A moving target
By Dr. Janice Keefe and Rachel Ogilvie
Ongoing increases in the proportion of older Canadians, particularly those aged 85 and over, in most provinces/territories is translating into increased demand on services across the long-term care continuum. This has created concern about the ability of citizens to access home care services in a timely manner, with reasonable wait times and relative equality across the country.
Home care services, when they operate as intended, support a reduction in unnecessary long-term care and hospital admissions by enabling individuals to remain in, or return to, their own home. Across Canada, the basket of services offered through publicly funded home care programs is generally consistent, with some variation in the number of available services and the mechanisms of service delivery. What does differ is the way in which jurisdictions capture administrative home care data that are used to assess and improve home care services. Home care wait time is a measure that has yet to be clearly defined, or has been defined to meet the evaluative needs of the health care system rather than to reflect the day-to-day experience of the home care client.
In January 2014, information was gathered from key informants representing all 13 jurisdictions across Canada, in an attempt to identify current wait times for chronic and acute home care clients, across four umbrella areas (homemaking, personal care, nursing and allied health professional services). This data existed at a provincial/territorial level for just two jurisdictions—Ontario and Yukon Territories, through the Canadian Institute for Health Information. In select jurisdictions, informants indicated that wait time data was being tracked by some health regions, but not by all and that the data were not submitted to the provincial/territorial government. The work was further complicated by different definitions of what “wait time” meant (e.g., referral to assessment; assessment to service; referral to service). Informants expressed frustration about trying to improve upon an important health system outcome for which they had no measure.
In the absence of numeric wait time data, an effort was made to garner experiential data from key informants about home care wait times in their jurisdiction, with three themes emerging: geography, human resources and client acuity.
Canada is a geographically diverse country, and as such geography is an integral factor in planning for future home care services. For some jurisdictions, having a high rural/remote population posed challenges in the provision of home care; for others, the rural context supported the provision of home care services. An important factor related to geography, which impacted the perception of home care wait times, was the willingness of citizens in rural/remote communities to work together to bridge the gap between what was available for home care services and what the individual needed. Travel costs were a common challenge related to geography, whether as a component of the negotiation with private contractors or as a direct cost to the province/territory. As a result of long travel times, some jurisdictions limited the provision of homemaking services to those in urban areas, as they could not fiscally justify travel costs to provide such services alone.
The most-commonly cited factors contributing to home care wait times across Canada were related to human resources. The first identified factor was the ability of jurisdictions to recruit and retain both paraprofessional and professional staff. For paraprofessional staff, informants identified the inability to pay adequate wages as a recruitment challenge. This issue was compounded by travel time and costs, factors that impact staff retention, particularly in rural/remote areas. The challenge of staffing and of training staff in rural/remote regions, was noted. It was also challenging to retain nurses and allied health professionals due to the ever-increasing caseloads.
The maintenance of a sufficient workforce to provide the required level of care had an impact on jurisdictions in a number of ways. Smaller jurisdictions operated their home care services with a finite amount of human resources and this limited the system’s ability to adapt to sudden or additional demand. For many jurisdictions, sufficient human resources was a key consideration when deciding whether they would offer homemaking services, and a contributing factor in wait times for assessment. The very nature of home care services also made the management of human resources a challenge. The demand for home care services is generally morning-weighted, with fewer human resources required in the afternoon. This made it challenging to maintain a sufficient complement of staff to cover morning needs.
Geography was also discussed in conjunction with human resources, with informants pointing out that staff in rural/remote regions must have a broader skill base to accommodate the needs of clients and limit wait times. Health care professionals and paraprofessionals worked together by necessity to provide the full complement of care required by clients, often with the community nurse or nurse practitioner overseeing the home support staff. Rural/remote regions tended to attract new professionals, which posed difficulties when sensitive skills such as palliative care delivery were not yet developed.
Informants confirmed a widely recognized increase in the number of clients requiring acute care in home care programs across the country. Acute clients are given priority for services when compared to chronic clients. This reality in the provision of
home care is especially pronounced in rural/remote areas where one or two acute/palliative care/advanced dementia care clients impact the ability of the system to provide services to chronic care clients in the same community. Informants expressed concern about the gap between available home care services and the need for long-term care admission. For some rural/remote areas, home care services were available only on weekdays. As a result, clients were entering long-term care sooner than necessary in part due to caregiver burnout and the long-term care facilities were generally located in larger urban areas. This issue was especially troublesome for regions with large populations of Aboriginal Peoples as, historically, there is a strong cultural impetus to remain at home, or at least in one’s own community, for as long as possible. Another issue in client acuity was that of physician awareness of available services and thus earlier referrals to reduce home care wait lists. Clients were being referred at higher than necessary levels of acuity, creating a reactive rather than proactive home care system.
The future of home care wait times
Home care wait times can be defined and conceptualized in many ways and it is important to understand what each jurisdiction labels as home care wait times in order to understand the cross-national perspective.
Jurisdictions are grappling with whether to quantify “wait time” as the time from referral to assessment, assessment to service, or referral to service; with each measure weighted more toward either the needs of health care decision makers or home care clients. While almost all jurisdictions identified the gathering of home care wait time data to be under development and a priority issue, it was clear that this research was between two and five years ahead of the data. An opportunity exists for stakeholders to engage in conversations about the identification of comparable data points. If this conversation does not occur, in the future we will have access to provincial/territorial-level wait time data but it will not be comparable across the country.
Please note that the views expressed herein do not necessarily represent the views of Health Canada (Funder) or the Provinces/Territories that participated in the study.
Janice Keefe, Ph.D, is a professor in the Department of Family Studies and Gerontology at Mount Saint Vincent University, and director of the Nova Scotia Centre on Aging.
Rachel Ogilvie, MA, is research manager of the Maritime Data Centre for Aging Research and Policy Analysis.