Home Healthcare Services

Index

• What is home care?
• What kind of services are available?
• How is home care funded?
• Who is eligible for home care and how is it accessed?
• How does the assessment process work?
• How is publicly funded home care delivered?
• Who provides the care?
• How is safety and quality ensured in home care?
• Do home care services change from one province or territory to another?
• Are services and supports for family caregivers available?

Home or community care encompasses a broad spectrum of services that allow individuals with a wide range of health problems and disabilities to live in familiar surroundings, attend school, maintain gainful employment or participate in other valued activities. Home care can act as a substitute for short-term acute care delivered by hospitals and long-term care provided by facilities such as nursing homes.

The focus of home care services extends beyond the immediate medical problem to include management of one's condition and environment in order to prevent emergency room visits, hospital admissions or transfers to residential care facilities, all of which can be more costly to the health care system. Additional emphasis is also placed on illness prevention, again with a goal to reduce health costs in the long-term. In order to achieve the broader objectives of home care, services offered include social and educational components, and require more input and participation from the client and family.

In addition to allowing clients to remain where they feel most comfortable, surrounded by loved ones, home care also empowers clients and their families by enabling them to take charge of their own care. In contrast to other sectors of the health care system where individuals must conform to institutional policies and regulations, home care is responsive and sensitive to the needs and preferences of clients.

Although it sounds ideal, the home care sector faces a number of challenges. Home care is not governed by the Canada Health Act which helps ensure consistency and availability of hospital and physician services to all Canadians. As a result, the home care services that are funded by public dollars vary from province to province. In addition, some products and services normally available in the hospital sector, such as medications, medical equipment and supplies, and 24 hour care/supervision may not be fully covered in the community and must be paid for through private insurance plans or by the clients themselves.

Home care is revolutionary in both the way services are delivered and the services themselves. Services that traditionally could only be delivered in the hospital environment, such as dialysis and chemotherapy, can now be safely provided in the comfort of one's own home.

Home care services include the following:

• a needs assessment that considers not only the client but also the family
• case coordination and management from admission until discharge
• professional nursing services, including complex care and specialized services such as paediatrics
• homemaking and personal support services (e.g. assistance with bathing, grooming, food preparation and meal planning, bedside care and assistance)
• rehabilitation services including physiotherapy, occupational therapy, speech language pathology, dietitian services and social work
• oxygen and respiratory therapy
• Meals-on-Wheels
• respite services

There are three possible funding sources for home care services:

1. Publicly Funded Home Care

The majority of the publicly funded home care provided in Canada falls under the jurisdiction of the various Departments/Ministries of Health and/or Social/Community Services of the provincial and territorial governments. Federal transfer payments for health also include financial support for home care. The federal government does manage some home care programs directly for certain clients, such as services required by veterans (through Veterans Affairs Canada), and the First Nations (a joint initiative by Health Canada and the Department of Indian Affairs and Northern Development). Most of the overall policy guidelines and standards for home care, reporting requirements and monitoring activities are dictated by the provinces and territories, however, the responsibility for allocating government funds appropriately are delegated to local or regional health authorities. More recently the trend has been for province to distribute home care dollars using a formula based on population needs rather than past usage. The local or regional authorities are also responsible for determining a client's eligibility to receive service, as well as for the provision of service, either directly or through contracted agencies. Due to the many different jurisdictions governing home care, limits on the amount and types of government funded services varies from province to province. In some cases, co-payments may be required.

2. Coverage through Insurance

Often private insurance plans will fund all or part of an individual's care. For example, in the case of a vehicle accident, services may be covered through automobile insurance. Extended health benefits plans purchased privately or available through employee group plans may also provide coverage in cases of illness or accident. Insurance companies will place a limit on the amount they will pay for home health care services over a specified period of time. They may also maintain a list of preferred home health care providers from which to choose. In some cases, private insurers will choose to settle a claim with a lump sum payment. It will then be up to the claimant to decide on how the money will be spent. The latter option is more flexible as many companies will only allow claims for the more costly professionals such as nurses, rather than unregulated workers providing personal support and assistance which may be all that is required.

