AMy home is not my home anymore:@ Improving Continuity of Care

AMy home is not my home anymore:@
Improving Continuity of Care in Homecare
December 2001
Christel A. Woodward, PhD
Julia Abelson, PhD
Brian Hutchison, MD, MSc
Funding provided by:
Canadian Health Services Research Foundation
Ontario Ministry of Health and Long Term Care
Principal Investigator:
Christel A. Woodward, PhD, Professor
Centre for Health Economics and Policy Analysis
Department of Clinical Epidemiology and Biostatistics
McMaster University, 1200 Main Street West
Hamilton, Ontario L8N 3Z5
Telephone: (905) 525-9140, ext. 22879
Fax: (905)546-5211
E-mail: [email protected]
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(www.chrsf.ca).
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AMy home is not my home anymore:@
Improving Continuity of Care in Homecare
Christel A. Woodward, PhD1
Julia Abelson, PhD1
Brian Hutchison, MD, MSc1, 2
1
2
Department of Clinical Epidemiology and Biostatistics, McMaster University
Department of Family Medicine, McMaster University
Acknowledgments:
We would like to thank the Hamilton Community Care Access Centre and community homecare
agencies in Hamilton for their assistance in carrying out this study. We especially appreciate the
support for this research provided by our research advisory group. The participation of the Hamilton
Community Care Access Centre homecare clients is gratefully acknowledged.
Table of Contents
Key Implications for Decision Makers ........................................................ i
Executive Summary .................................................................................... ii
Context.........................................................................................................1
The Homecare Sector in Ontario.....................................................2
The Homecare Sector in the City of Hamilton.................................3
Implications of the Research Findings.........................................................4
Improvements in Communication ....................................................4
Service Provision .............................................................................4
Contracts and the Contracting Process...........................................5
Human Resources ............................................................................6
The Approach...............................................................................................6
Results..........................................................................................................7
What do key stakeholders see as important components of
continuity of care in homecare? ......................................................7
What problems exist with care continuity......................................11
What facilitates continuity of care? ...............................................12
What challenges are there to overcome?.......................................13
What kinds of clients are most affected by lack of
care continuity? .............................................................................16
What are the effects of managed competition? ..............................19
What strategies can be pursued to improve continuity of
care under managed competition?.................................................21
Additional Resources .................................................................................22
Further Research ........................................................................................23
References..................................................................................................25
Additional Bibliography ............................................................................25
Key Implications for Decision Makers
$
In the mid-1990s, Ontario’s homecare sector underwent dramatic changes in the way
services are organized and paid for, as a system of managed competition was
introduced.
$
The main barriers to continuity of homecare lie in problems with staff and a lack of
information.
$
Problems with continuity of care can occur when care plans are being designed and
evaluated and when services are being delivered by homecare workers.
$
The systems for monitoring service contracts and service delivery are inadequate,
resulting in duplication and poor continuity.
$
There is a high turnover rate in the homecare sector, due to lower wages and benefits
than the institutional sector.
$
Homecare clients should have consistent service providers to maximize efficiency
and improve care continuity – when service providers know how the home is
organized, they can work more quickly and efficiently.
$
Service providers must consistently have the appropriate knowledge and skills to
effectively do their jobs.
$
Co-ordination of services to meet the care plan for homecare recipients is necessary
for continuity of care.
$
The competitive bidding process means Community Care Access Centres and
service providers cannot work collaboratively, which hinders continuity of care.
$
Better communication among stakeholders is required. Communication – especially
during transition periods – is inadequate between case managers and service
providers, resulting in poor continuity of care.
i
Executive Summary
Context
The management of homecare services changed following the 1995 election of a new
provincial government in Ontario. Forty-three not-for-profit transfer agencies called
Community Care Access Centres (CCACs) were created to manage homecare and act as
purchasers of services for homecare clients. CCACs were directed by volunteer
community boards overseeing the introduction of competitive contracting for homecare
service provision. At the same time, hospital downsizing led to patients being discharged
sooner, sicker, and more likely to need homecare during their recovery at home.
In this environment, we examined what continuity in homecare means for different
stakeholders, including longer-term clients, case managers, service providers, and
community physicians. We also examined the problems with care continuity that clients
experienced, the implementation of the competitive contracting model, and the impact of
competitive contracting on continuity of care and the consistency of homecare personnel
for clients in one Ontario community.
The Implications
There are many implications of our findings for policy makers, case managers, and
service providers. Policy makers must think of the homecare sector in terms of the
broader healthcare system, and they need to pay greater attention to the factors that
promote continuity of care.
