Home Care In Ontario Research Articles

Transitioning to a new Casemix grouper to fund long-term care homes in Ontario, Canada

Health system accountability and the capacity to care for the elderly with increasingly complex care needs is a challenge across many jurisdictions. The move to increasing accountability has necessitated greater and improved measurement of healthcare processes and outcomes. In 2005, the response by the Ontario Ministry of Health and Long-Term Care was to implement the Resident Assessment Instrument (RAI)-Minimum Data Set (MDS) 2.0. One purpose for the introduction of the assessment tool was to facilitate the transition to a new Casemix grouper with associated weights. In long-term care in Ontario, homes are funded based on an envelope system. The majority of expenses related to resident care are provided for in the Nursing and Personal Care (NPC) envelope, which is 100% adjusted for resident acuity. The NPC envelope represents approximately 60% of envelope funding in the sector. Since 1993, this adjustment was based on the Alberta Resident Classification System (ARCS). Assessors from the Ministry measured ARCS once a year and, from these data, residents were classified into one of seven Casemix groups to formulate the province’s Casemix measurement. Long-term care (LTC) homes are funded based on their specific Casemix measure relative to the provincial Casemix measure. Over time the validity of ARCS, and the ability to fairly and equitably distribute funding based on it, came into question. The introduction of the RAI-MDS 2.0, and the Casemix grouping algorithms associated with it, provided alternatives in order to improve the allocation of funding based on Casemix. In collaboration with sector representatives, the Ministry determined that the Resource Utilization Groups (RUGs) 34-group model was best suited to Casemix-adjusted activity in long-term care. A transition model was developed and implemented in order to ensure system stability.

Postoperative disposition and health services use in elderly patients undergoing colorectal cancer surgery: A population-based study

Little is known about the postoperative status and support needs of patients undergoing colorectal cancer operations. The objective of this study was to describe the disposition and resource use of Ontario's elderly population undergoing colorectal cancer operations as well as to identify predictors of outcomes using population-based data. A total of 33,238 patients aged 50 years and older with a diagnosis of colorectal cancer were identified using International Classification of Diseases 9 and 10 codes in the Ontario Cancer Registry linked to procedure codes in the Canadian Institute for Health Information Discharge Abstract Database representing colorectal operations within 6 months of diagnosis from 1997 to 2004. Data on an individual's home-care use were collected from the Ontario Home Care Administrative System. The cohort was divided into the following age groups: 50-64 years, 65-74 years, 75-79 years, and 80 years and older. The primary outcomes assessed were postoperative mortality, length of stay, discharge disposition, need for home care, and readmission within 30 days. Based on univariate and multivariate analyses, patients aged 75-79 years and 80 years and older were more likely to die in hospital (odds ratio 2.84; 95% confidence interval 2.32-3.47 and odds ratio 5.72; 95% confidence interval 4.76-6.88), stay longer in hospital (2.78 [standard error 0.22] and 5.16 [standard error 0.19] days, respectively), not return home (odds ratio 5.62; confidence interval 3.99-7.98 and odds ratio 11.59; confidence interval 8.32-16.13), receive home care (odds ratio 1.44; 95% confidence interval 1.34-1.55 and odds ratio 1.71; 95% confidence interval 1.59-1.83), and be readmitted (odds ratio 1.31; 95% confidence interval 1.19-1.45 and odds ratio 1.59; 95% confidence interval 1.44-1.75) compared with younger individuals. The rate of discharge home for patients aged 80 years and older was more than 78%. Factors predisposing patients older than 75 years to poorer outcomes were higher Charlson comorbidity score, urgent admission, construction of a stoma, and reoperation. Although discharge-related outcomes worsen with age, most elderly patients do well and can return home after a colorectal cancer operation. Elderly patients require more support; therefore, discharge planning should be part of preoperative assessment and discussions.

