There are hidden costs of moving care out of hospitals

Connie’s story

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.

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  1. ServO

    %featured%Seems to me the provinces did the same thing in the mental health sector in the 80′s and we now see little to no access to publicly funded non-acute mental health services in our communities.%featured% The burden of illness is then placed at the feet of family docs, caregivers, families, communities and police, rather than health care provides with expertise (such as social workers, counselors, psychologists, psychiatrists).
    As Canadians we need to understand that if you need healthcare from someone besides an MD or nurse you generally need to pay for it yourself. We do not have a healthcare system that provides universal access to healthcare services, rather it is a physician compensation mechanism and if you have a problem that is better managed by a different health profession, get out your wallet.

  2. Craig Roxborough

    This is an important discussion to be having as we move forward. The increasing age of our population is certainly going to put pressure on our health care system and increasing access to and improving home care are likely to be central to managing this increase in demand. Especially given that many long-term care homes are already often at capacity with long wait lists (this is at least the case, in my experience, in Toronto). Hopefully by shifting priorities to home care and removing some of the costs associated with unnecessary hospitalization or institutionalization we can re-allocate some of these saved resources/money to improve the quality of care for patients and the working environment for those providing home care.

  3. Dorothy Pringle

    This well done article identifies several of the significant issues confronting the home care sector. Here are a couple of others. The home care sector as a desirable work environment for nursing (including personal support workers) and rehabilitation providers has diminished considerably over the last 20-25 years. The significant difference in wages is a major driver but the competitive bidding approach of CCACs has required provider agencies to cut costs wherever they can in order to win contracts. This means the care providers rarely, if ever, go to the office to meet with colleagues or supervisors to discuss challenging patients. Home care workers do not benefit from any sense of colleagueship; theirs is a solitary professional life. The concept of team is a myth. Much of the autonomy previously associated with being a nurse or rehab professional is now assumed by the CCAC case managers who decide to a large extent what they do, how frequently they do it and when the patient is discharged. There is some opportunity to negotiate changes to these directives but it is limited. Students in these professions rarely have an opportunity to experience work in this sector because they slow down the workers and drive up costs. These are short-sighted consequences of our current cost constrained system and have a serious impact if we are to have the stimulating and rewarding work environment necessary to attract health care workers to provide for the needs of the more complex patients envisioned for the future.

  4. Ontario Association of Community Care Access Centres

    Thank you for raising a very important issue – improving the working conditions for community-based health care workers and providing more support for informal caregivers needs to be a priority for all of us. We absolutely require proactive capacity planning and resourcing for both as we move care closer to home. To clarify, however, in the home and communty sector, there hasn’t been any real competitive bidding since 2004, except for medical supplies and equipment. We have moved to a quality and value approach to home care where CCACs and care providers form teams of support for patients – a circle of care – sharing information effectively and using proven methods of care. CCACs are committed to continuous quality improvement. We do a provincial survey every year, and this year, on average, 90 per cent of CCAC patients reported they were satisfied overall with the care they received. To read more, here is a link to the most recent CCAC Quality Report:

  5. Salimah Valiani

    Congratulations to the authors and to Healthy Debate for committing space to the crucial issue of hidden costs of elder care at home. The Ontario Nurses’ Association has raised many of the same issues – as well as concrete solutions – in two research papers. We invite the authors and readers of Healthy Debate to engage further on the issues and ONA’s proposed recommendations by accessing the papers at the following links:

    Among the recommendations proposed are a minimum of 3.5 hours per day of funded and regulated care for elders and others in need at home, including registered nurse care and personal support.

  6. Canadian Home Care Association

    Why, when faced with something new or a possible change, do we always focus on the negatives?

    Home care is, and should be, the focus of our future health care system. We are not moving care out of hospitals – we are proving care in the right place at the right time by the right person.

    Yes, we face challenges in the home care sector, but they can, and are being addressed – what we need to do is work together, share best practices, learn from other jurisdications and embrace change.

