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Hidden Challenges of Moving Care Closer to Home

I read this recent article about Ontario's new provincial palliative care plan designed to make dying at home, or at least closer to home, a reality. It reminded me of a blog that I wrote a few years back about the challenges of moving care closer to home. I think it is still relevant today, so without further ado...

Benefits of Moving Care Closer to Home Ontario is increasingly leaning towards transitioning patients out of hospital beds and into care settings in their community, or better yet their homes. As Dr. Danielle Martin has pointed out, "not all patients who occupy hospital beds need acute care and not all patients in long-term care facilities need to be institutionalized". For many patients, care can be provided effectively in their own home.

Bringing Care Home, a report from the expert group on home and community care in Ontario supports this move, and provides recommendations to improve the patient experience, promote equal access to services in communities across the province, and identifies opportunities to support a sustainable and accountable community-focused health care system. 

There are many reasons for moving services out of the hospital ward and into your community: Population changes are increasing demands on health care services and the resources available are not increasing at the same rate, it significantly improves patients’ satisfaction with healthcare services, improves patient's attitudes towards their care, and improves patients knowledge of their individual conditions and treatments. Some international studies have found community and home care provides better access for patients in terms of the travel distance needed to see a specialist, as well as reduced waiting times for a specialist appointment.  And some evidence suggests that community based specialist care is as safe and clinically effective as conventional hospital care

A strong argument at the system and political level for shifting towards more community and home-based care is the reduction in costs. For instance, caring for terminally ill patients in an acute-care hospital is estimated to cost over 40% more than providing care in a hospital-based palliative-care unit, more than double the cost of providing care in a hospice bed, and over 10 times more than providing at-home care . The average per diem cost to support a patient in an Ontario hospital bed is about $842, in a long term bed is $126, and at home is only $42.

Hidden Challenges and Costs But it is not all roses and sunshine. There are hidden costs and challenges to moving care out of hospitals and into our homes and communities. We have to think about these, and address them, or we won't be able to achieve this admirable goal.

Lower wages - One of the reasons that home and community care can cost less is that personal support workers in the home care sector are often paid less than hospital based colleagues. They can be paid as little as $12.50/hour compared to hourly rates of $18 to $23 for their hospital-based colleagues.  

Working Conditions - Many personal support workers and other community workers are not unionized like their hospital based colleagues. They can face split shifts, physically demanding work, healthcare challenges (strained backs, etc.), travel, and the potential for unsafe conditions.

Standards and Practices - An OACCAC study points out there is insufficient research to create consistent province-wide standards and best practices, and an inability to collect and communicate standardized critical information needed to assess quality and deliver better client outcomes.

Ability to Share Data - Our team has also seen first hand in several of our projects one of the most persistent challenges facing our community organization clients - the lack of an IT tool that can be used to provide one common assessment and share client information. Often, clients/patients are required to provide the same story and personal health information each time they are assessed by different community organizations.

Burden Shifts to the Family - Moving care into the home means hospitals can provide less nursing care, less housekeeping, laundry or kitchen services. Where hospitals employ large staffs to provide these services, in the home care sector many of these services are provided by patients’ families. While it is a cost and resource saving for hospitals, it can be a source of expense and a source of stress for families to arrange.  Dr. Martin also points out that it is important to recognize that many patients who need home care do not have families to care for them.

Timing is Right There are many good arguments for moving care closer to home, and the Ministry of Health and Long-Term Care has supported many of the studies related to that move. However, more thought will need to be provided towards the hidden costs and challenges, in order to achieve a sustainable, high quality home and community care system.

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