3. Privately Paid Home Health Care

Where government-funded programs and private insurance limits do not meet a client's needs, services may be purchased privately from home health care providers. The only limitation on the care received is the ability to pay for the services, as well as their availability in a geographic area.

In order to receive publicly funded home care in Canada, an individual must be able to:

• provide the appropriate proof of residence in a province (and/or Canada);
• undergo a needs assessment conducted by the appropriate provincially designated authority;
• prove the care required is in response to an unmet need (this part of the assessment may consider income and access to unpaid caregivers such as family and friends);
• provide an environment that is safe and suitable for service delivery; and
• provide consent for service either directly or through a legal representative.

In order to access government funded home health care services, the easiest starting point is to contact one's family doctor. Although their referral is generally not required, local physicians should be aware of the authority responsible for delivering and administering publicly funded home care. Alternatively, a search under Home Health Care or Nurses in the Yellow Pages should provide the name of the government appointed body to contact as well as a list of local home health care agencies that will also be able to provide advice and assistance.

The Northwest Territories, as well as the provinces of British Columbia, Alberta, Saskatchewan, Manitoba, and P.E.I., have established local or regional health authorities to undertake the delivery of home health care. A different structure exists in both Ontario and Quebec. In Ontario, 43 not-for-profit organizations called Community Care Access Centres (CCACs) were established with responsibility for home care. Similarly, Quebec provides and manages home care services through its 146 Local Community Services Centres (CLSCs).

The province of New Brunswick has created two programs to administer home care. The first program, the Extra-Mural Program (EMP) focuses more on health services and is administered by the Institutional Services Division of the Department of Health and ommunity Services. Care is provided through eight Regional Hospital Corporations. The second program, the Long Term Care Program, focuses on long-term residential care and home support services, falling under the jurisdiction of the Family and Community Social Services (FCSS) Division of the Department of Health and Community Services.

Administration of Nova Scotia's home care program is kept at the provincial level through four regional offices of the Department of Health. Finally, the Social Services Branch of the Department of Health and Social Services administers the Yukon's home care program.

Most of Canada's provinces and territories are moving toward the use of a standardized assessment tool, however, the specific tool used will vary among the different jurisdictions.

The assessment process generally consists of an intake or screening phase followed by an assessment using standard criteria, followed by the development of a care plan. In some areas, planning for discharge of short-term clients and regular needs reassessments for long-term clients are also included as part of the initial assessment process. In all cases the assessment emphasizes the needs of the client, with most provinces and territories factoring in the availability of informal support, although the weighting of this component differs. In some jurisdictions, income factors are also considered.

Required interventions are established following the assessment, creating the starting point for the development of a care plan. This planning process generally involves the client and the family so that personal needs and preferences can be incorporated into the plan.

All provinces and territories in Canada offer certain functions through a single point of entry. The most comprehensive set of functions includes admission to the home care program, referrals to programs andservices, as well as total case management. The least comprehensive set offers only admission and referrals.

All government funded Canadian home care programs have public employees or staff of publicly fundedcommunity agencies providing the single point of entry functions, however, the extent to which public employees are involved in the actual service delivery varies. Generally speaking, there are four different service delivery options:

1. Professional services (e.g. nursing and rehabilitation) and home/personal support services are contracted out. Ontario has almost completed the transition to this home care model, with only some therapy services still being delivered by internal staff.
2. Public employees deliver some professional services. Other professional services plus home/personal support services are contracted to external agencies. This is true for Nova Scotia and Manitoba.
3. Public employees deliver all professional services, with only home/personal support services being contracted out (e.g. New Brunswick, Newfoundland, British Columbia and Alberta).
4. Public employees deliver and administer all home care services (e.g. Saskatchewan, Quebec, P.E.I., Yukon and the Northwest Territories).

The agencies which are contracted to provide professional and home/personal support services are a mix of private and not-for-profit organizations. Ontario employs a managed competition system where all interested agencies are invited to bid through a formal Request for Proposal process. Successful bidders are selected based on the best quality for the best price, with most of the emphasis being placed on quality factors.

Professional nursing services are provided by registered nurses (RNs) and registered or licensed practical nurses (RPNs or LPNs). While the RPN/LPNs have a college education with a more limited scope, RNs may have a college or university background. In some cases, care may be provided by nurses with specialized skills and education in areas such as I.V. therapy, wound care and mother/baby care.