Young Adults With Traumatic Brain Injury in Long-Term Care Homes: A Population-Based Study

AbstractThe aim of this research was to identify the number and characteristics of adults under the age of 65 with a diagnosis of traumatic brain injury (TBI) living in long-term care homes (nursing homes, homes for the aged and charitable homes) in Ontario, Canada. Methods: The study used a cross-sectional design. Secondary data analysis of a comprehensive provincial database of long-term care homes was conducted. Results: Of the 399 residents coded as having a TBI, 154 were < 65 years of age. Virtually all residents were limited in personal care and required assistance for eating (94.2%), toileting (92.2%) and dressing (99.4%). A large percentage also required care for challenging behaviours, while care needs due to substance abuse was common among 12.3% of TBI residents. Conclusion: As similar research in Australia has found, young persons in long-term care homes in Ontario, Canada, have high level personal health needs, however the appropriateness of this environment is questionable.

Using More End-of-Life Homecare Services is Associated With Using Fewer Acute Care Services

Healthcare systems are investing in end-of-life homecare to reduce acute care use. However, little evidence exists on the timing and amount of homecare services necessary to reduce acute care utilization. To investigate whether admission time to homecare and the amount of services, as measured by average nursing and personal support and homemaking (PSH) hours/week (h/wk), are associated with using acute care services at end-of-life. Retrospective observational cohort study. Decedents admitted to end-of-life homecare in Ontario, Canada. The odds ratios (OR) of having a hospitalization or emergency room visit in the 2 weeks before death and dying in a hospital. The cohort (n = 9018) used an average of 3.11 (SD = 4.87) nursing h/wk, 3.18 (SD = 6.89) PSH h/wk, and 18% were admitted to homecare for <1 month. As admission time to death and homecare services increased, the adjusted OR of an outcome decreased in a dose response manner. Patients admitted earlier than 6 months before death had a 35% (95% CI: 25%-44%) lower OR of hospitalization than those admitted 3 to 4 weeks before death; patients using more than 7 nursing h/wk and more than 7 PSH h/wk had a 50% (95% CI: 37%-60%) and 35% (95% CI: 21%-47%) lower OR of a hospitalization, respectively, than patients using 1 h/wk, controlling for other covariates. Other outcomes had similar results. These results suggest that early homecare admission and increased homecare services will help alleviate the demand for hospital resources at end-of-life.

Supporting Evidence-Based Practice for Nurses through Information Technologies

To evaluate the usability of mobile information terminals, such as personal digital assistants (PDAs) or Tablet personal computers, to improve access to information resources for nurses and to explore the relationship between PDA or Tablet-supported information resources and outcomes. The authors evaluated an initiative of the Nursing Secretariat, Ontario Ministry of Health and Long-Term Care, which provided nurses with PDAs and Tablet PCs, to enable Internet access to information resources. Nurses had access to drug and medical reference information, best practice guidelines (BPGs), and to abstracts of recent research studies. The authors took place over a 12-month period. Diffusion of Innovation theory and the Promoting Action on Research Implementation in Health Services (PARIHS) model guided the selection of variables for study. A longitudinal design involving questionnaires was used to evaluate the impact of the mobile technologies on barriers to research utilization, perceived quality of care, and on nurses' job satisfaction. The setting was 29 acute care, long-term care, home care, and correctional organizations in Ontario, Canada. The sample consisted of 488 frontline-nurses. Nurses most frequently consulted drug and medical reference information, Google, and Nursing PLUS. Overall, nurses were most satisfied with the Registered Nurses Association of Ontario (RNAO) BPGs and rated the RNAO BPGs as the easiest resource to use. Among the PDA and Tablet users, there was a significant improvement in research awareness/values, and in communication of research. There was also, for the PDA users only, a significant improvement over time in perceived quality of care and job satisfaction, but primarily in long-term care settings. It is feasible to provide nurses with access to evidence-based practice resources via mobile information technologies to reduce the barriers to research utilization.

