National home care standards urged

Home care has become one of the fastest-growing areas in Canadian health care over the past decade, though, as is often the case in Canada’s fractured health care landscape, some provinces are performing better than others.

It is difficult, however, to compare the state of home care in different jurisdictions because the very notion of home care differs from province to province. This is why, according to Marg McAlister, a project manager for the Canadian Home Care Association, Canada needs a set of national standards for home care.

“It is hard to compare province to province because each defines the roles of various professions in home care differently,” says McAlister.

The most comprehensive look at home care across Canada can be found in the Canadian Home Care Association’s Portraits of Home Care in Canada 2008 (www.cdnhomecare.ca/media.php?mid=1877), an update of a 2003 report that gave home care leaders the opportunity to “have their voices heard through their descriptions of home care as it is known and understood within each of their respective jurisdictions.” Though the document warns that “valid comparisons cannot be made because of the absence of data definitions and the variation of data collection and reporting across Canada,” it does offer “snapshots” of home care programs, which highlight such features as governance, organization, services, quality and accountability (Table 1).

There is a significant nation-wide variation in the maximum number of hours per week of home care services that people are entitled to access.

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With respect to governance, there is little variation across the country, with 12 of 13 provinces and territories operating home care services under the jurisdiction of their ministries of health. The lone exception is New Brunswick, where home care is run by the New Brunswick Department of Health and Wellness and the New Brunswick Department of Social Development.

Legislation for home care, on the other hand, varies widely — tucked into various acts, orders-in-council, guidelines and policies. “This lack of a specific legislative framework for home care contributes to the wide variation in access and availability of services across Canada,” the report states.

In terms of services, almost all jurisdictions offer core services such as case management and home care nursing. There are many other services, however, and some are offered in certain places but not others. For instance, speech language therapy is available in Alberta and Ontario, but is not available in Saskatchewan or Manitoba. Social work is part of home care in British Columbia and Alberta. It is not part of home care in Nova Scotia and Saskatchewan.

“Services such as nursing and personal support in the home, they would be offered in every province across every province,” says Margaret MacAdam, president of Age Advantage, a Toronto, Ontario-based company that offers gerontological consultation and strategic planning. “Beyond that, they offer a range of home care services.”

Again, it is difficult to do a detailed provincial comparison because jurisdictions have different names and definitions for the services they offer. In some places, for example, bathing and grooming assistance may fall under home support services, whereas in other places it may fall under adult day services. What is clear, though, is that Canadians have access to a wide selection of services, though that access is far from equal.

“Home care polices, services and their delivery vary greatly across the country, as each home care program evolved in response to the needs of their community and existing resources,” the report states. “An example of this variation is in the availability of supportive services for individuals with long-term chronic conditions which may include home support, homemaking and options for assisted living facilities.”

There is also a variation across Canada in fee structure. According to the 2008 report, four provinces do not charge direct fees for home care services: Ontario, Manitoba, Quebec and Prince Edward Island. (Canada’s three territories don’t charge fees, either.) The fees in the remaining six provinces are based on people’s incomes, and generally apply to long-term supports and residential care. In British Columbia, the maximum amount of fees that can be charged is $300 per month, the same as in Alberta. In Saskatchewan, the ceiling is higher, at $421 per month.

Another variable between jurisdictions is the maximum number of hours per week that, under normal circumstances, people are entitled to access home care services. In Quebec, for instance, the average upper limit is 35–40 hours per week, whereas in Prince Edward Island, the weekly maximum is 28 hours. British Columbia has a working guideline of 30 hours per week, and in Ontario, people can receive up to 80 hours in their first month of home care, that limit dropping to 60 hours for each additional month. (All figures from Health Canada: www.hc-sc.gc.ca/hcs-sss/pubs/home-domicile/1999-pt-synthes/section_4-eng.php).

The Canadian Home Care Association’s report also contains a metric called “hospitalization rates for ambulatory care sensitive conditions,” which they define as hospitalization rates for conditions that could be provided in the community, and which serve as an indicator of appropriate access to community-based care. This national average of this rate in 2005–2006 was 389 admissions per 100 000 people. British Columbia had the lowest rate (320) and Nunavut had the highest (1104).

When it comes to funding, most jurisdictions spend somewhere in the neighbourhood of $120 per capita, though some exceed that amount (Newfoundland and Labrador: $190; New Brunswick: $177.13) and some fall below (Saskatchewan: $110; Northwest Territories: $97.37). In terms of percentage of health funding dedicated to home care, Alberta (7.36%) and Manitoba (6.7%) are among the leaders, while Prince Edward Island (2.28%) and the NWT (1.49%) are among those pulling up the rear.