E. Shapiro (2002). The health transition fund synthesis series: Home care. Ottawa, Health Canada.

http://www.hc-sc.gc.ca/htf-fass/english/home_care_en.pdf

Executive Summary
The Health Transition Fund (HTF), a joint effort between federal, provincial, and territorial governments, was created out of the 1997 federal budget to encourage and support evidence-based decision making in health care reform. Between 1997 and 2001, the HTF funded approximately 140 different pilot projects and/or evaluation studies across Canada. In order to communicate research evidence from the projects to decision-makers, experts were employed to synthesize the key process and outcome learnings in each of nine theme or focus areas: home care, pharmacare, primary care/primary health care, integrated service delivery, children's health, Aboriginal health, seniors' health, rural health/telehealth, and mental health.

This document summarizes the key learnings from 45 projects in the home care theme area. It has been prepared by Evelyn Shapiro, Professor/Senior Scholar, Department of Community Health Sciences, Faculty of Medicine, University of Manitoba. Public expenditures for home care services have more than doubled over the last decade. As many as one million Canadians use home care each year, and those numbers are expected to rise in the next two decades. This growth in both numbers and costs has raised concerns about whether it is occurring by default or by design, and whether access to and use of home care should depend on where Canadians live rather than on what they need. It is in this context that the lack of universality in home care services across Canada is increasingly leading to a call for a national home care approach with a single-entry access system.

At the same time, the trend of downsizing the hospital system is increasing the burden on home care programs and is pressuring the home care sector to transform itself from a continuum of care program to one that is subservient to the priorities of the acute care sector. This trend raises the question as to whether the cost of this shift makes sense.

The 45 Health Transition Fund (HTF) studies that fall under the home care rubric demonstrate the home care program's interest in improving services and addressing the pressure points on the system. The projects may be clustered into several major themes:
o making home care services more consistent across Canada;
o providing evidence as to whether home care is a substitute for long-term and acute care services or is in fact an add-on cost;
o exploring how home care might move beyond the traditional model of care targeting the elderly and disabled populations to include currently unserved or underserved subpopulations;
o examining how provincial policies and systemic issues might be impeding the best and most appropriate use of home care; and
o providing services outside the hospital setting.

One key to addressing research questions regarding some of these issues lies in improving the adequacy as well as the reliability of home care information systems. Many of the HTF projects relied on quantitative data but could not start without first gathering baseline data, thus impeding their ability to meet their projected deadlines. The development of a national database is progressing, but its eventual success will depend on the recognition that good provincial data are essential and that provincial policy differences will continue to create problems for the database's capacity to interpret the data.

Significant findings of the projects include a key national study involving 15 interrelated substudies, which found that in British Columbia, where data was available, home care for the elderly is a cost-effective alternative to various levels of care in long-term care facilities. The implications of the projects' findings for organization, management, legislation, service delivery, and resource allocation in regard to home care are fundamental.

Home care projects seeking means to reach underserved populations met with a degree of success in determining how First Nations and Inuit communities could implement their own home care programs, in addressing the unmet needs of the mentally ill, and in improving services to those with dementia, half of whom live at home.

A key finding resulting from studies that attempted to reduce the use of hospital emergency rooms and in-patient beds is that comparatively few studies achieved that goal. Indeed, there are serious implications for home care services that seek to substitute hospital services, and these approaches must continue to be thoroughly pilot-tested. As well, the increasing preoccupation with hospital substitution, as demonstrated by several HTF studies examining how to provide in-home neonatal services, diabetic education, and telehealth services, should raise serious concerns that home care is being led into acting as a substitute for public health services.

Scant attention has been paid to how home support services are organized and delivered. A recurrent theme in the HTF home care reports is dissatisfaction among both case managers and clients with home care policies in jurisdictions that purchase these services from external non-profit or for-profit agencies. And as home care service delivery faces new challenges in meeting the needs of a wider variety of clients, issues of human resource training, management, and wages are becoming of crucial importance. Together, the HTF projects helped encourage innovations in the home care sector. The HTF's major contribution was in insisting on an evaluation of their effectiveness. The following recommendations arise directly from the project reports or address gaps and priorities that arise from an overview of all the projects.

To Senior Federal and/or Provincial Policy-Makers
o It is time for both levels of government to implement a national home care program that
treats all Canadians equally and equitably. The absence of a federal- provincial agreement on a national home care program means that where Canadians live, rather than what they need, determines access to services, residency requirements, the payment of user fees, and the continuity of service providers. Furthermore, since user fees for support services create perverse incentives to use a more costly alternative, serious consideration must be given to basing access to a universal national home care program solely on a professionally assessed need for both health and support services.
o The current separation between case managers and service providers must be addressed. In situations where the public case management function of home care services is coupled with the private service delivery function, the efficiency, cost-effectiveness, and quality of care are hampered.
o Home care programs should not be pressed to assume the responsibility of filling gaps in public health services. Provincial policy-makers should review legislation to clarify both their own role and that of their regions as to which level is responsible for ensuring that gaps in resources are addressed by the most appropriate health care sector.
o If policy-makers decide to reorganize primary care, they would be well advised to start by thoroughly evaluating the results of this change before considering any change in the status or mandate of home care. Home care is a front-line but not a primary health service, and it is a unique blend of health and non-medical support services.
o The need for a Canada-wide data system must be addressed in order for provinces to compare their resources to those of other provinces and to research the relationship of home care use with the use of other health care services.
o Senior policy-makers must address the issue of home care standards and of who should be responsible for monitoring them. They must also address current and future human resource issues affecting the organization and delivery of home care programs.

To Regional and Home Care Managers
o Ways must be found to eliminate or reduce barriers that impede home care's vital links with hospitals and long-term care facilities.
o Regional managers must assume a leadership role in collaborating with hospital and home care managers to address the structural and systemic issues impeding the best use of resources.
o Both regional and home care managers must be careful to identify the potential "losers" if a decision is made to incorporate an innovation into their regular programs within their current budgets. The HTF projects synthesized in this document have added to our understanding of the issues facing home care in Canada. They make the case that home care's role in the health care system must be acknowledged and strengthened.