Resource utilisation and costs of palliative cancer care in an interdisciplinary health care model

This paper presents a detailed description of health care resource utilisation and costs of a pilot interdisciplinary health care model of palliative home care in Ontario, Canada. The descriptive evaluation entailed examining the use of services and costs of the pilot program: patient demographics, length of stay broken down by disposition (discharged, alive, death), access to services/resources, use of family physician and specialist services, and drug use. There were 434 patients included in the pilot program. Total costs were approximately CAN$2.4 million, and the cost per person amounted to approximately CAN$5586.33 with average length of stay equal to over 2 months (64.22 days). One may assume that length of stay would be influenced by the amount of service and support available. Future research might investigate whether in-home palliative home care is the most cost effective and suitable care setting for those patients requiring home care services for expected periods of time.

Potentially inappropriate management of depressive symptoms among Ontario home care clients

To examine the prevalence and correlates of potentially inappropriate pharmacotherapy (including potential under-treatment) for depression in adult home care clients. A cross-sectional study of clients receiving services from Community Care Access Centres in Ontario. Three thousand three hundred and twenty-one clients were assessed with the Resident Assessment Instrument for Home Care (RAI-HC). A score of 3 or greater on the Depression Rating Scale (DRS), a validated scale embedded within the RAI-HC, indicates the presence of symptoms of depression. Medications listed on the RAI-HC were used to categorize treatment into two groups: potentially appropriate and potentially inappropriate antidepressant drug therapy. Adjusted logistic regression models were used to explore relevant predictors of potentially inappropriate pharmacotherapy. 12.5% (n=414) of clients had symptoms of depression and 17% received an appropriate antidepressant. Over half of clients (64.5%) received potentially inappropriate pharmacotherapy (including potential under-treatment). Age 75 years or older, higher levels of caregiver stress and the presence of greater comorbidity were associated with a higher risk of potentially inappropriate pharmacotherapy in multivariate analyses. Documentation of any psychiatric diagnosis on the RAI-HC and receiving more medications were significantly associated with a greater likelihood of appropriate drug treatment. Most clients with significant depressive symptoms were not receiving appropriate pharmacotherapy. Having a documented diagnosis of a psychiatric condition on the RAI-HC predicted appropriate pharmacotherapy. By increasing recognition of psychiatric conditions, the use of standardized, comprehensive assessment instruments in home care may represent an opportunity to improve mental health care in these settings.

The Reform of Home Care Services in Ontario: Opportunity Lost or Lesson Learned?

With the release of the Romanow Commission report, Canadian governments are poised to consider the creation of a national home care program. If occupational and physical therapists are to have input in shaping such a program, they will need to learn from lost opportunities of the past. This paper provides an overview of recent reforms to home care in Ontario with an emphasis on rehabilitation services. Data were collected from documents and 28 key informant interviews with rehabilitation professionals. Home care in Ontario has evolved in a piecemeal manner without rehabilitation professionals playing a prominent role in program design. Rehabilitation services play a critical role in facilitating hospital discharges, minimizing readmissions, and improving the quality of peoples' lives. Canadians will benefit if occupational and physical therapists seize the unique opportunity before them to provide meaningful input into creating a national home care program.

Can a publicly funded home care system successfully allocate service based on perceived need rather than socioeconomic status? A Canadian experience

