|Post-acute Home Care Coverage|
|Awaiting a National Home Care Program|
|Implemented in this survey?|
All Canadian provinces provide home care services but provincial programs differ in many respects. In 2003, the federal government and the provinces agreed to further develop short stay home care services, a minimum basket of services and to begin creation of national standards as part of a larger agreement on health service renewal. The 2003 Health Accord marked a policy shift in terms of shared national goals about the importance of short-stay home care in provincial health care systems.
2003 Health Accord: Improving access to and quality of short-term home care services
The goal of the home care section of the 2003 federal/provincial/territorial Health Accord was to ensure that Canadians have access to quality home and community services. The intent of the initiative was to improve access to short-stay services for those recovering from an acute episode, those with mental health conditions and those at end-of-life. As well, a minimum basket of home care services across the country was to be developed by the provinces and territories in an effort to harmonize access to a basic set of services across the country. Lastly work was to begin on developing national standrads for home care. To accomplish these goals, the federal government created a five-year Health Reform Fund which provided new funding for reforms in home care along with primary care and catastrophic drug costs.
10-Year Plan further strengthens home care
In 2004, the features of the 2003 Health Accord were incorporated into a federal/provincial/territorial 10-Year Plan to Strengthen Health Care in which the commitment to home care services, among others, was continued. The Health Reform Fund was replaced by a ten year commitment by the federal government of $41.3 billion in new funding for health services included in the Plan. Under the Plan, the provinces/territories continued to provide first dollar coverage for certain home care services (post acute home care, short-term home care for those with mental health concerns and those ar end-of-life). They also agreed to report annually to their citizens on progress toward implementing home care services. Work on developing home care standards was to continue. A Health Council of Canada was created to monitor the accomplishments of the provinces in meeting the objectives of the Health Accord and of the subsequent 10-Year Plan.
The commitment to home care services in the 10-Year Plan to Strengthen Health Care recognizes that home care is an "essential part of modern, integrated and patient-centered health care". The home care objectives include improving patient quality of life by allowing them to recover at home, reducing acute care costs by substituting care at home for hospital care, and making better use of inpatient beds. The goals also include providing choices for those at end-of-life and those with chronic mental health conditions.
Provincial home care programs had been providing home care services for those recovering from an acute episode, those with mental health concerns and those at end-of-life, as well as for those with chronic home care needs. In 2003/04 total public spending on home care is estimated to have been $93.60 billion in current dollars, an average annual growth rate of 6.1% since 1994/95. New federal funding in the Plan was intended to assist the provinces to continue to provide short-stay home care services and if possible to expand them. In 2004, additional federal funding of $500 million was provided under the Canada Health Transfer for 2005/06 specifically to improve progress on home care services and catastrophic drug coverage.
Those recovering from an acute episode of illness, those with mental illness, those at end-of-life
|Degree of Innovation||traditional||innovative|
|Degree of Controversy||consensual||highly controversial|
|Structural or Systemic Impact||marginal||fundamental|
|Public Visibility||very low||very high|
The inclusion of home care in the 2003 Health Accord and the 10-Year Plan to Strengthen Health Care marked national health policy consensus that home care services were critical to the development of modern health care systems in Canada. Canadian studies had demonstrated that home care services could be cost-effective and that they responded to consumer demand for care options. Provincial government had been providing home care services for many years but the new agreements recognized that the federal government had a role in assisting the provinces and territories to finance the growing cost of home care. In return, the federal government received assurances that the provinces would be accountable for implementation of the home care (and other) sections of the Health Accord and the 10-Year Plan. However the provinces were not held to any specific dollar expenditures on home care services defined under the Plan.
The change was based on an agreement that timely access to health care services was a priority for health reform in Canada; home care was one of the reform areas.
|Implemented in this survey?|
The inclusion of home care services as a priority area for health reform in 2003 reflected concerns by the provinces that home care, along with other health issues such as primary care reform and drug coverage, health human resources and quality of care, was one of the areas needing additional financial support. The premiers of the provinces as well as federal political leaders were facing increasing pressures to improve access to care for Canadians. Thus the 2003 Health Accord and the later 10-Year Plan to Strengthen Health Care were not vehicles for new health ideas at the provincial level as much as they were national policy statements about the need for additional financial support by the federal government to assist the provinces with health reform.
The commitment to home care funding by the federal government was supported by two important reports published in the fall of 2002; one from the Standing Senate Commiteee on Social Affairs, Science and Technology (Kirby Report) and the second from the Commission on the Future of Health Care in Canada (Romanow Report). Both reports underscored the role of home care in health care systems and recommended that home care services be included as an extension of medically necessary coverage under the Canada Health Act.
In 2003, a widely reported study on home care human resource issues documented that home care services were negatively affected by cost constraints. At the same time as these policy-relevant reports were issued, widespread problems of timely access to both primary care and hospital services as well as rapidly rising public health expenditures encouraged provincial governments to view home care services as a means of supporting independence at home, and reducing utilization of hospital and long-term care facilities.
