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into the home: <br>the cost of moving health care out of hospitals

Toby Harris, CEO of Travers Independence, a Kitchener-based non-profit that serves adults with aquired brain injuries and physical disabilites poses at one of its eight locations on May 7, 2015.Glenn Lowson/The Globe and Mail

It was one of the showpiece promises that Ontario's Liberals made before their government fell last year: A $4-an-hour wage hike for the personal support workers who are critical to the government's plans to shift health care out of expensive hospitals and into the home.

More than a year and an election victory later, the PSW "wage enhancement" program is beset by so many complexities that the government has delayed indefinitely the second phase of the pay hike – a $1.50-an-hour raise that was due April 1 – while it works to mop up the problems on the ground, a Globe and Mail investigation has found.

Twenty-seven mostly non-profit health-care agencies across the province are refusing to accept the government-funded increase and pass it on to their workers, while one of the largest private-sector employers of PSWs in Ontario cut what it pays in mileage and travel time just after the first phase of the raise kicked in last fall, leaving some employees worse off than they were before the wage-enhancement program began.

The PSW raise was also more expensive than expected, costing the province at least $77.8-million in 2014-15, 56 per cent more than the $50-million earmarked for the first year of the pledge.

Although Health Minister Eric Hoskins has vowed that this year's portion of the raise will eventually be doled out retroactively to April 1, the delay has caused "a lot of confusion, uncertainty and frustration," among PSWs in the home and community care field, according to Kelly O'Sullivan, the chair for CUPE Ontario's health-care workers.

"It adds to the ongoing precarious nature of this work," she said. "You can't even depend on a wage increase that's been promised to you by the government."

The government's PSW Workforce Stabilization Strategy was designed to make home-care work less precarious, not more.

PSWs deliver more than half of all home-care services, helping clients to dress, bathe, prepare meals, tidy up and manage medications, among other tasks. Yet their paycheques are traditionally smaller and their schedules more erratic than those of PSWs who work in hospitals and nursing homes, making it difficult to retain quality workers in home and community care.

Convincing PSWs to choose the home-care field is essential to the Ontario government's efforts to keep people out of hospitals and nursing homes for as long as possible – a way to stretch increasingly scarce health-care dollars and respond to the public's desire to heal and age at home.

People interviewed for this story were quick to praise the Liberals for trying to improve the lot of home-care PSWs and their clients by raising their minimum wage to $16.50 an hour from $12.50 over three years. The intention was laudable, they said. The execution of the plan was not.

"This should be the best news story ever," said Deborah Simon, the chief executive officer of the Ontario Community Support Association, which represents hundreds of non-profit agencies that help people at home. Instead, Ms. Simon said, the Byzantine rules around the pay hike have created an "administrative burden" for organizations.

At the heart of the problem is which workers – and which kinds of work – qualify for the government-funded pay bump.

While the government set a wage floor of $16.50 an hour as of 2016-17, it delivered the public funds through a "wage enhancement" that only applies when PSWs are providing "personal support services" funded by Local Health Integrated Networks (LHINs), the province's regional health authorities.

That means time spent in training, travelling to clients' homes or performing tasks such as food preparation do not qualify for the higher rate. Initially, even statutory holidays were paid out without the increase, although that has been reversed.

Jason Lye, national head of independent living services at March of Dimes, says his agency spent months clarifying provincial rules, only passing on the first phase of the raise retroactively to workers in February in the form of a "blended rate" that takes into account how they historically have divided their time.

"The way I like to interpret it is when you see the whites of the clients' eyes, you are paying the $1.50," Mr. Lye said.

There were other complications. The raise goes to all PSWs doing work that qualifies, meaning the $4 increase goes to everyone, whether they are making a base wage of $12.50 or $22 an hour. That has put pressure on employers to give raises to others, such as registered practical nurses and supervisors.

The rules also exclude some PSWs because of where they work or because the provincial funds that pay for their services do not flow through the province's 14 LHINs. The result is that PSWs within the same organization can be treated differently.

Kingsway Lodge Fairhill Residence in the southwestern Ontario town of St. Marys chose to reject the increase because it would create an untenable disparity in its already well-compensated PSW work force. Hourly wages there range from $17.73 to $20.44.