Requests for proposals process should be changed so that CCACs can better compare
information from service providers, and better mechanisms are needed to monitor how
well the service providers follow contract terms, including guarantees regarding
communication strategies and consistency of personnel. As well, longer contracts would
provide greater stability for both clients and the homecare workforce.
ii
Case managers and service providers should consider lengthening the contract overlap
period to ensure knowledge about clients is passed on to new workers. More effective,
active communication between service providers and case managers is necessary, and
case managers should have lighter case loads to allow sufficient time for case planning
and review. As well, monitoring systems should be developed to ensure high consistency
of care. One possible way to alleviate problems would be to use primary provider teams
and backup teams to reduce the number of workers visiting a client. Another would be to
stop using short appointments for homemaking services, as fewer, longer appointments
are a more efficient use of time.
The Approach
Over the two years of the study, we used a variety of research approaches to develop an
understanding of continuity of homecare and the issues surrounding it. In particular we:
y
conducted key stakeholder interviews;
y
surveyed clients;
y
examined client care provision records;
y
studied sections of agencies’ service delivery proposals; and
y
discussed our findings and implications with our advisory group.
The Results
Continuity of care in homecare has two dimensions that interact with each other to
promote continuity: case management and service provision. Case management includes
negotiating a care plan with clients and their families, and then monitoring and reevaluating the plan to ensure efficiency. It also involves co-ordinating services to
effectively meet the care plan. Service provision includes ongoing service delivery by
providers who consistently have appropriate knowledge and skills to meet the clients’
needs. There must be ongoing, accurate observations of the clients’ conditions. Most
importantly, clients and their caregivers must develop trusting relationships, and the
various members of the care team must communicate well with each other. Clients also
believe consistent timing in their care appointments facilitates continuity of care.
iii
There are several problems with both case management and service provision that
interfere with continuity, however, and there are aspects of the competitive bidding
process used in the Ontario homecare sector that exacerbate the difficulties in achieving
continuity of care. Some of the barriers to continuity include human resource problems,
inadequate communication among stakeholders (particularly during transition periods),
differing client needs (which make it impossible to have a “one size fits all” care plan),
the diversity of the community care sector, and inadequate systems for monitoring
service contracts and delivery.
Two strategies facilitate and support homecare continuity: effective communication
among all stakeholders and consistent personnel. Current communication strategies are
primarily passive, except when working directly with the client, and clients who require
multiple visits per week generally have less consistency in personnel.
The home as a setting for care also presents novel challenges to care delivery that
contribute to the need for greater care continuity and/or make it more difficult to deliver
care continuity. These include a different idea of what is acceptable to clients regarding
service provision than if they were in an institution, and the need for knowledge about
how the home is organized to deliver services effectively. An additional difficulty is that
the healthcare team is not in one setting where they can meet regularly, and most
communication among team members is likely to be passive.
iv
Context
Homecare, the provision of an array of a health and social services designed to support
living at home, is the most rapidly expanding sector of the Canadian healthcare delivery
system.
Although resources allocated for homecare have increased rapidly, funding increases
have not matched the growing need for homecare. For example, inflation-adjusted
homecare expenditures by the Ontario Ministry of Health and Long-Term Care grew by
70.9 percent between 1991 and 1999; yet they were still seen as inadequate.
Three trends have influenced the rapid growth in homecare expenditures. First, the
financial constraints faced by Canadian hospitals during the 1990s led to earlier discharge
of people recovering from surgery or acute illnesses, who were more likely to enter the
homecare system. Second, demographic changes due to increased life expectancy mean
that there are more frail, elderly people who need ongoing health services and support to
remain in their homes. Third, a growing segment of the population has chronic illnesses
and physical disabilities. These people are living longer, often at home, where they
require some nursing and other support services. These factors have created pressure on
the homecare sector to deliver services to a growing number of clients with a wide range
of needs. Service delivery may be an acute-care substitute for a short period, or it may be
a long-term care substitute or a method for maintaining functioning levels or slowing
deterioration in health over an extended period of time.
The structure of homecare systems differs across provinces. Four models are used to
deliver publicly funded homecare: public provider (all providers are public employees);
public professional and private home support (public employees provide professional
care, and home support care is contracted to private agencies); mixed public and private
(public employees provide case management, and services are provided by either private
or public employees); and contractual (publicly funded services are delivered by a mix of
1
for-profit and not-for-profit agencies who are awarded the right to deliver services
through a competitive bidding process). This latter model, currently used in Ontario, was
studied.
The Homecare Sector in Ontario
In 1996, the Ontario government established Community Care Access Centres (CCACs),
which are mandated to assess potential homecare clients and arrange delivery of
homecare services through a range of community for-profit and not-for-profit private
agencies (Witmer, 2000). The CCACs provide a case-management function for
homecare clients. In their role as government transfer agencies they contract out service
delivery through a process that involves competitive bidding by agencies for service
delivery rights, based on requests for proposals issued by local CCACs. This competitive
bidding process was developed in the hope that they would promote effective, highquality services delivery at the “best” (cheapest) price.
