Home care – it’s critical we get it right this time

Ontario’s Community Care Access Centres could have been very different had events unfolded differently in the early 1990s.

At the beginning of that decade home care was considered to have more of a leg in social services than health care.

The Rae government, like those that followed, were attempting to transition services from hospital to community and realized the potential of home care to look after patients discharged early from hospital.

The NDP were also sensitive to complaints that health care policies were being decided by the provider community, not by the users of the system. To that end, they not only encouraged widespread consultation, but even funded groups – particularly those representing seniors and the disabled – to speak to their communities and report back on what they heard.

That process was massive, involving more than 75,000 people, 110 provincial associations, 1,800 submissions and nearly 3,000 public meetings – all taking place within a five month window.

While the previous Peterson government had preferred more of a brokerage model – similar to today’s CCAC model which contracts to for-profit and not-for-profit agencies – the consultation process demonstrated that there was little appetite for a system most believed to be bureaucratic and fragmented.

The Ontario Community Support Association had been pushing for a number of principles that the government of the day found itself agreeing with. They include not-for-profit delivery, consumer control and participation, integration of health and social service needs, balance between prevention and treatment and integration of the assessment, case management, and comprehensive service delivery.

While far from perfect, the majority consensus evolved towards something called a multi-service agency which would operate at arms-length from government along similar lines of a public hospital corporation. Planning would be done through a special committee attached to the district health councils. That committee would have significant and broad-based community representation including both health care and social services stakeholders.

Most services would be directly delivered from this agency. The plan was to limit the involvement of for-profit providers to 10 per cent, reflecting what was then the status quo in home care delivery. That didn’t upset the for-profits in the early 1990s.

No sooner had these multi-service agencies been set up, the Harris government won election and decided to instead pursue the model most patient groups didn’t favour – the brokerage model. He ordered the newly rechristened CCACs to divest themselves of direct care staff, claiming it was somehow a conflict of interest. Most complied, even if it meant considerably higher costs to the public and dubious quality control. So much for the common sense in the common sense revolution. In a handful of situations, CCACs sought exemptions because either the cost of contracting out was so prohibitive or because there were no available community providers to bid on the contracts. To date, most of these CCAC direct care staff – mostly therapists – remain in place.

The Harris government set no limits on for-profit involvement, and through competitive bidding soon a majority of agencies were profit-taking from the public purse. At times competitions drove up costs dramatically as the government had little negotiating leverage, only the ability to select a winner from what often turned out to be very limited field of competition.

When contracts turned over, that’s when things got ugly as patients often lost the providers to whom they had built up a long term relationship. New agencies struggled to recruit staff when they won contracts away from established community-based organizations. Given the choice of starting over again with a new agency, many professionals and support staff simply left for other sectors or other work altogether.

Sensing the public mood, the opposition Liberals showed up at rallies opposing Harris’ competitive bidding.

Dalton McGuinty arrived at a VON rally in Windsor and said “if we begin to look at health care as a commodity to be auctioned off to the lowest bidder, we’re looking at a reduction in the quality of services. That’s what we’re beginning to experience today in Ontario.”

That sentiment was soon forgotten as the government changed hands in the fall of 2003 but the issue remained. After a bitter battle in Niagara where the VON lost the nursing contract after a century of service to the community, then Health Minister George Smitherman called a moratorium into competitive bidding and asked former Liberal Health Minister Elinor Caplan to conduct a review into the bidding process – but not alternatives to it.

Absurdly, under pressure from the growing for-profit industry, Caplan decided the whole thing would be okay if they simply extended the length of the contracts, allowing providers up to nine years before having to go back into competition.

That never happened in large part because the community that opposed the brokerage model in the 1990s still opposed it in 2004. The NDP had appropriately called it “cut-throat bidding” in the legislature and many Liberals MPP were privately expressing discomfort for supporting an idea they opposed so vigorously in opposition.

The Liberals tried to bring back competitive bidding in 2008, but foolishly began the process in Hamilton where union-sentiment ran strong. A massive winter rally in Hamilton shook up the Liberals and derailed that plan, Health Minister Smitherman cancelling a competition that was already in progress and extending the moratorium indefinitely. Since then contracts have been renewed by government on an individual basis. Where it was necessary to expand services, or where an agency had failed, the government simply juggled so-called “market share” among existing provider agencies.

Health Minister Deb Matthews originally said competitive bidding would come back, but last year told the RNAO that competitive bidding was now dead. Almost.

The government now says they will try to reallocate market share where necessary, but when that is not possible they will still run a competition. We haven’t seen one yet.

Home care is hardly in an ideal state, yet like the NDP in the early 1990s, government is relying upon it to deliver increasingly complex care, often to a patient population discharged with ever higher levels of acuity from hospital.

It still is fragmented, wages and benefits are far below those working in more institutionalized settings, and there appears to be few repercussions for agencies that cannot fulfill their contracts. Matters were confused further with the government’s aging at home strategy. Rather than place it under the framework of the CCAC, it was left up to the LHINs to decide which support services would be delivered and by whom. Some put services back in the hands of the CCAC, others did not.

While some professionals put up with greater job insecurity and lower levels of compensation because they truly love working in a community environment, increasingly contract home care is becoming a high-turnover environment, with newly graduated nurses and other newly minted health care professionals getting their initial experience in a sector that should really be for the more experienced. Unlike a hospital, where a professional support network is close at hand, home care often relies on professionals working in relative isolation in their client’s homes.

Under Dalton McGuinty, home care services also shifted less from the medical model and more to in-home support services. The last decade actually saw a decrease in visiting nursing, therapies and social work. On the other hand, millions more hours of personal support were added.

There was a glimmer of hope that we would see an evolution back towards the original multi-service agency model as the CCACs began directly hiring mental health nurses, wound care specialists, rapid response nurses, and nurse practitioners.

Looking for a way out of this stalemate, we had proposed something similar to former Health Minister George Smitherman, answering new demand directly and gradually reallocating appropriate market share internally to the CCAC.

By getting into the game, the CCACs would also have a public comparator to keep their contractors in check on cost and quality. The government could also monitor the CCACs costs and quality against the contract agencies.

Evolving the CCACs into direct care providers would also bridge the gap between assessment, case management and treatment. At present agencies are not compensated for the time treatment professionals spend with case managers – time that could be used to ensure comprehensive assistance is appropriately rendered.

It would also blunt the attack from the right – the Ontario Conservatives vowing to dismantle both the CCACs and the LHINs if they come to power. The replacement would be so-called 30-40 “hub hospitals” which would further expand the fragmented brokerage model to much of the rest of health care.

Twenty years ago we were on the cusp of a modern integrated and comprehensive system of home and community care in this province.

What’s infuriating around recent proposals is the inconsistency of it all. Recently we reported on a bizarre pilot project that would disengage case managers as advocates and put far too much trust in the hands of profit-seeking organizations to organize care to their benefit, not necessarily that of their clients or the public interest.

Twenty years ago there was growing consensus around a set of principles for home care. We didn’t keep home care in the hands of not-for-profits. We don’t have an integrated system. We don’t have a balance of prevention and treatment. Assessment and case management is still conducted separately from care delivery.

This month the Ontario Health Coalition is conducting home care roundtables with community organizations across the province. Much of what they are hearing is not all that different from what Ontarians told government 20 years ago.

Former Royal Commissioner Roy Romanow called home care the next essential service. It is critical that we get it right this time.

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