Home Care: The Unfinished Policy

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Home Care The Unfinished Policy

• Dr. Judith Shamian
• President and CEO
• VON Canada

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Home Care in Canada

• Array of services, provided in the home and
  community setting, that encompass health
  promotion and teaching, curative intervention,
  end-of-life care, rehabilitation, support and
  maintenance, social adaptation and integration
  and support for the informal (family) caregiver
• Home care has been left out of the National
  policy umbrella (not part of CHA).This leads to
  grave consequences.

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Current Reality

• Home and Community Care definition is very
  restrictive
• Investment and funding is restrictive
• Workers in sector are underpaid in most provinces
• The industry is under serviced by the technology
  which is available

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Everyone has a role to play

• As community nurses what role do you play in
  ensuring Home and Community care is on the policy
  agenda??
• Strength in partnerships
• Beyond medical care

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Community vs. Care

• Agenda needs to shift
• More being demanded from the system
• Flexibility required

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Determinants of Health

• To keep Canadians healthy, must go to more than
  traditional health care
• Income and Social Status
• Child Development
• Physical Environment (i.e. Housing, air quality,
  food)
• Social Support
• Education and Literacy
• Work conditions
• Personal Choices

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History of Home Care Policy

• Canada Health Act came into force April 17, 1984
• Allows Parliament to impose conditions on
  provinces by withholding transfer payments when
  in violation of the act
• 5 Key Principles
• Comprehensiveness
• Universality
• Portability
• Accessibility
• Public Administration

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Comprehensiveness and Portability

• There is not one single monolithic health care
  system in Canada
• 13 provincial/territorial systems, plus federal
  military and First Nations
• Not all services fully funded
• Romanow reported Canadians pay out of pocket for
  30 of Health Care costs (Home care 50/50)
• Home care in particular is provided at varying
  levels of comprehensiveness in different systems

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Accessibility

• Appropriate timely access to care is a major
  challenge for Governments
• Many health services provided in the home not
  deemed Medically Necessary
• Home and community care is key to improving
  access to care

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Funding

• Recently concerns about sustainability of
  Canadas Health Care system have forced decision
  makers to examine alternative methods of delivery
• Home care is, after years of being marginalized,
  considered a lower cost way of delivering care
• 140 increase in use of Home Care between
  1995-2001
• Not being appropriately funded, or integrated
• Not protected under CHA

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Dis-integration of Care

• Access to services and supports is unevenly
  distributed across the country and even within
  province/territory
• Service frequently operates in silos,
  disconnected
• Gaps in care, difficult to navigate, inconsistent
  quality, availability
• Client-centred Care

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Home Health Care Home Support Services The
Paradox

• People with Chronic care requirements have
  medically necessary care needs (not covered by
  CHA)
• Often these needs are supportive care (bathing,
  cleaning, meal prep.) not medical care
• The World View/GestaltHealth care
  (funding)illness care (funding)

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Cost Effectiveness of Home Care

• Over time chronic home care is significantly less
  costly than care in a long term facility
• Real results from long-term study in British
  Columbia average annual costs to government per
  person
• Moderate Care needs
• 9,634/year in the home, 25,742/year in
  institutions
• Highest level, Chronic level of Care
• 34,859/year in the home, 44,233/year in
  institutions
• British Columbia has realized actual savings by
  holding down future construction of long term
  care facilities and making investments in Home
  Care
• Hollander, M.J. (2003)

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Home Care The Unfinished Policies

• Romanow Commission and Kirby Committee did not
  address ongoing (chronic) care needs when
  considering home care.
• Short term, particularly acute care replacement
  is recognized
• Often services outside professional services are
  not covered
• This is increasingly shifting home support onto
  family members, and voluntary organizations

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1. Who is providing Home Care

• Professional Practitioners
• Volunteer Services
• Informal Support
• Caregivers
• Family, Friends, Neighbours
• Community Social Support Services

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1.1 Caregivers

• 2.85 million caregivers in Canada
• 77 of caregivers are women
• 70 are 45 and older, and 25 are 65 and older
• Each caregiver (between 45-64 years) providing
  help to an average of 1.3 seniors
• 60 have been caring for over 3 years and 20
  report caring for more than 10 years
• 700 000 caregivers report provide more than 10
  hours of care a week

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1.1 Caregivers

• Caregivers provide care which, if paid, would
  cost the Canadian Health Care system over 5
  Billion.

