Home care reform: how wrong are these incentives?

We probably wouldn’t have believed it had we not received the documents outlining the new plan for specialized home care funding.

It’s staggering in its ability to further complicate administration of home care and create so-called “efficiencies” for which the benefits would neither flow to the patient or the Ministry/LHIN/CCAC to facilitate more care.

Stuck with hundreds of contracts to supply home care and support services, the government has now decided it needs a new funding scheme to add to the long journey the modest health care dollar has to travel before reaching a home care client.

Keep in mind the home care dollar starts in the high altitudes of the Ministry of Health, where each spring it rushes down the slopes to the Local Health Integration Networks, where it pools and gently flows towards the Community Care Access Centres. From there it branches out from the CCACs into hundreds of small tributaries before reaching the home care agency. Sometimes that money is used by the agency to provide direct care by agency employees, other times it continues to trickle down to individuals who are treated as independent contractors. This is a journey that can often take the better part of a year for the home care dollar.

Within that long journey there are many eddies and pools in which this money gets trapped en route to serving the needs of Ontario’s home care patients. It’s one of the reasons why administrative costs for home care are conservatively estimated to be about 30 per cent (as compared to less than 10 per cent for hospitals).

It is at the CCAC level where the real action begins. The CCAC case managers, sometimes called care coordinators, assess clients, assign care services, and follow-up to ensure the client is receiving appropriate care. Often they have to play the role of advocate on behalf of their clients. They also play the role of system navigators and ensure a seamless transition to those in their care. New accountability requirements placed on these case managers have meant they have been able to spend less time face-to-face with patients and more time filling out paperwork. That has meant about $100 million more spent on case management between 2007-08 and 2010-11.

If that wasn’t enough, now the province is actually piloting a new funding and administration model, where much of the coordination presently done by the CCAC case manager is devolved to the private home care agency.

In these models it’s not clear who these new coordinators will be at the agency. Are they new positions, or are they going to burden an existing shortage of home care nurses with additional responsibilities?

These new unnamed coordinators will receive lump sums for each “client” from the CCAC and decide how that money should be spent. Each client will be assigned funding based on their assessment by the CCAC case manager. The new agency coordinators will decide what care is appropriate, or what the government likes to say is – wink wink – creating “innovation.”

The “outcome” in “outcome funding” is often very simple and will be the only measure the case manager looks at. That also reduces the case manager’s role as advocate during the clinical journey.

It never seems to have occurred to the geniuses behind this plan that the majority of these agencies are for-profit companies that are going to be far from objective in deciding where this money goes. When you are a for-profit company, ideally you want as much of that funding to stop with your agency and your shareholders.

Few agencies have the scope of operation that would facilitate everything from nursing to social work to therapy to support services. In some cases, it could mean having to reluctantly contract out to your competitor. In some parts of the province the CCAC is the only direct community provider of some services, such as physiotherapy. This means the CCAC would have to contract an agency to contract the CCAC.

If the Minister of Health thinks this is efficient she needs to give her head a shake.

The plan poses some risk for the agencies – for example, what happens if the money is not enough and the CCAC refuses to extend more? The silence by agencies suggests they believe the gamble will be worth it. Here’s the payoff: if the envelope of money is not entirely spent, the agency gets to keep the difference.

Ask yourself, what is the government actually incentivizing?

The first is to use a smaller scope of professionals instead of a team approach. If an agency feels its nurse could get by without some other agency’s social worker or physiotherapist, they might just want to try it out (again, what the government calls “innovation”). What if the nurse doesn’t have a specialization in palliative care, would any RN do just the same?

The second is to use less qualified staffing, as the less it costs, the more the agency collects in profit. There appears to be a lot of latitude for this these days. That includes whoever plays this coordination role. What happens if the coordinator doesn’t speak French in a predominantly francophone part of the province? This is already a problem at the agency level in parts of Ontario. Given the nursing shortage, it may be a very pertinent question.

The third is to provide less visits. Before agencies got compensated by the visit, now they can make more money with fewer visits. Of course, if you provide less, none of the savings gets passed on to the CCAC or the public purse.

The fourth is what happens to patients who have multiple health issues or don’t heal as well, or as in the case of palliative care, don’t die when they are supposed to?

The government says the agencies can’t discriminate against high needs patients – that they have to accept the referrals. What they do with those difficult or more complex referrals is another question. Theoretically the lighter needs patients will balance out the heavier needs patients, but the haphazard nature of this plan suggest it will be as predictable as the outcome of a roulette wheel. It’s hard not to imagine that the agencies will do everything they can do to discharge the patient so they become someone else’s problem when they re-enter the system.

What happens when there is disagreement on the outcome? Is the CCAC really going to ask for its money back? What will it cost to resolve? How does that work in palliative care where the client may already be deceased?

And what about the present idea that if a care recipient is unhappy with their present provider, they can call the CCAC and get care from an alternate agency? How does that work when it is the agency itself deciding who provides care to this patient?

Then there is the question of complaints when the primary contact becomes the agency providing the service.