    Solving health human resource issues needs a system wide approach – recruitment, wages, education, career paths and safety are all part of the package. It is not as simple as pointing fingers at service provider organizations. There are excellent programs across the country that support home support workers and family caregivers. Let’s learn from them.

    Ontario is on the right path. It may not be smooth, but they are commited to making it right. Let’s all help by providing solutions and sharing new ideas instead of dwelling on problems.

    • SK

      Wouldn’t that be great? To share ideas and provide solutions is theoretically an excellent idea. However, the reality here in the home is that the civil servants working for CCAC and the second level tier employees of the providers are not anxious to hear from the caregivers or the patients. Apparently, as long as it saves money, it is not even necessary to enforce the care plan and ensure that providers actually provide the service. Example – no psw’s available to assist in the home 25% of the time demanded on the care plan for over a year now and no one seems to be able to solve this problem. This causes a senior caregiver to provide daily care for her quadriplegic husband. Any ideas or solution would provide relief!!

  7. Irene Jansen

    Thank you to the authors and healthydebate for giving us a broader perspective on the facility to home shift. The hidden costs to clients, families and workers are often overlooked. This is a refreshing debate.

    The Canadian Union of Public Employees (CUPE) has documented the growing access and quality problems in continuing care (residential long-term care and home care), largely due to inadequate public funding and regulation, commercial involvement and its exclusion from medicare. And we propose concrete solutions.

    Instead of pitting “home” against “institution” – and using this to justify privatization, policy-makers should improve both, and remove exploitation (of patients/clients/residents and caregivers, paid and unpaid) from the choice of setting.

    %featured%Canadians should have access to medically necessary services free of charge at the point of use, whether the setting is a hospital, LTC facility, home or community agency. %featured%Care should be safe and of high quality. To achieve this, both provincial and federal governments need to take action. For its part, the federal government should, as part of a new health accord, establish a national continuing care program with funding tied to Canada Health Act standards, plus minimum staffing and phasing out of for-profit delivery.

    For more on this and other public solutions for health care, see:

    This healthydebate article – and the policy shift it addresses – stirs up reactions because there is a lot at stake. Private for-profit providers are growing, and corporations in this sector (long-term care and home care) are merging, increasing their clout in policy development. More public money is being shifted from client care to corporate profits, and non-profit providers are displaced. Working conditions and quality of care suffer; the two are interwoven, as this article shows. For more on the impacts of privatization on quality of care, including a large body of empirical evidence, see:

    • Lucas Lu

      Hi Irene,

      I find your comment very fascinating. Where you wrote “quality problems in continuing care (residential long-term care and home care), largely due to … commercial involvement and its exclusion from medicare”, can you explain a little bit about what are the “quality problems” and “commercial involvement”?


  8. Alan Boucher

    %featured%Is this article not turf protection?%featured%

    Because of demographic and economic realities healthcare cost will be pushed into the community. When people pay privately market forces will exert and prices for care and therefore wages will be bid to an equilibrium. Of course people are paid more in the public sector where labour economics are distorted. But why should private persons pay the same premium wages as the government to meet what already is a financially appalling need?

    Moreover home care is relatively safer as there is normally only one patient in a stable condition with family to assist, known routine and a more casual pace as opposed to say a hospital work setting.

  9. pat armstrong

    The article raises critical issues that need to be addressed and does so effectively. What is missing though, is a discussion of the cost to women of the move to home care.
    Unpaid health care is a gender issue, an equity issue and a human rights issue. It is a gender issue because women and girls throughout the world do the overwhelming majority of unpaid health care. It’s an equity issue not only because women do much more of this labour and more of the labour that is most demanding and daily. It is also an equity issue because women with the fewest economic resources are the most likely to do the heaviest work and because those who need care experience inequities in the amount and quality of care they receive as a result. For example, in 2006, half a million women compared to a quarter million men, spent 10 or more hours a week providing unpaid care or assistance to seniors, with half those women putting in 20 or more hours. If we are to recognize, as the Universal Declaration of Human Rights (1948) does, that everyone has the right to health, then unpaid health care is a human rights issue because those who provide unpaid care too often suffer disproportionately from ill health as a consequence of this work and are thus denied the highest attainable physical and mental health. This includes the many children, and especially girls, who also do such work. The right to health requires the right to provide or not provide unpaid health care, and thus access to the conditions that support this right.see p

    • Jeremy Petch

      Thanks, Pat. You are of course absolutely right. Thanks for bringing this to the discussion.