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2. Hospital Downsizing and Shorter Length of Stay

• Patients going home sicker and quicker
• Home care expenditures grew by 11 from 1990-1998
  (Health Canada)
• Number of Canadians receiving publicly funded
  home care grew by 60 from 1995-2003 (Health
  Council of Canada 2002)
• Need outpacing development and expansion of Home
  care programs
• Families and volunteer caregivers picking up the
  slack

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3. Changing Demographics

• Aging population
• Seniors to account for 27 of the pop. by 2056
  (Stats Can, 2006)
• 9.9M Baby boomers are now between 40 and 60
  (Foot, 2004)
• That generation will require decades of chronic
  care and disease management
• Innovative ways to deal with challenges

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3. Baby Boomer Generation

• Baby boomers will change the way the health care
  system functions
• Greater Chronic Disease rates
• Less likely to choose institutional care
• Self-managed care

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4. Health Human Resources

• Crisis Situation
• Nursing Shortage
• Aging population means greater demand, as nurses
  retire, less supply
• Even if RNs worked to age 65, Canada will lose
  13 of its RN workforce by the end of 2006.
  (OBrien-Pallas et. al., 2003)
• Canada needs to graduate 18,000 RNs annually but
  barely graduates 8,000 now (Ryten, 2002)

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The Policy Agenda To Finish the Unfinished Policy

• First Ministers identified Home Care as a
  priority area in plan to reduce wait times and
  improve access to care
• In reality took a limited and restrictive approach

Did not recognize the importance of home care in
caring for those with long-term care needs and
for the frail and elderly, who need help to
remain in their homes
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Broadening and standardizing the basket
(Principles of CHA)

• 3 Categories of Home Care that provide 3
  different functions
• Prevention and maintenance care for people with
  low level care needs who would otherwise
  deteriorate
• Acute care substitution for hospital care
• Long term/chronic care substitution
• First Ministers Accord addressed only limited
  acute home and community care, including end of
  life

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Gaps to Fill

• Creativity and innovation required to fill the
  gaps in policy
• Integration of Home Care into Health Care System
• Inclusion in the Canada Health Act
• Greater integration of Health Care System and
  Social Support system
• Addressing social determinants of health, not
  just health problems
• Volunteer and Caregiver support formalized

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Invest in Innovation in Care

• New technology allow for more treatments to be
  carried out at home
• Making the home environment safer
• Remote treatment opportunities for rural, First
  Nations, Northern gaps in provision

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QUESTIONS

• Should home and community care services be looked
  at as a substitute for wider public health
  services, or as a compliment to the public health
  system?
• What should governments be doing to improve the
  quality, availability and coordination of home
  and community care services?
• What types of funding arrangements are necessary
  given that services are often provided on a local
  or regional basis by a range of private or
  not-for-profit organizations?
• What role should home and community care play
  within our public health system in the future,
  and what barriers prevent us from moving the
  national agenda forward?

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Recommendations from the Future of Homecare in
Canada Roundtable

• 1. The home and community care sector must work
  collectively to develop a medium- to long-term
  Home and Community Care strategic plan that can
  guide expansion within the sector and coordinate
  that expansion with innovations in other sectors
  of the health system.

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Recommendations from the Future of Homecare in
Canada Roundtable

• 2. The home and community care sector,
  facilitated by the Canadian Home Care Association
  (CHCA), should develop a public awareness and
  government relations campaign to highlight the
  important contribution the sector makes to health
  care today and the even greater contribution it
  can make in the future.

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Recommendations from the Future of Homecare in
Canada Roundtable

• 3. The Canadian Home Care Association should
  coordinate the public and governmental awareness
  campaign and harness the power of the collective
  by building the Home and Community Care
  Coalition.

• 4. The home and community care sector should
  focus on improving homecare data by establishing
  a comprehensive homecare research agenda, with
  increased targeted funding through the Canadian
  Institutes of Health Research (CIHR).

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Recommendations from the Future of Homecare in
Canada Roundtable

• 5. In regards to health human resources within
  the home and community care sector, training,
  accreditation, and compensation schemes need to
  be expanded and improved. Measures are also
  needed in the short-term to counter increasingly
  dire labour shortages.

• 6. The Canadian Home Care Association should
  convene a National Best Practices in Homecare
  event that will conclusively identify successful
  and transferable systems and procedures, and that
  will inform government decisions regarding
  investment in homecare.

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Home Care The Vision

• In future, home and community care will
  constitute a valued and essential element in the
  continuum of health and social services provided
  to Canadians. Home and community care will
  provide patient-centred services to assist
  citizens in remaining independent and functional
  in their home and community. More than simply a
  cost-effective alternative to hospital-based
  care, home and community care will provide
  personalized services to patients and supports
  for caregivers that are evidence-informed an
  community-based and seamlessly integrated into
  broader array of health and social services.
• The Future of Homecare in Canada, Roundtable
  Outcomes and Recommendations for the Future

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• Home care is an essential component of the health
  care system. What Canadians need is a
  comprehensive home care to keep them safely in
  their homes/communities (or in an appropriate
  non-institutional supportive living arrangement)
  with quality of life

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• Judith.shamian_at_von.ca