The measurement of quality in homecare is in its infancy, which complicated the
implementation of the bidding process. Consensus about what quality in homecare
means or how it should be defined or evaluated does not exist. There are no standardized
quality indicators for homecare. We do not know whether homecare that we would
subjectively consider “high quality” produces better outcomes than “usual care,” because
no consensual definition of these terms exists. To develop sound measures, the processes
and outcomes involved in homecare need to be carefully defined to allow their precise
measurement. For example, continuity of care is usually seen as a “good” thing that is
important to care quality. Yet, how it operates in the homecare setting and its
contribution to homecare outcomes are not known.
The introduction of managed community care attempted to “even the playing field” and
allow a greater range of provider agencies to enter the homecare service delivery market,
including for-profit companies. Prior to the introduction of the 1996 reforms, not-forprofit organizations dominated the provision of professional services such as nursing and
therapy while the provision of homemaking services was shared between not-for-profit
2
and for-profit agencies. Unionized workforces dominated not-for-profit organizations,
while non-unionized workforces dominated the for-profit agencies. Companies (either
for-profit or not-for-profit) that established homecare businesses after 1995 were
exempted from pay equity laws by which existing companies had to abide. The “new”
agencies therefore, theoretically, had an advantage over their competitors on the pricing
side of the equation.
The Homecare Sector in the City of Hamilton
The Hamilton CCAC, one of the largest in Ontario, serves a population of about 500,000
and was one of the last to be established, in October 1997. The first competitive bidding
process was initiated soon after the CCAC’s establishment, and the first service contracts
were awarded in November 1998 for approximately one-third of all nursing and
homemaking services provided in the region to clients living in the downtown “core”
area of the city. A second bidding process took place in 1999 to award nursing service
contracts for the remainder of the CCAC’s client population. In the first contracting
process, one agency received a contract for 73 percent of homemaking services provided
to the core area. A single agency (new to the community) gained the remaining 27
percent of market share. On the nursing side, a single agency received a contract for 80
percent of services delivered, while the remaining 20 percent went to another agency.
Major questions addressed in this study include:
1. What do key stakeholders see as important components of continuity of care in
homecare?
2. What problems exist with continuity? Are there barriers to and facilitators of
continuity?
3
3. What are the effects of managed competition on continuity of care?
4. What kinds of clients are most likely to be affected by lack of care continuity?
What kinds of clients require high continuity of care?
What strategies can be used to improve continuity of care in homecare under managed
competition?
Implications of the Research Findings
Several strategies to improve continuity of care in homecare were identified. These
strategies relate to improvements in communication, service provision, contracts and
funding, and human resource policies.
Improvements in Communication
More effective communication strategies are required to ensure that care plans are
developed through consultation with clients (and caregivers, where present) and are
delivered with consistency. Communication should be ongoing among all stakeholders.
More direct, active communication between stakeholders is required. Each service
provider tends to communicate actively with the client; however, for communication
among the care team, passive communication is relied on too heavily. Improved and
expanded use of communication technologies are needed that ensures that active
communication that provides feedback to the person communicating occurs. More
effective communication is required about the bidding process and its results within the
CCAC and among CCACs, providers and clients.
Service Provision
The case loads of case managers must allow sufficient time for care planning, case
monitoring and reassessment. Service provision must start with a careful assessment of
needs through consultation with the client and all stakeholders. The key caregiver of a
client should be involved in the care planning and implementation process. Special
attention should be given to ensuring that a high level of care continuity is maintained for
vulnerable clients such as the frail elderly, those suffering from dementia, mental health
4
problems, acquired brain injuries, or serious mobility impairments, and people who are in
the terminal phase of life or have caregivers who are at risk for burnout. Their care must
be handled very carefully, especially during transitions created by managed competition.
Agencies should consider using a primary provider with a small team and a regular
backup team to avoid frequent visits by personnel who do not know the client, the way
the home is organized, or the client’s care needs. The care team should be aware of how
many other different services and providers are also visiting the client’s home. CCACs
and agency managers should rethink the use of one short appointment (one hour or less)
for homemaking as they are often an inefficient use of time. Fewer, longer appointments
allow homemakers to get more work done.
Contracts and the Contracting Process
The requests for proposals used must spell out the information to be contained in a bid
precisely enough to agencies that those reviewing the contract can make decisions based
on comparable data from each bidding agency. Contracts and the contracting process
must address agency capacity issues and critical mass. Contracts must be of sufficient
volume to allow agencies to sustain themselves. Extending the length of contracts is also
needed to add stability to the system and help stabilize the human resource pool. Some
specialization in contracts to ensure that vulnerable groups are served appropriately
should be sought. Requests for proposals should require agencies to describe how they
will ensure a high level of care continuity to such vulnerable groups. After new contracts
have been awarded, the hand-over period between agencies/personnel must be long
enough to ensure appropriate, smooth transitions. When managed competition forces
agencies to rely on part-time staffing to the detriment of full-time employment, the longterm stability of the workforce is jeopardized. Including requirements for active
communication and use of innovative communication strategies in requests for proposals
will ensure that these important features are part of agency contracts. Better strategies are
needed for monitoring contracts, once awarded, to ensure that agencies comply with the
terms of their contracts.