  10. Dale

    PSW’s are very much under paid for what is required of them, and yes they do clean people’s homes and do the dishes as well as shop for there clients. If they don’t, a lot of times there is no one else who will.

    With Senoirs soon to account for over 25% of our population PSW’s are becoming the new backbone of our future Healthcare!

  11. kvellow

    I am a psw whom works in a long term care home full time

    We are understaffed

    The government needs to wake up and PUT RATIO seniors per caregiver

    and Strick guidelines to the Nursing Homes for how their funding is spent

    4 staff should be for 32 clients for a complete shift in a long term care setting at all times for the safety of seniors and patients

    I agree HOME care rates should be increased Agencies make way too much money and CAREGIVERS make the agency a good place.

    Then our seniors would have the absolute care and caregivers would have the time to listen and they would not be as lonely,,,, Our seniors

  12. Sharon Wilton, Project Share

    When there is a mindset that views ” livelihood” as linked to dependence , knowingly or unknowingly, the dependence is fostered. This makes the vulnerable person very important ….as long as they remain vulnerable.

    Q- How do you turn living independently …back into independence?


    Concurrently apply the following

    – a step down process inside the institution itself that orientates community workers, and clients to emerging options that they move toward “ together”

    – a restructuring of the financial dependence for the private owner of the buildings and chattels.

    – the funding of the “person” must be separated from the cost of operations.

    – the same access to community service options that the ” person” would receive in a private home setting must be made available to them while still in the institution ..AND. . follow them to residence of choice

    – the staff complement providing direct service inside the facility in the capacity of PSW are not required to perform other duties than direct ” personal service” and costed as such with ultimate direct payment by the “ now funded client “ ( not provider ) which gives client autonomy through authority

    An example in a rural setting:

    – A regulated setting with a fixed ” per diem” rate where clients served may be lodged permanently or per diem in short term stays
    – Maintenance contracts outsourced to qualified, trained personnel ( e.g. use local hospital for housekeeping, laundry, maintenance service in a fixed pattern
    – Inhouse staff focus on quality of life using Community Outreach worker linking community programs where both sides access services and provide social programs
    – Direct service link with worker and client in a pattern that permits:
    1. consistent case management link between worker and client using the same PSW staff to follow client ( in whatever setting) under both direct and indirect funding options
    2. advocacy link for client moves with domiciling selection of client ( shared or independent) e.g. chaplin service
    3. inspection and quality standards from public health

    You might ask “what would the result be?”

    In the first instance a large part of this model was applied and was amazingly successful. The classify & sort issues related to staff/ client mix; adherence to safety standards and protocol; job and work routines; outsourcing and insourcing; quality standards ; etc were all followed.

    The result:
    Reduced costs to all; great interest from Health Council; political attention; job satisfaction and higher earning opps for frontline worker; community animation for inhouse services ( diners club, spa day, community connections)

    Private sector providers assumed some components of the model and applied it to “hotel type” accommodations with quadrupled rates.
    Public sector payor unable to get past internal lobbyists at highest levels seeking to preserve “coordination control”

    Possible future:
    The approach to the client in terms of service design and application must first start with the existing structure phased out. This phasing is also important to the “person” seeking to live independently and must be done in a way that accommodates both “relocation trauma” and “environmental fantasy”. Entropy issues cannot be ignored. Many changes can be made structurally that will not be seen directly by the enduser but will undergird change.
    The leaders for change have to be presently operating outside of private sector dominance and this can only occur in their new role as “ program funder” ( versus direct service provider).
    This means the private sector leader ( who is already partnered with the public $ ) must concentrate on it’s easiest/ highest source of revenue ( coordination versus provision) and entrepreneural activity in a direct connect between frontline and client must be structured simultaneously. In this way the options for the client are more varied and more accessible ( versus more limited) .