The present quantitative study evaluates the degree to which socioeconomic status (SES), as opposed to perceived need, determines utilisation of publicly funded home care in Ontario, Canada. The Registered Persons Data Base of the Ontario Health Insurance Plan was used to identify the age, sex and place of residence for all Ontarians who had coverage for the complete calendar year 1998. Utilisation was characterised in two dimensions: (1) propensity - the probability that an individual received service, which was estimated using a multinomial logit equation; and (2) intensity - the amount of service received, conditional on receipt. Short- and long-term service intensity were modelled separately using ordinary least squares regression. Age, sex and co-morbidity were the best predictors (P < 0.0001) of whether or not an individual received publicly funded home care as well as how much care was received, with sicker individuals having increased utilisation. The propensity and intensity of service receipt increased with lower SES (P < 0.0001), and decreased with the proportion of recent immigrants in the region (P < 0.0001), after controlling for age, sex and co-morbidity. Although the allocation of publicly funded home care service was primarily based on perceived need rather than ability to pay, barriers to utilisation for those from areas with a high proportion of recent immigrants were identified. Future research is needed to assess whether the current mix and level of publicly funded resources are indeed sufficient to offset the added costs associated with the provision of high-quality home care.

Predictors of Influenza Immunization Among Home Care Clients in Ontario

This study examined factors associated with the receipt of influenza vaccination among Ontario home care clients. Home care clients were assessed, as part of a routine home visit, during a pilot study of the Resident Assessment Instrument - Home Care (RAI-HC) in 12 Ontario Community Care Access Centres (CCACs). The RAI-HC is a multidimensional assessment that identifies clients' needs and level of functional ability. Multiple logistic regression was used to identify factors associated with influenza immunization in the two years prior to assessment. The overall rate of immunization reached about 80% by 2002. Factors such as age, respiratory problems, diabetes and congestive heart failure were associated with greater uptake, but overall rates of influenza immunization were lower than expected. Low education, smoking and poor medication adherence were negatively associated with influenza immunization. In addition, there was considerable variation in uptake among CCACs after adjusting for other significant individual-level independent variables. Comprehensive assessments like the RAI-HC can be used to help identify and respond to health promotion and disease prevention issues in this population, and to compare rates across Canada.

Exploring limits to market-based reform: Managed competition and rehabilitation home care services in Ontario

The rise of neo-liberalism, which suggests that only markets can deliver maximum economic efficiency, has been a driving force behind the trend towards using market-based solutions to correct health care problems. However, the broad application of market-based reforms has tended to assume the presence of fully functioning markets. When there are barriers to markets functioning effectively, such as the absence of adequate competition, recourse to market-based solutions can be expected to produce less than satisfactory, if not paradoxical results. One such case is rehabilitation homecare in Ontario, Canada. In 1996, a “managed competition” model was introduced as part of a province-wide reform of home care in an attempt to encourage high quality at competitive prices. However, in the case of rehabilitation home care services, significant obstacles to achieving effective competition existed. Notably, there were few private provider agencies to bid on contracts due to the low volume and specialized nature of services. There were also structural barriers such as the presence of unionized employees and obstacles to the entry of new providers. This paper evaluates the impact of Ontario's managed competition reform on community-based rehabilitation services. It draws on data obtained through 49 in-depth key informant interviews and a telephone survey of home care coordinating agencies and private rehabilitation provider agencies. Instead of reducing costs and improving quality, as the political rhetoric promised, the analysis suggests that providing rehabilitation homecare services under managed competition resulted in higher per-visit costs and reduced access to services. These findings support the contention that there are limits to market-based reforms.

Market-Modelled Home Care in Ontario: Deteriorating Working Conditions and Dwindling Community Capacity

The closure of a non-profit, unionized home support agency in Hamilton in 2002 offers an illuminating case study of the local impacts of Ontario's contractual approach to home care. A survey of the 317 support workers who were laid off revealed that only 38 percent stayed in the home-care sector; most were absorbed by for-profit, non-unionized agencies where their employment conditions deteriorated. These findings are at odds with the long-established connection between quality of home-care employment and quality of home-care service. They have implications for developing criteria for dispersing public funds in mixed economies of community care, and for conceptualizing the capacity-building responsibilities of governments in their coordination.