Rehabilitation services are also provided by licensed professionals such as physiotherapists, occupational therapists, speech language pathologists, dietitians and social workers. These services are sometimes offered through home care programs to assist those who are coping with both long-term and short-term disabilities including accident and illness-related injuries. As well as treating physical and emotional needs, clients are taught techniques to help them cope, especially in cases of long-term or permanent disability.

Today, most individuals have their personal care needs met by workers other than professional nurses. A variety of names for these unregulated employees are used including: Home Care Attendants, Home Care Aides, Health Care Aides, Home Support Workers, Personal Support Workers, Attendant Outreach Workers, auxiliaire familiale et sociale and Homemakers. Some workers are capable of providing both homemaking and personal care, while others have less training and are only able to provide the homemaking component. Depending on the jurisdiction, homemaking and personal care may or may not be provided by the same worker. Systematic training programs for these individuals vary from province to province and very few home care programs dictate contractual training requirements. The skills and training of staff within a home care setting are therefore not necessarily ensured.

Since home care services fall outside the Canada Health Act (except by its mention as an "extended health care service"), home care is not publicly insured in the same way as hospital and physician services and is therefore subject to less regulation. In response to concerns over the quality of home care services in Canada, the Canadian Council on Health Services Accreditation developed an accreditation process specific for the home care sector. Home health care providers can now voluntarily apply to the Council to undergo an external accreditation process that includes a complete review of health services and administrative processes. Agency accreditation therefore indicates a compliance with national standards focused on delivering high quality health services.

Since home care is being delivered outside of an acute or residential care setting, the safety of both the client and the worker is less ensured. Although there may be provincial or territorial guidelines governing safety in the home care sector, it is often up to the individual provider agencies to educate their staff and clients about how to handle risky situations and also to monitor and take action on any incidents. For example, the lack of uniformity with regard to the training and suitability of unregulated workers should be addressed by agencies delivering personal/home support services through hiring and selection criteria and internal education and training.

There are a number of similarities and differences that exist between the different provincial and territorial home care programs.

The similarities are:

• Home care programs are the responsibility of the Departments/Ministries of Health. (sometimes combined with the Departments/Ministries of Social/Community Services)
• Home care programs provide services that include nursing, personal care and homemaking services.
• Home care programs serve clients of all ages, with a broad spectrum of medical and social needs, with most clients requiring long-term care.
• Home care programs across Canada have similar requirements for eligibility.
• Home care programs provide integration and coordination of services.
• Home care programs provide case management through public employees.
• Home care programs provide professional nursing services at no cost to their clients, although there may be limitations in terms of the frequency or intensity of visits, or in terms of overall eligibility.
• Home care programs apply co-payments or income assessments for the provision of home support services.
• Home care programs have been experiencing increasing budgets.
• Home care programs are undergoing regionalization to allow them to be more responsive to local needs.
• Home care programs face similar challenges in terms of the training of unregulated workers, the division of tasks between regulated and unregulated workers and the recruitment of staff of all designations into the home care sector.
• Home care programs are subject to frequent changes due to increased levels of research and innovation in the sector.

The differences are:

• Home care programs are governed by different legislation, regulations, and policies from province to province. Even within a province, professional and unregulated services may be governed differently. In some instances there is no legislation specific to home care.
• Home care programs differ with respect to their calculation of client contribution for home support services and how those charges will be levied.
• Home care programs differ with respect to the range of services offered.
• Home care programs differ with respect to the mix of public, private and not-for-profit agencies delivering care.
• Home care programs differ in the information systems used to record and analyse data.
• Home care programs differ in the funding levels per capita.
• Home care programs have different policies with respect to certain areas (e.g. access, service quality and standards, the role of family members).

The importance of the role of family caregivers is beginning to be recognized. Until recently, the focus of home care was on the client with the home care requirement. The physical and emotional demands placed on informal caregivers must be addressed to achieve the overall objectives of home care and improve the quality of care for the client. As such, there has been a rise in the number of services and supports available for family caregivers. Some home care programs are beginning to recognize the client and the family as the unit of care and are expanding their services to include respite for caregivers.