Home care in Ontario has been a controversial subject for decades. In 1995, the Mike Harris government implemented Community Care Access Centres or CCACs, and a managed competition model for service providers. This system changed the face of home care, but did it cause more harm than good?
In the 1980s and 1990s, political parties unanimously agreed that reform was needed, as there was no formal home care system and provincial government spending in health care was too high. Each party proposed a new home care model, and after their election the Harris government passed the Home Care and Community Services Act.
CCACs were introduced to better help individuals live independently at home and to provide information about care options through community support agencies. However, the introduction of a competitive procurement process was driven by an effort to cut costs.
The managed competition model allowed CCACs to contract out to several different service providers. Long-standing not-for-profit service providers began to be replaced by private, for-profit service providers. Between 1995 and 2001, the for-profit share in Ontario home care rose from 18 per cent to 46 per cent, while the not-for-profit shares dropped by 28 per cent. After a contract with a service provider expires, CCACs are able to hire a new set of service providers.
The competitive bidding process has led to disorganization and confusion in the home care system for employees and for patients (often referred to as "clients"). Health care personnel can work for multiple agencies hired by the CCAC, and patients have different "caregivers" coming into their homes on a daily basis. The process also puts downward pressure on salaries, benefits and working conditions of home care workers.
The Ministry of Health and Long Term Care put a moratorium on the competitive bidding process of CCACs in 2004 but the system still suffers from this structure. As the recent 2015 Ontario Health Coalition report highlights, funding is passed through four tiers of administration before reaching the front line of patient care.
The government provides an inadequate amount of funding for the growing demand, and this funding is imbalanced among centres and is not used effectively. Funding per capita varies greatly between the regional CCACs, since it is allocated on a historical basis, rather than a representative-basis. Some centres are only able to offer personal support care to "high risk" patients while others are able to provide services to many more individuals in need.
Health and personal support workers often prefer hospital jobs to home care positions. For patients, having multiple health care workers entering their homes is confusing. Patients in turn question the quality and continuity of the care they receive.
Home care is often required urgently, as the task of helping one to live independently is a huge burden on family caregivers. A 2010 report by Ontario's auditor general reported that 10,000 individuals were waiting for various home care services, ranging from eight to 262 days in 11 of the 14 CCAC regions. Individuals received their initial client assessments from between four days to 15 months after being deemed eligible to receive home care services.
The lack of continuity of care is astounding. In the CCAC model, a case manager first meets with the client and decides his or her eligibility for specific home care services for which the CCAC contracts out. Then, a member of each necessary service (nursing, occupational therapy, physiotherapy, social work, speech-language pathology, dietetics and personal care services) meets with the client and takes a patient history before the care can begin.
This process is cumbersome. Even within a specific service, such as nursing, a client may see a different nurse every visit, and is often required to repeat his or her medical history and "teach" the new worker. Many of the questions asked are not only repetitive but can be irrelevant. Standard of care is also a major concern. The 2010 report found that there were no standard service guidelines in place for all CCACs, and each centre created its own guidelines for the frequency and duration of services being provided.
Home care is an important part of the Ontario health care system. The provincial government should recognize that individuals prefer to be cared for in the comfort of their own home for quality of life reasons. But as long as cost effectiveness continues to be the main focus of the home care system, patient quality of care will be pushed aside.
Anita Anand, professor of law, University of Toronto; Sonia Anand, professor of medicine and epidemiology, McMaster University and Anjali Sergeant, research assistant. Contact: firstname.lastname@example.org.