    In researching this it was interesting to note that attempts in the USA for dividing home service and institutional service revealed a high client preference for institutional. The only difference between Canada and the US in service design appeared to be the “client payment responsibility for case management “ in the U.S. private home setting was prohibitive.( and easily manipulated). Some “community care concepts” in the US linked to “building” were also landlocked with fixed domiciling options that prohibited accommodating the structural change need in “care services”. This plagues the Canadian situation as “domiciling settings accommodate care categories” versus ” care categories accommodating the setting”
    Another great failure in community service options is the private entrepreneur seeking to provide mini institutional settings without any model of service provision or oversight linkages. As in the past these efforts can lead to significant abuse of vulnerable peoples ( often undiscovered).

    The unavoidable reality is the ” model” has to be more than ” the idea of the moment”. I no longer attend symposiums where only ideas are shared and many joke about plagiarizing each other ( which is no joke). There are many structures inside the blueprint that ensure the simplest results… and the hard work of understanding them cannot be avoided.

  13. Laura

    This article is a brief description of what I see in my situation with my grandmother, she is suffering delirium and the care she is getting from her family is far above anything we have ever had to think we would have to endure. She had a fractured hip in February and ever since has been suffering from delirium and other things. The Ontario Government through CCAC has cut hours of service for my grandmother to have in her home so that means I have no interaction with my own children. So, in essence 5 of us rotate through a strenuous day of coping which way her mind will switch. Then our government doesn’t have any financial support as I am unable to work as a strong value to system to see my grandmother through this. We had been put on a 24-hr care program seeing that at the beginning we had 4 hours a day for 60 days and now down to 2 hours a day when the family is starting to burn out. We try to manage the best way we can but this is getting ridiculous. Does anyone know of any services for volunteer to spare our family some time to breathe.
    This is not how I would’ve expected my grandmother to be for the last years of her life. It is not fair. This is not our home and native land. This is a poverty struck Canada.

    • Ann-Marie

      Not sure where you are but the VON has a drop in “Day Care” for clients with Alzheimer’s or Dementia. check to see if there is one in your community.

    • Lucas Lu

      Hi Laura, thanks for sharing your experience. Just curious, has your family considered using a private home care service?

  14. Cardinal

    I coordinate a community home support program in Ontario, and struggle daily with providing these services in a timely, respectful and accessible manner. The challenges are great; low paid, female, immigrant workers, with mutiple jobs, who must travel in the winter to client’s homes in inclement conditions with no guaranteed hours; low income, high risk clients, who are living in substandard housing, with concurrent diagnosis, and many health agencies and instituions involved with their care; the lenghty isolation that Ontario winters create; funding with no fixed administrative costs, only per diems; the many, time consuming administrative layers and hoops, that reduces resources and support to the client; and minimal resources for staff mentoring and support wtihin the community. In a country as wealthy as ours, can we not provide adequate care to the most vulnerable of those living in the community? The solutions are obvious; better funding formulas, including training and supervision dollars, service coordination; simplified administrative accountabilty. But most importantly a commitment and public policy to support meaningful and dignified community care.

  15. Abdulkhalek

    It is really inspiring issue in home care safety. However, formal home care services is relatively new and premature in my community, although with a quick expansion around the country. With this, the majoriy of health care organizations set up a home health care services for their clients as recommended by the health care system.
    Safety in home care is not yet assessed, but the area that I am working in , has a home health care with accredited services. This services is provided with the partnership with the home care welfare society. However, I think a safe home care should be a collaborative efforts among health and social institutions and community health services.

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