Elizabeth Muggah is a family physician and an assistant professor and director of quality improvement in the department of family medicine at the University of Ottawa.
Do we have the political will in Canada to solve the home-care crisis?
Studies have repeatedly shown that home care is the most cost-effective and patient-centred approach for our aging population. Home care is 40 per cent to 75 per cent less costly than equivalent stays in long-term care facilities, for example. It is estimated that up to 50 per cent of people on wait lists for long-term care beds could safely stay at home if appropriate services were available.
Despite such evidence, financing for home-care services does not meet the growing needs of Canadians. In a report last September, Statistics Canada estimated that of the 2.2 million Canadians who received some help or care at home, almost one in seven had insufficient services. And a half-million Canadians who need home care were not able to access any services at all. These unmet needs are putting unnecessary pressure on more expensive medical solutions, which patients themselves do not prefer. They want to cope with their conditions at home, with proper support.
Home care has two main aspects: acute, short-term care for people who would otherwise need to be in a hospital; and longer-term, preventive care to allow people to live independently and avoid hospitalization and institutionalization. In many jurisdictions, limited budgets for home care have meant cuts in services, particularly for preventive care. Thus, while patients can typically get short-term home care (help with dressing changes after surgery, for example), it is much less likely that a frail, elderly person with a chronic illness or disability will get nursing or home aid assistance to help with bathing.
In my practice, I see an increasing number of seniors at risk of ending up in hospital for things that can be avoided, such as falling while getting in and out of the bathtub. Or they end up moving, earlier than they want to, into expensive institutional care so they can receive what are sometimes simple and inexpensive services.
But whose responsibility is it to solve this crisis? In 2004, federal, provincial and territorial governments agreed to finance three types of home care: two weeks of short-term, acute home care after discharge from hospital; two weeks of acute mental-health home care; and end-of-life care. This was a good start. But many home services were left out, particularly preventive-care services, and wide differences remain across the country in terms of what is funded.
A solution to this problem is available but requires political will.
First, all provinces and territories should cover all basic home-care core services – not just short-term, post-hospital care, but also longer-term, preventive-care services. The investment required is relatively low and will reduce the need for other expensive investments in health infrastructure – from bigger hospitals to more long-term care facilities.
Second, we need to start measuring health-care outcomes that are aligned with the desire of patients to stay at home. The current focus on issues such as wait times for emergency-room visits is too narrow and creates pressure to address the effects, not the causes, of these problems.
Third, we need to give family doctors the flexibility to conduct home visits. The number of physicians doing house calls has dropped dramatically in the past few decades. In part, this is due to a fee structure in many provinces that acts as a disincentive for them to do so – offering less than what we pay to have our furnace checked. But the biggest barrier expressed by physicians is a lack of time: Typically only one patient can be seen at home for every three or four seen in the office. Innovative approaches, such as dedicated mobile family health teams, need to be explored.
Last November, the College of Family Physicians of Canada released a report calling for a national home-care strategy by 2016. Of note was the fact that 65 per cent of Canadians surveyed said a political party's position on home care would influence their vote. Let's hope our politicians are listening.