5
Human Resources
Several strategies could be used to better support the homecare human resource pool
available and lessen the turnover in this field. Besides longer contracts, possible
measures to stabilize the human resource pool for homecare include ensuring that there
are more full-time employment opportunities available in the homecare sector. More
workers would be attracted to and remain in this sector if their wages and benefits were
similar to other sectors. Ensuring that the necessary educational opportunities are in
place to train workers appropriately is also important. Standards for unregulated workers
are needed to raise clients’ level of trust in this category of worker.
Policy makers need to consider homecare within the whole healthcare system. For
example, one systemic solution to the homecare human resource problem is a common
human resource pool. This approach would help stabilize the human resources available
to homecare. However, the homecare human resource pool currently operates in isolation
from the health human resource pool for the primary and institutional care sectors in
Ontario. By integrating homecare into the rest of the healthcare system, homecare would
find its way onto decision makers’ radar screens and, therefore, have a better chance of
being considered in healthcare policy decisions.
The Approach
We collected both quantitative and qualitative data in this study using a mixed-methods
design. We also benefited from the knowledge and experience of our research advisory
group of homecare managers and decision makers. We used qualitative methods to
understand how continuity of care was conceptualized by managers, clients, caregivers
and workers in the homecare system who were associated with the Hamilton CCAC.
They also told us about their experiences with the bidding process. In total, 65 people
who had different vantage points regarding the homecare system were interviewed.
To understand more about the types of information agencies provided to the CCAC to
make decisions when awarding contracts, we studied a section of agencies’ responses to
the requests for proposals (their answer to the question in the request about how they
6
would ensure consistency of service providers). Supplemental information was sought
from the agency about how they defined three key concepts: team, continuity of care and
primary nurse.
We were interested in learning about the consistency of homecare personnel, the reasons
for changes in personnel, the factors that affected the consistency of personnel for a
client, and whether the consistency of service personnel improved after transfers from
one agency to another. To better understand these issues, we reviewed service provision
records for all nursing and homemaking homecare agencies involved with 600 clients –
200 from the city core where transfer of nursing and homemaking services occurred after
the first round of competitive bidding, and 400 from the surrounding area where transfer
of nursing services occurred after the second round of competitive bidding by agencies.
The records were sought for the twelve-month period during which new, competitive
contracts were awarded.
Information about reasons for provider changes, not available in administrative records,
was sought from clients and our advisory group.
We surveyed a random sample of longer-term clients to determine whether the
information that we had previously gained from client interviews was also the experience
of current clients.
We had many meetings with the agencies in the community to discuss our findings, their
implications, how these might be applied, and what further research might be needed.
Results
What do key stakeholders see as important components of continuity of care in
homecare?
Continuity of homecare exists when the services delivered are co-ordinated and follow
the objectives of a care plan developed for and with the client (and caregiver, when
appropriate). The services occur in an uninterrupted fashion, changing as the needs of the
7
client change and objectives of the care plan are met or revised. The people delivering
services consistently demonstrate the appropriate knowledge and skills to carry out the
care plan, provide accurate ongoing observation of the client’s condition, and have
established good rapport with the client and good working relationships with other
members of the care team with whom they must work to deliver the services needed (See
Table 1). Clients included consistency of timing of service delivery as part of continuity
of care. The slightly different nuances provided by our different types of reporters are
summarized in Table 2, including their perceptions regarding how well continuity of care
has been implemented.
Table 1: Dimensions of Continuity in Homecare
Managing Care
Description
Care Planning, Monitoring
and Review
A care plan is developed that is negotiated with the client and
caregiver and provides the services needed to meet the care plan’s
objectives. The delivery of care is monitored and adjustments are
made to the care plan as needed to ensure its objectives are met or
revised to meet changing client needs.
Care Co-ordination
All relevant care required by the client is arranged and delivered
without delays and disruptions in service.
Service Provision
Continuous Service Delivery
Uninterrupted service occurs as planned.
Consistent, Appropriate
Knowledge and Skills
Service providers consistently demonstrate the knowledge and
skills needed to deliver care to the client. Knowledge and skills of
three types are needed: related to the client and caregiver; related to
the care required; and related to the home.
Ongoing, Accurate
Observation
The client’s condition is continuously monitored. Changes in the
client’s condition are noted and reported to the appropriate service
providers and case manager.
Trusting Relationships
A relationship of trust is established with the client (and caregiver).
Effective Teamwork
Members of the team delivering healthcare and managing its
delivery have good working relationship.
