Expanding home care

options in Canada
Taking our company to
Deborah Simon, CEO the next level

November 16, 2021

 Land
Acknowledgement
The City of Pickering resides on land within the Treaty and
traditional territory of the Mississaugas of Scugog Island First
Nation and Williams Treaties signatories of the Mississauga and
Chippewa Nations. Pickering is also home to many Indigenous
persons and communities who represent other diverse, distinct
and autonomous Indigenous nations. This acknowledgement
reminds us of our responsibilities to our relationships with the
First Peoples of Canada, and to the ancestral lands on which we
learn, share, work and live.
 About OCSA…
OCSA was founded in 1992, when three legacy home and
community support organizations realized that they would have
a greater impact and speak with a more powerful voice if they
worked together.

Today, our pool of members has grown to over 220 community

governed, not-for-profit organizations of all sizes, providing a
wide variety of health and wellness services. Our services fall
into two large buckets – home care and community support
services which includes independent living.

OCSA home care members receive government funding

through regional entities now known as Home and Community
Care Support Services (HCCSS) and our community support
service (CSS) agencies, are primarily funded through a provincial
agency known as Ontario Health (OH).
 Reasons successive governments do not spend
funding on home and community care…..
1 Services relatively unknown by the public….
• Rapid expansion in the 90’s
• Improvement in accessing services
2 Lack of understanding of the capacity of the sector…
• Changes in hospitals - shorter lengths of stay and more outpatient surgeries/less
invasive procedures

3 Limited research/evidence on home & community care

• Focus on institutional care
• Advancement in clinical services
Reasons successive governments do not spend
funding on home and community care…..(cont’d)

4 The Canada Health Act

• Home and community care services not covered under this Act
• Provincial jurisdiction/varying models of funding and operation

5 The competition for the health care dollars

• High spend programs in health care
• Differing jurisdictional approaches
 2021-22 Ministry of Health – Spend by Program Area

Billions (Percentage %)
Hospitals $25.8 B (35%)
OHIP $17 B (23%)
Other Programs * $15 (11%)
Long Term Care $5.6B (8%)
Ontario Drug Program $5.4 (7%)
Community Programs ** $4.9 (7%)
Mental Health and Addictions $2.2B ( 3%)
Health Capital $2.0 (3%)
* Other Programs = includes public health programs, emergency health services, such as transfer payments for ambulances; Ontario Health; information
technology and other expenses.
** Community programs include community and home-based supports through five programs, the largest of which is funding for home care - $1.8B
 The Underappreciated Provincial
Diversity in Home Care
Patrik Marier, Department of Political Science,
Concordia University

IRPP Webinar - Expanding Home Care

Options in Canada, Nov. 16, 2021
Home Care is A Ubiquitous
Policy Priority
 The Fallacy of Canadian Home
Care
“(T)he largest proportion of policy development, adaptation,
and change is concentrated in the provincial sector”
(McArthur, 2007, p. 328)

 HC - Noticeably Absent from Federal Frameworks

 An “extended health service” in the CHA
 Weak coordination at the Federal Level
 No F/P/Ts
 Nothing akin to collaborations in education (Wallner, 2014)
 Provinces have had 50 years to develop their own unique
policies and programs!
 10 unique home care approaches, but with a concentration
of LTC spending in facilities
HC Policy and Right-Wing Politics

 Strong link between Conservative governments and the

semi-comprehensive managed market – AB & ON
 Population Aging and Ed Stelmach
 “Individuals have primary responsibility for preparing for their
senior years. This includes meeting their own basic needs,
and securing the resources they will require for the lifestyle
they choose as they age” (AB – Aging Population Policy
Framework).
 Ontario – 3 consecutive reforms 1980s/1990s – The electoral
success of the Conservative Party settled a highly partisan
battle on the shape and future of home care.
HC Policy and Left-Wing Politics

 Québec - PQ embraced a social economy model (1990s)

 EÉSADs provide > 7 millions hours in 100 locations (Home Support)
 Tax credit of $4 per hour (PEFSAD) and one that can reach
$14.24 based on revenues and RHA reference.
 Province offers some support for EÉSAD’s administration costs
 ESSADs also engage into contracts with Regional Health Authorities
(CISSS/CIUSSS) for home care services beyond home support.
 Manitoba - A Classic Public Service Model (NDP) Legacy
 Commission of inquiry – led by non-health actors (Social Work)
 Oldest publicly funded home care program in Canada (1974)
 Quasi-universal coverage (resource test)
 A privatization U-turn after a year in the 1990s (Chappel, 2011)
A Long-Lasting Legacy from Career Civil
Servants in Canadian Provinces?

 New Brunswick Exceptionalism

 New Brunswick vs. Nova Scotia (Cooper and Marier, 2017).
 The Extra-Mural Program (1981) – hospital without wall
 Program administered by a Social Development Ministry (only
province where HC is not in a Health Department).
 Most generous with regards to the social dimensions of care –
CHA (2013).
 “seniors file is wrapped up totally with social services” (Int. #4).
 Nova Scotia – Latecomer into HC, needed federal push.
 Conclusion: Emerging
Trends
• How to Involve the Federal Government?
• ”Everything begins and ends with healthcare” (Clerk of the Privy Council)
• Opting for an “Unequal, but equitable” approach?