‘You Need Them to Know Your Ways’: Service Users' Views About Valued Dimensions of Home Care

ABSTRACT Dominant approaches to evaluating supportive home care tend to be ‘top-down,’ undertaken from the vantage points of funding bodies and professionals, rather than from the perspectives of service users. A longitudinal, qualitative study of women receiving home care in Ontario, Canada explored their accounts of what constitutes good and responsive care. Participants identified four dimensions of care that they particularly valued: Minimized exposure, being known, staying in charge, and being able to speak. The implications of their perspectives for home care practice, evaluation and organization are discussed.

Venous leg ulcer care: How evidence-based is nursing practice?

Objectives: The objectives of this study were to (1) determine how congruent community-provided leg ulcer care was with best practice for venous leg ulcers and (2) identify organizational and clinical factors associated with the provision of best practice for venous leg ulcers. Design: The practice variation study group was an audit of nursing agency client records to determine the provision of care. Setting and subjects: The study population was a home care cohort of persons with venous leg ulcers (n = 66) who received care from one Ontario home care nursing agency between March 1999 and November 1999. Instrument: The audit tool was developed with a checklist reflecting the common recommendations from 3 international practice guidelines, as well as organizational and clinical factors that may influence or reflect best practice. Results: Half of client records (35/66) included an identified etiology of the leg ulcer. An Ankle Brachial Pressure Index score was documented prior to the initiation of compression on fewer than half of the records (21/44). Regular ulcer measurement was done for 11% of the clients (7/64). Two thirds of the clients (44/66) were treated with compression. More than 60% of the clients (40/66) had been seen by either a dermatologist or a vascular surgeon. Topical antibiotics were prescribed for two thirds of clients (44/64). Fifteen percent of clients (10/66) were assessed for pain, and 17% (11/66) received some form of pain management. Documentation of client education specific to the leg ulcer was present on 3% of records (2/66). The mean number of different nurses providing leg ulcer care to each client was 19. A registered practical nurse was the classification of nurse assigned to 43.8% (29/66) of the clients. Conclusion: Several gaps were identified in the care provided. A standardized approach to care is needed that includes a comprehensive leg ulcer assessment to determine the ulcer etiology, determination of an Ankle Brachial Pressure Index score to screen for the presence of arterial disease, and compression for all clients who meet the criteria for venous disease. A reorganization of services is required, which includes an increased role for community nurses in leg ulcer assessment and management. Organizational and clinical factors influencing the delivery of best practice need to be identified and addressed. (J WOCN 2003;30:132-42.)

Venous Leg Ulcer Care

Objectives The objectives of this study were to (1) determine how congruent community-provided leg ulcer care was with best practice for venous leg ulcers and (2) identify organizational and clinical factors associated with the provision of best practice for venous leg ulcers. Design The practice variation study group was an audit of nursing agency client records to determine the provision of care. Setting and subjects The study population was a home care cohort of persons with venous leg ulcers (n = 66) who received care from one Ontario home care nursing agency between March 1999 and November 1999. Instrument The audit tool was developed with a checklist reflecting the common recommendations from 3 international practice guidelines, as well as organizational and clinical factors that may influence or reflect best practice. Results Half of client records (35/66) included an identified etiology of the leg ulcer. An Ankle Brachial Pressure Index score was documented prior to the initiation of compression on fewer than half of the records (21/44). Regular ulcer measurement was done for 11% of the clients (7/64). Two thirds of the clients (44/66) were treated with compression. More than 60% of the clients (40/66) had been seen by either a dermatologist or a vascular surgeon. Topical antibiotics were prescribed for two thirds of clients (44/64). Fifteen percent of clients (10/66) were assessed for pain, and 17% (11/66) received some form of pain management. Documentation of client education specific to the leg ulcer was present on 3% of records (2/66). The mean number of different nurses providing leg ulcer care to each client was 19. A registered practical nurse was the classification of nurse assigned to 43.8% (29/66) of the clients. Conclusion Several gaps were identified in the care provided. A standardized approach to care is needed that includes a comprehensive leg ulcer assessment to determine the ulcer etiology, determination of an Ankle Brachial Pressure Index score to screen for the presence of arterial disease, and compression for all clients who meet the criteria for venous disease. A reorganization of services is required, which includes an increased role for community nurses in leg ulcer assessment and management. Organizational and clinical factors influencing the delivery of best practice need to be identified and addressed.