8
Table 2: Continuity of Homecare: Perceptions of Various Stakeholders in Ontario
Stakeholder Type
Managing Care
Continuity
Development,
Monitoring and
Review of Care
Plan
Co-ordination
Service Provision
Continuous
Service Delivery
Appropriate
Knowledge and
Skills
Ongoing
Observation
Client/family caregivers
Service providers
Case Manager
may or may not feel consulted; some
clients unaware of care plan or
interpret it as a list of services
provided
involved in negotiation of how
things are done in the home with
client and family and
implementation of care plan; must
translate it into action and may
modify it
develop care plan for publicly
funded services; report
sometimes plan not wellformulated due to hospital
discharge pressure, little time
for monitoring and reassessment
some report good co-ordination;
others report poor follow-through
may be unaware of other services
obtained
play key co-ordination
management role
report that service is usually
delivered; few missed appointments
and interruptions reported
work with scheduler at agency to
ensure care is consistently
delivered
see continuous service
delivery as their priority
report wide variation in worker’s
skill and knowledge level that
affects the quality of care they
provide, particularly homemaking
and personal support; complain
about need to convey the same
information again and again
homemakers require the most
knowledge about how the house is
organized, client likes and dislikes,
background; sometimes need
technical skills; need to know what
client can do for self to support
independence
recognize that workers may
vary; see selves as helping to
communicate knowledge
regarding client, care needs
and household
indicate this is a major area
of complaint from their
patients, particularly
differences in skills and
knowledge
nurses comment more frequently
about this aspect of their work than
homemakers, provide reassurance
to client that improvement is
occurring, alert physician to
problems
see themselves as also
monitoring the client by
telephone calls and reports
from service providers
suggest frequent changes in
nursing personnel do not
allow good monitoring;
cause unnecessary concern
and duplication of services
9
Physicians
sometimes not involved to
extent they feel is needed
Stakeholder Type
Managing Care
Continuity
Trusting
Relationships
Teamwork
Among Service
Providers
Consistent
Timing*
Client/family caregivers
Service providers
Case Manager
quality of relationship with service
providers more important to some
than others, e.g., if provider is a
source of social support; major
incompatibility may lead to request
for provider change; clients trust
nurses more quickly than
homemakers; lack of relationship is
depersonalizing
seen as necessary to carrying out
their responsibilities in the home;
negotiating how and sequence of
service delivery requires tact;
report some clients will cancel
visit rather than have a stranger
come to do the visit
need to establish client’s
confidence and trust; report
that clients value relationship
with service providers; some
clients may feel vulnerable to
being taken advantage of
report service providers often do not
know each other and may be
unaware of other services coming to
the home
important, especially for
homemaking services, as it supports
routines in activities of daily living;
unable to plan day effectively if
visits are at differing times each day
important to working together
effectively
must establish rapport with
members of the care team
homemakers indicate that when
assigned the same person
consistently, they are more likely
to be able to support clients’
wishes for consistent timing;
nurses report that urgent care
needs of other clients may interfere
with schedule and delay regularly
scheduled visits
not seen as part of homecare
continuity, but some
acknowledge clients prefer
this
* Only clients see this as central to care continuity
10
Physicians
indicate that need some prior
experience with nurse to be
able to judge the importance
of observations made
report that lack of consistent
timing of nursing care is a
complaint of their patients
What problems exist with care continuity?
Problems exist with both the management of care continuity and with service provision.
Issues in the management of care continuity. Case managers reported they were more
likely to be reactive than proactive in dealing with their clients’ needs. They carried large
case loads and lacked adequate time for care planning, monitoring, review, and coordination. Care co-ordination existed mainly for services directly paid for by the CCAC
and tended not to include other community services. Case managers who were stationed
at hospitals reported insufficient time to develop an appropriate care plan for clients who
were discharged very rapidly. Some clients were not aware of their care plans, and
service providers sometimes were unaware of or did not follow the service plan well.
Although services, once begun, were usually consistently delivered, gaps in service
delivery occurred due to waits for needed services or failure to follow through on services
promised to the client.
Issues in Service Delivery. Clients often expressed concern about the need to re-explain
their situation and care needs to new service providers who 1) sometimes did not possess
the skills to meet their needs, and/or 2) did not know how their households were
organized and required extensive explanation and direction. Sometimes, lack of ongoing,
accurate observations or limited trust in service providers’ knowledge led primary care
physicians to see patients to reassure themselves or their patients and their families.
Clients reported some homemakers were poorly trained and did not provide the care they
were supposed to deliver. A few clients complained that things had been stolen from or
broken in their home, but with the rapid turnover in workers they could not tell who had
done it. The absence of rapport between some clients and service providers made care
delivery less than optimal. Some clients refused to have a service provider visit if their
regular worker(s) were unavailable, even when they desperately needed the service (e.g.,
received palliative care).
11
What facilitates continuity of care?
The two major strategies used to provide continuity of care are communication and
consistent personnel. They are the vehicles by which care planning, monitoring, and
review, care co-ordination, continuous service delivery, consistent knowledge and skills,
ongoing, accurate observation of changes (or lack of change), and good rapport and
working relationships can be achieved.