• Accentuated biomedicalization of home care services

• Home support
• LTC vs. rehabilitation

• Push to accentuate the role of private providers

• ideological and pragmatic reasons.

• Working Conditions
• Shortages are increasingly acute

• Common Issues with Private Sector Providers

• E.g. rural areas
Thank you!

Contact : patrik.marier@concordia.ca
Models of Publicly Funded Home Care
(Marier, 2021)
Public Delivery Mixed Delivery Private Delivery Home
Home Support Home Support Support

Public Delivery Public Service Mixed Public Mixed Managed Market

Home Health Model Managed Market NB, NL, BC
Care SK, PEI, MAN Qc

Mixed Delivery Semi-Comprehensive

Home Health Managed Market
Care ON, NS, AB
The role of directly-funded care
programs on the Canadian home
care landscape
Christine Kelly, PhD
Associate Professor, Community Health Sciences, University of Manitoba
November 16, 2021
Job Action the University of Manitoba
• I am a member of the University of Manitoba Faculty Association and
we have been on legal strike since November 2, 2021.

• While striking, we can maintain essential research activities and

external obligations.
Background
• Direct funding (DF)
• Provides public funds to individuals to arrange their own home care services
• Sometimes a cash transfer, sometimes an allocated budget

• Also referred to as:

• Self-managed care (Canada)
• Family-managed care (Canada)
• Self-directed care (Canada)
• Cash-for-care (Europe)
• Direct payments (UK)
• Cash & counselling (US)
• Consumer-directed care (Australia, US)
• Related, but broader: individualized funding, personalization, client-directed care
More information:
Kelly, C., Jamal, A., Aubrecht, K., & Grenier, A. (2020). Emergent issues in directly-funded care: Canadian perspectives. Journal of
aging & social policy. doi:10.1080/08959420.2020.1745736

Kelly, C., Dansereau, L., Balkaran, K., Tingey, E., Aubrecht, K., Hande, M.J., & Williams, A. (2020). Directly-Funded Care Programs in
Canada. Centre on Aging, University of Manitoba, Winnipeg, Manitoba. https://doi.org/10.34991/847b-5q61
Pros and Cons, Strengths and Risks – but for
who?
Health care
system

Paid care
workers

Caregivers
–unpaid

Person
with care
needs
Risks of DF Home Care – Client and Caregiver Issues

• Can be difficult to find workers (Manthorpe et al, 2011)

• Can be difficult to generate ‘back up plans’ for when workers are sick (Kelly,
2020; Cranford, 2020)

• Administrative burden (Katzman & Kinsella, 2018; Ottmann et al, 2009)

Risks of DF Home Care – Care Worker Issues
• Discrimination and firing without cause (Cranford, 2020)

• Often no place to report work place safety issues, abuse, or working conditions
(Kelly, 2020)

Slide 7
Strengths of DF Home Care – Individual Level
Clients/Family Caregivers
• Overwhelmingly clients and families are more satisfied with DF care options
• Flexibility and empowerment (more for younger clients)
• Enables ‘social’ rather than ‘medical’ task shifting (Kelly, 2021)
• Allows for cultural, religious, and personal value ‘matching’ with workers (Cranford, 2020)
• Some programs allow people to hire family members, which can be beneficial for clients
living with dementia

Care Workers
• Enjoy a more holistic scope of practice
• May have a higher hourly wage compared to working through an agency, but not always!
• There are not many clear advantages for individual care workers
Risks of DF Home Care – System Level
• DF home care may exacerbate health inequities when scaled up (Carey, Crammond, &
Malbon, 2019; Carey, Malbon, Reeders, Kavanagh, & Llewellyn, 2017; Schmidt, 2017)

• Outcomes are more established for younger people with physical disabilities
(Woolham et al, 2017; Harry et al, 2017)

• More research is needed on DF care and health outcomes

• Risk for financial fraud? There is no evidence that supports this assumption
(Ottmann et al, 2009)

• Undermines formal care worker education and standardization of care worker

education (Kelly & Bourgeault, 2015)
Strengths of DF Home Care– System Level
• Draws on a different pool of workers (Toews, 2016)

• May help to serve rural areas

• Cost-neutral if not cost effective (Ottmann et al 2009; Slasberg et al, 2012)

• Moves the system towards more individualized care

Key Policy Areas to Watch for
1) Worker wages and wage parity
2) Health equity - Does it actually deliver in rural settings? Are people
of lower-socio economic backgrounds able to benefit?
3) Hiring family members
4) Guidance to help agencies deliver on the promises of DF care
5) Strike a balance a between a “light touch” and providing enough
policy and administrative support to maximize the benefits
Acknowledgements
This research is supported by the Canadian Institutes
of Health Research (PJT-148856 and PJT-169001)

Current Research Team: Research Staff:

• Christine Kelly, U of Manitoba • Yuns Oh
• Katie Aubrecht, SFXU • Kevin Balkaran
• Lisette Dansereau, U of Manitoba • Jen Sebring
• Maggie Fitzgerald, U of Saskatchewan
• Yeonjung Lee, U of Calgary
• Allison Williams, McMaster U

Contact: christine.kelly@umanitioba.ca