At present the government is looking at applying this model to specific home care work, including palliative care. However, there is no question the plan is to shift more of home care, if not all of it, to this model.

There was a brief moment when it appeared Ontario was going to get a more sensible home care system. After extensive consultations – some say too much consultation – the Rae government had decided upon a multi-service agency that would directly provide care, allowing for a small portion to be contracted out as a kind of safety valve to the system.

The Harris government instead blew that up and implemented their own ideologically based system of competitive bidding which drove up costs and drove out health professionals from the sector. This is something the PCs continue to cling to.

It looked like the McGuinty/Wynne government was beginning to understand. Recently it had actually begun hiring health professionals at the CCAC to provide direct care, including mental health nurses, nurse practitioners and wound specialists. The role of these individuals appears to vary from CCAC to CCAC, but much of this work is providing direct care to patients, not just “connecting.”

Incredibly, after making much initial noise about how much they liked competitive bidding, the for-profit agencies remained remarkably silent about its recent demise.

Could it be this is the trade-off?

For all the tinkering with home care, units of service for professional services have been in a lengthy decline for everything but shift nursing and respiratory services – both a relatively small part of the mix. The substantial increase has been in support services.

Given the dollars to do as they please, it will be interesting to see if “units” of service performed by agencies will even continue to be tracked.

What is worrying is these pilots appear to be pro-forma en route to new policy around funding. The government is intent on importing UK-based “outcome funding” despite its negative consequences.

Will we have a true independent evaluation of these pilots, or will it be implemented before we even get the results? Will the results of the pilots ever be made public?

With home care taking the biggest percentage increase in health care funding, it’s fair to ask whether that money will be spent effectively, or whether it will end up down one big rabbit hole?

Stay tuned!

5 responses to “Home care reform: how wrong are these incentives?

  1. Thanks for the canoe ride description of CCAC funding stream, it’s good to keep a sense of humour in amongst the analysis. It reminds me of ODSP’s model of Supported Employment, where company’s get incentives per person and outcomes. Certainly a highly problematic model

    I still wonder about the role of the LHINs in this as was not the idea of unique local answers/steps to the unique community context and resources a key driver?
    Where do ministry directives and local LHIN deployment of programs meet? Do they meet? Are there some pilots of non-profits. Anyways thanks for the analysis.

    How do you view, what seemed like a policy direction out of private clinics for physiotherapy or is that simply a bureaucratic step before a for profit company kicks in?
    See –MOHLTC’s side of the story about cuts to Physio therapy
    http://news.ontario.ca/mohltc/en/2013/04/more-physiotherapy-exercise-and-falls-prevention-for-seniors.html

    Bill Dare, Ottawa

  2. Hi Bill — Thanks for your comments. Certainly the canoe analogy brought up thoughts of being up creeks without a paddle. This new outcome funding policy appears to be coming directly out of the Ministry as every sector seems to be experiencing some form of it. In the latest edition of Portraits of Home Care in Canada, it specifically lists the shift to outcome based funding as something Ontario is pursuing. This is definitely not locally driven. The physio question is tough to answer because the government is only giving us part of the picture. How many physio visits were cut from outpatient units of public hospitals? We’re told over the last two years 50 per cent of Ontario hospitals reduced or cut entirely outpatient physio. The private OHIP clinics say they net funding is less than what it was before this realignment, meaning while the venue may be shifting, overall funding for physio is being reduced. The irony is that while the government says it is moving away from private for-profit delivery, both home care and long term care have a majority of providers who are for-profit.

    • Thanks for further explanation. You seem to frame “Outcomes” model as a bad approach but are we not all in our organizations driven by outcomes via logic models etc.? Is it not the process and values and dare I say evidence base is what matters here? What outcomes should we be advocating and laying out? That would be powerful in the fog and rhetoric flying about.
      Bill Dare, Ottawa

  3. I think we need to outline the Outcomes we on the frontlines are seeking more clearly. Does OPSEU/CUPE have some analysis that integrates what home care “consumers” are saying they need, with—– front-line worker perspectives in some kind of reader friendly (brief but pithy) outcomes format?

    Sounds like you know a lot about the issue/policy and literature, hard for front-liners to grapple with it.

    thanks for being willing to …”dialogue”,
    Bill Dare, Ottawa

  4. You would be much better off having that specific dialogue with a case manager, as there certainly would be expectations around the outcome for each client. Wasn’t patient-centered care (last year’s buzzword) supposed to be about treating patients as individuals? But why tie outcomes to funding? Don’t we want all patients to have good outcomes? Under this model, theoretically any agency could dumb down their process to save money and factor in a failure rate that still leaves them ahead of the game. If you offered an “incentive” for doctors to do their job better, do you think it would work? While we all want to earn a good wage, it’s a bit insulting to say we wouldn’t do our jobs properly unless a little extra was dangled before us. We were told for years that competitive bidding would bring a new era of innovation to home care, yet we have never heard one clear example involving quality patient care where that was the case. I’m sure if you dig into it you could find examples of innovation where the agency was able to rearrange their processes to make more money. But that’s not the same thing.

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