The organization operates a nursing home with round-the-clock care, a retirement home and six supportive-housing suites where residents receive a few hours of personal support per day. The wage enhancement would have applied only in the supportive apartments.

"There would be no way to do it because our staff flow between the three levels of care," said Theresa Wakem, the facility's administrator.

At Traverse Independence, an agency in Kitchener that serves adults with physical disabilities and acquired brain injuries, management had to find $27,000 in a $6-million budget to give eight PSWs working in a day program the same raise as their colleagues.

"It was a hardship," said CEO Toby Harris. The agency eliminated half a supervisor's job to cover the increase and hopes the excluded workers will eventually be covered.

At least one large, for-profit home-care company chose to claw back compensation in other areas shortly after the first phase of the raise took effect last fall, retroactive to April 1, 2014.

A memo sent in November by Revera Home Health to non-unionized PSWs in North Simcoe and Muskoka, and obtained by The Globe, says the government-funded raise "takes the place of any other increase that Revera would have normally provided" – an apparent contravention of a provincial directive. A second Revera memo to Ontario staff, also obtained by The Globe, outlines a reduction in pay for mileage and travel time for non-unionized PSWs, effective Jan. 1 of this year.

Revera Home Health has since been bought by Paramed, the largest provider of in-home health care in the province. A spokeswoman for its parent company, Extendicare Inc., declined comment on decisions made by Revera, but said Paramed is complying with the ministry's directives.

Trish Barbato, who headed Revera's Home Health division before the sale, said the travel rate reductions applied to all staff – not just PSWs – and was not linked to the government-financed raise. Ms. Barbato said it was the firm's intention to review the PSW pay grid after the first phase of the wage enhancement, adding there is "no standard" for an annual pay increase in the sector.

One PSW who has works for Revera Home Health in London said the company's decision to cut mileage and travel time cost the PSW about $200 per paycheque, more than erasing the government's pay increase.

"The wage enhancement helped a little bit, but we're still on the losing side," said the PSW, who asked not to be named. The company's London employees are not unionized.

The PSW said some workers in London are refusing to serve clients outside the city because they are paid so little to travel there. "If I drove six hours in the county, I'd be lucky to get paid for three hours," the PSW said.

"Some of [the clients] don't get seen," the PSW added. "And then there's a thing called the family back-up plan. If a PSW can't make it the family has to rely on their own back-up plan. Try to get a relative to go see the client, stuff like that."

Dr. Hoskins said before the Liberals committed to the pay increase, "we didn't have a tremendous amount of information about our PSWs – who they're working for, how much they're being remunerated, specifically."

The ministry is gathering data so it can "fine-tune" the second year of the program, including whether future increases should apply to all PSWs, even those already earning much more than $16.50 an hour, he said.

He added that nearly 500 health-service providers have passed the increase on to their PSWs and the government expects the 27 holdouts to follow suit.

As for Revera's changes, "I find that unacceptable," Dr. Hoskins said. "The ministry would be looking into those circumstances if they were brought to our attention."

Sharleen Stewart is president of the health-care arm of the Service Employees International Union, which organized the push for a $16-an-hour minimum wage. SEIU members stood cheering behind former Health Minister Deb Matthews last year spring when she announced the wage increase just two days before the government introduced a budget that was ultimately defeated, triggering the election.

Ms. Stewart is proud of what SEIU's campaign accomplished, but she is frustrated that the increase does not apply to all work. "It's all over the map," she said. Her members only realized the two-tiered nature of the reforms last October when their first cheques arrived with the increase and they saw it did not apply to all of their hours. "It's a work in progress," she said. "We are hopeful we will sort it all out."

Ms. O'Sullivan, the CUPE representative, called the program's rollout "a reflection of a broader problem" with home and community care in Ontario.

"If we can't figure out – we as in the government, the agencies and the unions – how everyone should be getting something as simple as a wage increase in an equitable way, can you imagine if you are a family member or a patient needing care, what the system must be like?"

This is the first article of a Globe investigation into the challenges of moving health care out of hospitals and into the home. If you have a personal story to tell, contact Elizabeth Church at and Kelly Grant at

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