their colleagues in hospitals and long-term care.
The primary driver of lower wages in the community is that there is significantly less unionization compared to the hospital sector. According to Stella Yeadon, a representative for the Canadian Union of Public Employees, this is largely because union organizing is very challenging in the home care sector. Unlike the hospital environment where workers are in a single building, home care workers rarely meet one another. As a result, traditional labour organizing methods have tended to fail in this sector.
According to a report from the Ontario Health Coalition, another historical contributor to lower wages was the Ontario government’s procurement policy for Community Care Access Centres (CCAC), which required CCACs to contract out home care services. While competitive bidding for contracts was somewhat successful in keeping costs down for CCACs, it did so largely by “driving down wages,” according to the authors of the report. This procurement policy has been frozen for the last several years, but served to set a historically low baseline for wages in the community care sector.
Healthy Debate contacted a large Ontario provider of home care services regarding the wage disparity between home and hospital care, but the company was unable to provide comment by press time.
Ross Sutherland, co-chair of the Ontario Health Coalition and a registered nurse who has worked in both acute care and home care, worries that turnover as workers leave home care for higher paying jobs at hospitals is bad for patients. “In the community, you need a trusting relationship between a caregiver and a patient,” he says, “but trusting relationships need stability, and one of the things we’ve seen is that when wages are low you get a much less stable workforce. This means patients at home don’t always get the continuity they need.”
Low wages and limited benefits across an entire sector raise concerns about the possibility of recruiting skilled care workers. “People with the higher education will go where they can get the higher pay,” says Sutherland, “this makes a lot of sense to me… I’ve done this myself, actually.” These concerns are offset somewhat by work hours in home care, which tend to be flexible and therefore attractive to some workers. However, since travel time can be extensive and is often uncompensated, low wages could pose real barriers to recruiting and retaining staff.
Worker safety unknown
Another area of concern is worker safety in the home care sector.
Health care workers face substantial health risks as part of their work, due to their exposure to infectious diseases, violence from patients/residents with dementia, allergic reactions from chemical agents, and injuries resulting from lifting patients.
“The home care sector is relatively new, it’s grown quickly, and it’s relatively invisible,” says Cam Mustard, president of the Institute for Work and Health. As a result, there is not currently good Ontario data to determine how safe home care is for health care workers, as compared to delivering care in hospitals or long-term care facilities. “This is a dimension of the expansion of homecare that we’re late in realizing the importance of,” he says.
There is currently limited data on the occupational health risks of delivering care in the home. However, some care may be riskier in the home, where workers are more likely to be without either backup from other staff or mechanical assistance (such as patient lifts), as compared to workers in a hospital or a long-term care facility.
As home care expands, better data on worker safety in the home will be needed to keep the workforce healthy and safe.
Greater burden on families
Another source of cost savings for the government of moving care into the home comes from having to provide less nursing care, and not having to provide housekeeping, laundry or kitchen services in the home. Where hospitals employ large staffs to provide these services, in the home care sector many of these services are provided by patients’ families.
Kim Peterson, vice president of clinical services for the Champlain CCAC, is concerned that there is already too little support for caregivers. Any expansion of home care, she says, “must be accompanied by a major expansion of caregiver supports, including financial support.”
Despite its importance, support for family caregivers was notably absent from both Ontario’s Action Plan for Healthcare and the year-one update released last month. Support for caregivers is part of Ontario’s new Seniors Strategy, but it remains to be seen how much of this strategy will translate into action.
It is also important to recognize that many patients who need home care do not have families to care for them. Charmaine, another home care PSW interviewed by Healthy Debate, says “for most of my clients, I’m all they have. I’m their best friend. But right now the CCAC only pays for me to be with them one, maybe two hours a day. It’s not enough – they’re alone – there’s no one to care for them but me and they need more help.”
Expanding home care while maintaining quality
While many patients prefer to be cared for at home, they also want the quality to be just as good as it is in other settings. At the moment, it is not clear that this is the case, and lower wages and riskier environments raise the possibility that the quality of care may be negatively affected as services are moved from hospital to community settings.
And while patients prefer to be cared for at home, this may not be sustainable for their families without more supports for caregivers.
While moving more care into the home may be the right direction for Ontario, the hidden costs of this transition will need to be addressed. Maintaining both a skilled workforce and healthy unpaid caregivers may require additional spending, which might reduce the the anticipated cost savings of moving care into the home. The alternative, however, could be a home care system that fails to deliver the quality patients expect.