Elderly people's accounts of home care rationing: missing voices in long-term care policy debates.

Fundamental shifts in state intervention in recent years have resulted in steady curtailment in public provision of community and social care. A longitudinal study of elderly women receiving home care in Ontario explored the reverberations of these shifts in the texture of frail elderly people's lives. Three distinct accounts of negotiating unstable and rationed home care were discernible. "Taking charge" was an active account of women successfully impressing their particular needs and identities on home care provision. "Pushed over the edge" was a vulnerable account of insufficient and depersonalized care in which participants felt themselves practically and emotionally out of control. In "Restraining expectations", women adjusted silently to the shortcomings of home care, stoically making themselves smaller as they found their previous orbits and identities unsupported. Home care's front line emerged as a complex site of struggle for identity and agency--a struggle in which elderly people engage with inventiveness and determination but also with dwindling support, few witnesses and in mounting isolation.

Frail and Disabled Users of Home Care: Confident Consumers or Disentitled Citizens?

ABSTRACTHealth care cuts and restructuring are shifting the site of acute care from hospitals to homes and prompting provincial governments to introduce varying forms of mixed economies in home care. Typically, such arrangements seek to drive down public costs and to reposition service users as “consumers” of market-modelled care. Drawing on an ongoing study of frail elderly women and women with disabilities receiving home care in Ontario, this paper explores the significance for service users of these economic and political objectives. Rather than feeling like consumers free to exercise choice and demand quality in the mixed economy of home care, they experienced their positioning within it as insecure and subordinate and its supply as unpredictable and meagre. The implications of these findings for fashioning secure and equitable public responses to elderly and disabled citizens who need assistance at home over the long term are discussed.

Manufacturing Social Exclusion in the Home Care Market

This paper examines how the health care perspective which dominates home care obscures the broader processes of social exclusion that play out in this arena of public policy. A study of elderly women and women with disabilities receiving home care in Ontario reveals how managed community care generates and reinforces service users' social isolation and their spatial, institutional, and political exclusion. Analysis of study participants' experiences points to the challenges of moving away from a market discourse and a health framework to develop home care policy which achieves the inclusion and participation of elderly citizens and citizens with disabilities in need of assistance at home.

The development of Ontario's Home Care Program: A critical geographical analysis

In order to gain a greater breadth of understanding medical geographical issues, such as medically underserviced regions, medical geographers are paying more attention to health policy. Using existing evaluations, an historical analysis of home care programs in Canada's largest and most populous province informs how developments in long-term health care policy have contributed to the geographical inequalities that exist in home care services throughout the province. The geographical bias in the testing, planning and implementation of home care programs has influenced their availability, accessibility and quality in the underserviced region of northern Ontario. Exploring the history of long-term care policy in Ontario also sheds light on the contemporary politics of welfare reform taking place in much of the western world. In many western countries, home health care has moved from being a complementary or alternative form of long-term care, to the favored form of long-term care. The most recent long-term care policy reform in Ontario points to the decentralization of long-term care, a strategy that has already been in affect in some western countries.

Registered nurse employment in Ontario home care programs.

The utilization of Ontario home care program services has expanded dramatically in recent years, resulting in increasing demand for, and greater employment of, registered nurses in such programs. This paper examines the employment of registered nurses in Ontario home care programs, through registrant data collected by the College of Nurses of Ontario between 1984 and 1989. A sociodemographic and employment profile of home care program nurses is presented (contrasted with registered nurses in other employment settings), along with an analysis of the mobility of registered nurses to and from Ontario home care programs over the five-year period.