Communication patterns within homecare are complex. Good communication may be
achieved through a variety of methods, including face-to-face meetings, telephone calls,
voice messages and written messages left in the home. Excellent communication allows a
care plan to be developed and implemented that best meets the needs of the clients and
their family caregivers. It also assists the case manager in monitoring how well the plan is
implemented and allows rapid readjustment of the care plan and services provided when
a client’s needs change. It is required to ensure that the care received is well-coordinated. Good communication ensures that service providers are aware of what is
happening and changes that have occurred. It permits sharing of knowledge about the
client and caregiver, the care required and how it can best be delivered in this household.
It is needed to build effective partnerships with clients and their families and the other
members of the care team.
Consistent service personnel were valued highly because they dramatically reduced the
complexity of communications required and improved service providers’ ability to make
accurate observations across time, important to both physicians and case managers. All
of the aspects of care continuity were supported by consistent personnel. Consistent
personnel gain detailed tacit knowledge of clients and their care needs. They understand
the context in which the needed care is delivered, the client’s home.
“If you get to know the person who is coming to help you, I think it is a
far better arrangement. Certainly it is a better arrangement for the person
who is doing the helping, because they not only get to know you and how
you like things done but they get to know where the equipment is. You
12
know, you go into a strange apartment each time and you could spend
quite a lot of time finding whatever is required to do the laundry.”
-ClientService providers are often chosen by their agency to work with the client because they
have the specific requisite skills. The development of good rapport with the client and
family is facilitated by consistent personnel. Clients reported greater personal comfort
with the service providers whom they had gotten to know and trust. Having consistent
personnel allows a good working relationship to develop among members of the care
team, which makes communication among service providers easier. Consistent personnel
is not a guarantee that the same person delivers all the services that a client needs. But,
within service type, consistent personnel can be provided by small teams of two or three
workers, particularly if there is a primary provider who delivers most of the services.
What challenges are there to overcome?
Issues related to communication. Lack of effective communication creates problems in
all aspects of care continuity. In our study, stakeholders reported many communication
breakdowns and failures. Difficulties with communication were exacerbated during
transitions. Mainly passive communication strategies are used, except when working
directly with the client. They are not adequate to ensure good information transmission.
Service providers may be unaware of other services that the client receives. Service
providers may not understand the care plan well enough to implement it appropriately.
More active communication is needed, particularly between service providers of the same
type and between all service providers and the case manager. A telephone survey of 111
CCAC clients revealed that 25 percent did not know whom to call if they needed changes
in the type of services they received or their frequency or if they had a concern about a
worker who came to their home.
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Clients disliked having to repeatedly explain how their house was organized, their care
routines and what needed to be done when different workers (especially homemakers)
were sent to deliver care. It reduced the time available to get the help that they needed
during a visit.
Issues related to consistent personnel. Although clients were reluctant to complain
about homecare services, as they often saw them as vital to staying in their home, they
often commented on the need for consistent personnel as something their homecare
lacked, at least for a period of time.
“The lack of continuity is very wearing on older people, particularly if you
don’t feel very well and you have to tell everybody the same thing, you
know, where the cleaning supplies are, what they are to do.”
-ClientIn some cases, the relationship that developed between the service provider and client
was also a source of social support. For these clients, who are often socially isolated,
frail, elderly people, this aspect of the encounter was highly valued. In other cases, the
client felt a relationship was necessary so service delivery would not feel dehumanizing.
Physicians commented that rapid changes in nursing personnel in the home created
problems for them and their patients. For example, a new nurse might become alarmed
about the state of a client, when in fact the client’s state had improved. This upset the
client and the family and often created the need for an office visit to reassure the patient
and rule out deterioration. Other times, physicians asked homecare clients to visit their
offices because they had no prior experience with the homecare nurse that would allow
them to judge the accuracy of the report received.
“The care is not seamless. I feel like it’s choppy. I feel like there’s a lot
more phone calls generated just out of the fact that there’s people not
knowing each other. I feel that I don’t have as much confidence in many
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of the nurses that are now going in. Patients tell us they rarely get the
same nurse twice, there aren’t those kind of critical relationships being
developed right now.
-PhysicianClients tended to feel more comfortable with changes in the nursing staff, whom they saw
as professionals with very similar skills, than with changes in homemakers, who did not
have any special qualifications and whose skills varied considerably.
Consistent personnel is hard to achieve in homecare given the rapid turnover that some
agencies reported, with up to 40 percent of workers leaving during a year. The human
resource issues are complex, and many relate to how homecare is organized in Ontario
and the bidding process. Thus, they will be discussed later.
Issues related to the home as a site of care. The home is a unique setting for healthcare
delivery that presents some novel challenges. When care is provided in a private office,
clinic or hospital, the client comes to what is considered a “public” place. The home, in
contrast, is a “private” space, usually reserved for family members and their guests.
Guests, except for close friends and family, do not usually enter private areas of the home
such as the bedroom, or open cupboards and closets or drawers of dressers, unless
specifically invited. With homecare delivery, this privacy is lost. This factor makes
consistent personnel with whom they form a relationship very important to homecare
clients. Clients who experience many different homecare workers reported a sense of loss
of the feeling that their home is their refuge. When different workers arrived each day to
deliver the same services, things were sometimes left in different places, went missing, or
were broken.