Taken together, the reports and the pressures on provincial health care systems created momentum for the federal provincial negotiations that resulted in specific mention of home care in the Health Accord and the subsequent 10-Year Plan. The parties agreed that home care development was as much an area for health reform as primary care, acute care and pharmacy services. The emphasis on short-stay home care services in the agreements was very much shaped by the Romanow and Kirby reports which identified post-acute home care and support for caregivers of dying relatives as the home care areas of highest priority. The Romanow report also included care for those with mental illness as a priority area. These three areas were included in the two agreements but neither agreement included a specific allocation of new federal funding for home care in the total of new funding to be made available.
National home care associations and the Canadian Association on Gerontology had long been advocating for equal access of Canadians in need of home care services. The associations while recognizing the importance of short-stay services would have been happier with a commitment to all home care services. The focus on short-stay home care services marked a modest achievement because post acute home care users comprise 33 percent of home care users nationally, a minority of total home care consumers. As well, the definition of short-stay was limited to two weeks.
|Federal government||very supportive||strongly opposed|
|Provincial governments||very supportive||strongly opposed|
|Home care providers||very supportive||strongly opposed|
|National Provider Associations||very supportive||strongly opposed|
|home care consumers||very supportive||strongly opposed|
|advocacy groups||very supportive||strongly opposed|
The commitments of the 2003 Health Accord and the 10-Year Plan have been incorporated into the budget acts of subsequent years.
|Federal government||very strong||none|
|Provincial governments||very strong||none|
|Home care providers||very strong||none|
|National Provider Associations||very strong||none|
|home care consumers||very strong||none|
|advocacy groups||very strong||none|
The provinces have been implementing short stay home care services and did develop a basket of home care services in September 2004 to be provided on a first dollar coverage basis. But they did not commit to providing home care services without user fees. Work has continued on developing a national home care reporting system and on standards.
Health Council monitors home care reforms
The Health Council of Canada was created to monitor health reforms included in the 2003 Health Accord and the 10-Year Plan. In 2005, the Health Council of Canada published a background paper on home care which analysed the commitments included in the agreements. The report highlighted the lack of clarity of some of the language and intention. The Council recommended that future agreements provide greater clarity of definitions, eligiblity criteria, and functions of short-term home care, acute community mental health and end-of-life care. The Council also called for steps that would establish a mimimum platform of home care services that would be offered by each province and steps that would reduce eligibility and finanial inequities across the country. It recommended that the Canadian Institute for Health Information continue its work to develop home care data standards, performance indicators and the adoption of common or comparable clinical assessment tools and to implement nationwide data collection. In its most recent annual report (2007), the Health Council stated that it was not known if or how fully health ministers reported to First Ministers on home care goals by the deadline of December 31, 2006. But all provinces, with the exception of Prince Edward Island, reported that they have met the requirement to provide first dollar coverage for short term (two weeks) acute home care services, community mental health services and end-of-life care. The Canadian Institute for Health Information is working with some provinces to create a Home Care Reporting System; in early 2007, five regions in British Columbia, Alberta and the Yukon will submit home care data. Later Saskatchewan, Manitoba, Ontario and Nova Scotia may be participating in the system. The development of national standards is continuing.
Evaluation of the impact of federal investment in short-stay home care was not included in the agreements.
Still differences in home care programs between provinces and territories
There continue to be provincial differences in eligibility requirements, service baskets, amount of service and fees for home care services. Home care services are not insured services under the Canada Health Act (although both the Kirby and Romanow Reports had recommeded this) and thus do not have to meet national requirements of universality, accessibility, portability, comprehensiveness and public administration. Instead, they are provincially defined programs that have some amount of federal financial participation but each province has the authority to decide how to run its home care program and to what extent it will use federal dollars for its home care program. Figures on the extent of federal dollars being spent on home care services are not available from the provinces. Nor did the agreements address the full range of home care services being delivered by provinces; rather federal financial participation was restricted to short term (two weeks) post acute care, mental health services and services for those at end-of-life.
Increasing expenditures on home care
The Candian Institute for Health Information published new data on home care expenditures in March 2007. The agency found that compared to 1994/95 in 2003/04 home care programs increased nursing and personal support (home health) services while reducing home support (homemaking and household assistance). Although home care expenditures increased on average by 6.1% annually, numbers of users increased by only 1% annually. A study published by Health Canada in 2006 found that users receiving home health services increased from 39% in 1994/05 to 52% in 2003/04. Those receiving home support fell from 46% in 1994/95 to 36% in 2003/04. Thus it appears that at the time of development of the new agreements, provinical home care programs were implementing a policy of providing increased access to short-stay (i.e. post acute and end-of-life care) services and reducing access to long-term home care for those with on-going functional problems.
Does focus on short-term home care services deteriorate care for those in need of long-term services?
Since development of the agreements in 2003, home care analysts have been concerned about the impact of the agreements, fearing that they may divert attention away from the needs of long-term or chronic home care patients in favor of the needs of short-term patients. There is Canadian data indicating that focusing on short stay home care services may be short-sighted in terms of long-range cost effectiveness because it overlooks the role of long-term home care in preventing nursing home and other health costs for those with chronic care needs. Using data from British Columbia, Hollander found that, for all levels of care needs, on average, long-term supportive home care was significantly less costly than care in long-term care facilities and that home support may be able to substitute for acute care services.
There have been no formal reports on the impact of the policy.
|Post-acute Home Care Coverage|
Process Stages: Policy Paper, Idea, Pilot
|Awaiting a National Home Care Program|
Process Stages: Policy Paper, Idea, Pilot