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Thursday, January 24, 2008

HomeCare Financially Squeezed

Home care services scrutinized
Former health minister promises to find solutions

System is squeezed financially, Caplan acknowledges


Ontarians deserve "the best quality for the best price" from community home health services, and Elinor Caplan pledges to help them get it.

In her first major interview since she was appointed to review the way contracts are awarded for home health care, the former Ontario Liberal health minister and member of the federal cabinet, says she'll conduct an impassionate, logical review based on "facts and evidence."

But Caplan, along with home care service providers and their lobby groups, all say to varying degrees that the underlying problem is insufficient money.

Caplan acknowledges the "system is squeezed" financially. But by "best price" she does not mean lowest, she says.

And an official with the association representing for-profit firms says flat out that no service provider can provide the scope of care that was offered years ago. Today, the care offered is "truncated," says Susan VanderBent, executive director of the Ontario Home Health Care Providers' Association.

She says that although provincial laws specify which services should be provided, tight budgets mean they are not.

Years ago, personal support workers went into homes for three hours a day, but now it is likely to be just under an hour, VanderBent says. "(They) run inside, say `Get your clothes off and get into the tub.'

"But we have to do the best we can with the money we have," she adds.

The system is "tearing away the fabric of community health care," says the association representing the non-profit service providers.

"The not-for-profit home and community care agencies are in jeopardy of closing their doors forever," says Susan Thorning, chief of operations for the Ontario Community Support Association.

She cites a study released this summer by McMaster University researchers which found that the change has driven many frustrated service providers out of the business.

It also found that some providers made successful bids for contracts they knew they could not fulfill.

Caplan says she is open-minded but also has some firm ideas about fixing the problems.

"I don't think it matters so much to the client who is in the uniform ... just that the person in the uniform is giving good quality care," she says.

She vows to find a way to improve the system in a non-partisan and non-political way.

"Face it, three different governments tried to fix home care for 15 years and no one has gotten it right yet," she says.

A battle has brewed over the contract system ever since the former Tory government introduced "managed competition" to the home care sector in 1996. When the Liberals were elected, many in the home care sector expected the Request For Proposals system would be radically overhauled, if not scrapped, based in part on their pre-election promises.

Though much of the debate has centred on whether the new system has favoured the generally larger for-profit providers over the usually smaller non-profit services, Caplan says this will not be the focus of the review.

It will instead look at the bigger picture, she says, and how it's affected by the way contracts are awarded. She says the ongoing evolution of primary health care has a much bigger role for community home care, because people now know staying in your home is better for your health and much less costly.

"We need to focus on the person getting the care. But still be accountable," Caplan says.

Many clients and service providers and their associations, both non-profit and for profit, agree with that statement but say it's not that simple.

Anne Leon, 61, has been receiving a mix of free, subsidized and market-rate services for her 93-year-old father. When dementia set in and her father became confused, she was told it was to be expected. It took months before she finally got a doctor to visit him every other week. Finally, the doctor told her his mental confusion was caused by too much potassium. Because his medication causes a loss of potassium which, if lacking, can damage the heart, he was being given a diet rich in the mineral.

Leon is very angry about the months her father spent suffering needlessly and says the dementia caused him to fall more than once, requiring that he be readmitted to hospital, after waiting in emergency for hours.

"Such a waste of taxpayers' money," she says.

Odette Maharaj, of the non-profit Scarborough Support Services, says the new system favours large private firms because they can offer economies of scale. To benefit from economies of scale and compete, a small non-profit obtains a contract and then subcontracts the work to another, she says.

The system treats people like "widgets" and no longer gives service workers a chance to really assess a client's needs or to refer them to available services, says Maharaj.

The for-profits, however, say good care doesn't require the same caregiver day in and day out and this is, in fact, impossible.

VanderBent says the tender process is a good one that needs fine-tuning. And she says the allegation that "the lowest price gets the contract" is not true.

She points to a University of Toronto study on her association's website that says the new system is more transparent and rigorous, more accountable, and has led to clearer standards. It improved invoicing, the amount of services offered and made for expanded and more flexible hours.

But whether a group was for-profit or non-profit "was less of a factor in determining the quality of care ... than other factors related to ... conditions of employment and work experience," the study found.

VanderBent points out that research shows 40 to 50 per cent of elderly people who fall and break their hips will likely die within two years.

"Personal support ... homemaking services ... never get done (the same way) anymore. There isn't the money. But this is the stuff that keeps an 85-year-old in home, away from falling and out of hospital."

Another issue is that after acute care — for example, major surgery — a person's needs are assessed before they are sent home, but it's hard to judge what those are until they're at home, she says. But if they are later found to need more care, "it is very hard to get those extra hours," she says.

Thorning says the home care sector is the only major player in the health care system that has to constantly, at huge expense, bid every three years for contracts and if this were the case across the health care system, there "would be chaos."

The new tender system decides who gets money to provide home health care community services. In total, 43 community care access centres were created in 1996. They decide how to allocate services such as nursing care, physiotherapy, personal care assistance, homemakers' services, as well as equipment like oxygen and wheelchairs and medical supplies.

The U of T study concluded that some community care access centres are "confident that quality of care has improved, some believe that it has declined, some are undecided."

The McMaster study said the changes caused "greater (health system) costs" because costly crises were not detected in time.

Caplan will tour the province and aims to spend about two months gathering information, another two months analyzing data and studies, and two months writing the review.

She hopes to come up with ways to make things less disruptive for all parties and to continue to improve quality of care, while making providers more efficient and cost accountable.

The Toronto Star