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“My home is not my home anymore. I really don’t like four different
people being in my house every week, things get broken and nobody
knows how they got broken. Nobody breaks things on purpose, so they
should just mention it.”
-ClientHomecare differs from care outside the home in that providers who work together in an
office, clinic or hospital share physical space, often know each other quite well, share a
common medical record and may have regular meetings. Close proximity allows team
members to be aware of the skills and expertise that others possess, as well as the
accuracy of the observations made by them. In homecare, providers are deliberately
scheduled to not overlap with one another, because this would make the home congested.
Lack of direct contact impedes communication among homecare team members; they
usually leave messages for each other but rarely talk directly with each other. Lack of
proximity also means that travel time is needed. Many of the workers are not reimbursed
for their travel costs by their employer. Length of visits also becomes an issue. If
homemaking visits are scheduled to start on the hour, with no allowance for travel time,
clients lose some promised work time due to travel between homes.
Finally, tacit knowledge about the home and its organization are needed to deliver
services. The ways homes are organized are as individual as people are. This kind of
information is difficult to communicate effectively among workers, making the need for
consistent personnel greater in home support services.
What kinds of clients are most affected by lack of care continuity?
Homecare services are provided to a wide range of clients who differ vastly in their care
needs, levels of mobility, communication capabilities, and cognitive abilities. Clients can
have acute-care needs or chronic-care needs and may receive homecare for several
months or for many years. Types of clients whom service providers and case managers
identified as requiring a high level of continuity of care include: people with chronic
health problems that involve significant physical, mental health, or cognitive disabilities;
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people in the terminal phase of their illness; frail, elderly people; people with complex
medical regimens; and people whose caregiver is under a lot of stress.
The reasons that each group requires high continuity of care differed. Clients who have
cognitive impairments due to dementia or brain injuries tolerate changes poorly
(become confused and upset by changes in their environment). A highly structured and
predictable environment permits them to function as independently as possible and
maximizes their coping abilities. Service providers need to learn what the clients’
abilities are and how to relate to them.
“It makes the continuity of care a lot better now I have the same
homemaker. Before that, it was much more difficult for me, because
they’re constantly having to ask me things if it’s someone different.
Several times I had bad experiences with people because I look fine, but
sometimes I don’t come across as fine because of the brain injury. If I am
more tired then I’m not very alert, and I’m sort of more dysfunctional than
I was before.”
-ClientClients with significant psychological problems often take a long time to develop trust
in other people; if suspiciousness is one of their symptoms, changing service providers
may exacerbate their illness. Palliative care clients and their families are learning to
cope with an impending death; they are emotionally vulnerable. Caring for them includes
listening well and counseling. They do not open up about their feelings to people who
are strangers. Pain management is often complex and requires high levels of coordination and expertise.
Frail, elderly clients also require high levels of care continuity. They have limited
energy and become frustrated and stressed by the need to repeatedly explain their care
needs to strangers. They often require help with intimate activities such as dressing and
bathing and feel uncomfortable doing these things with the help of a succession of
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strangers. They are vulnerable to victimization of various sorts and may be socially
isolated. They need to feel that they can trust the people who are providing services to
them. For some, the service provider provides social support and becomes a substitute
for missing friends and family.
“They are the most victimized from fraud or abuse in a variety of different
ways.”
-Service provider managerPhysically disabled clients, whether elderly or not, often have significant mobility
problems and need assistance with many very personal activities of daily living like
bathing and dressing. Often they have limited energy available to them and are also
vulnerable to abuse or neglect. Continuity of care allows them to continue to do what
they can do. The provider learns to know which tasks the client can handle alone or with
limited assistance.
“If they can do for themselves, I let them do for themselves. Say I’m
giving a person a bath and they’ve got use of their hands. Then I’ll say,
‘well do you want to wash yourself?’ So if they can wash the front of
them, I wash the back. I like to help out when they’re doing something
instead of me just taking over their life. They want at least something to
save for themselves.”
-HomemakerClients with complex medical regimens require personnel with a high level of
knowledge and expertise regarding their care needs. When clients’ caregivers are under
considerable stress, good continuity of care is needed. The caregiver may not be able to
leave the home to go shopping or attend to other matters except during a visit by a service
provider. She must trust the service provider enough to feel comfortable taking some
respite. If the caregiver becomes unavailable to the client, institutional care will be
required.
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What were the effects of managed competition?
Competitive contracting affected the organizations involved, relationships among
organizations and among providers, individuals working in this sector and client care.
There are transaction costs associated with competitive contracting for the CCAC (staff
time devoted to the bidding process, the implementation of transitions following the
awarding of contracts and the requirements for case managers to establish relationships
with a new set of providers) and for the agencies (attending meetings about bidding,
developing the proposal, managing changes within the agency and with clients brought
on by the outcome of managed competition). The effects on people and individual
organizations are described in Table 3.
Awarding new contracts in the homecare sector typically alters the market share of
service provider agencies. In Hamilton, this involves the potential reconfiguration of 10
or more major service provider agencies. Further, it is almost a certainty with any
contracting process that a percentage of clients will experience a “transfer” to a different
agency. In a sample of 600 clients, 123 clients transferred from one agency to another;
21.5 percent when both homemaking and nursing contracts were awarded, 13.3 percent
when only nursing contracts were awarded. Clients who transferred to a new agency saw
about twice as many service providers during an episode of care as those who did not
transfer. Transfer did not lead to service by an agency that provided more consistent
providers. Higher service needs put clients at greater risk for transfer to a new agency.
Service intensity was the major explanatory factor in predicting the number of providers
seen.
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Table 3
How Transitions in Homecare Cause by Managed Competition
Affect People and Organizations
How transitions affect people
y
y
y
y
y
y
clients, nurses and homemakers are upset about severing long-standing relationships
case managers are concerned about ensuring continuity for their clients
case managers have the burden of communicating bad news to clients
case managers may be operating without full information; lack of predictability can be stressful
providers are affected variably depending on whether contracts are awarded in new geographic
areas or not
provider instability and lack of security affect performance
How transitions affect organizations
y increased CCAC staff time spent implementing transition (e.g., case manager time spent
explaining transition and changes to clients, dealing with client complaints, requests for
exemptions)
y increased CCAC staff time establishing new relationships with provider agencies and individual
providers
y staffing unpredictability within service provider agencies as providers leave for other agencies and
new staff must be hired
y agency ability to meet contractual obligations may be threatened by inability to recruit/retain staff
y
reorganization of staffing complement to meet obligations of a new contract creates instability
within provider agencies and severs relationships between clients and providers as well as between
providers and case managers
While agency-to-agency client transfers are an obvious outcome of the contracting
process, clients may experience provider changes within the same agency, also resulting
from the contracting process. Even if the same agency is awarded the new contract, it
may need to alter its staffing complement and assignments to meet the terms of the new
contract, such as market share or geographic service delivery area changes, or the
obligation to provide a different array or intensity of services requiring a different
staffing complement in that area.
The consequences for agencies of meeting their contractual obligations may be new
hirings, the reassignment of staff to different geographic regions, or the termination of
some workers. If a service provider agency loses a contract, this results in, at least in the
interim, the reduction of hours or termination of some employees within the unsuccessful
agency if they cannot or choose not to be redeployed to another area where the agency
still holds a contract. The transition feature of the competitive contracting model severs
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long-standing, trusting relationships between case managers and providers and clients
and providers, contributes to destabilizing homecare staffing in a community, and can
adversely affect client care and homecare worker performance. Workers find the
possibility of these kinds of changes unsettling and may exit to the long-term care or
hospital sectors, where jobs are more stable and wages are higher. Besides being upset
about severing long-time relationships, clients experience all of the problems mentioned
previously related to gaps in continuity of care when agency transfer occurs.
What strategies can be pursued to improve continuity of care under managed
competition?
Some of the strategies we identified grow out of the research itself, others from our
discussion with our community partners and the discussion generated by our workshop
for policy and decision makers in Toronto.
Managed competition was brought in to ensure that service contracts were awarded to
bidding agencies that would deliver the highest quality of service at the lowest cost.
However, what is meant by quality was unclear and methods to measure it were not
available. Forty-three new CCACs each developed their own requirements for requests
for proposals. Examining the section of the request that asked agencies to describe for
the Hamilton CCAC what benchmarks they used to monitor consistency of providers, we
found that the descriptions given were very difficult to compare across agencies. We
propose that CCACs adopt uniform guidelines in requests which ask agencies for
carefully specified, comparable information. The Hamilton CCAC has revised the part of
its request for proposals dealing with information about consistency of providers.
Our study of 600 clients’ experiences with consistency of providers during an episode of
care made it clear that agencies are just beginning to develop computer systems that can
monitor how well they are meeting the benchmarks for consistency of providers that they
indicate they will achieve as part of the contract. CCAC management systems track only
the number and type of services that were paid to an agency. They do not capture
information about who the providers of service are. Thus, they cannot track problems
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with provider consistency. Agencies should report on how well they are meeting the
benchmarks they agreed to meet. CCACs should have an independent means of verifying
the extent of agency compliance. Data management and monitoring deserve further
attention.
Communication between the CCAC and agencies and within agencies could also be
improved. We had hoped to develop a proposal to evaluate the effects on outcomes of
more active communication between the primary nurse and primary homemaker and the
case manager compared to the current system where active communication rarely occurs.
Unfortunately, the continuing changes in Hamilton CCAC leadership, along with the
realization that this intervention is more expensive than current procedures, made the
project infeasible. Communication during transition periods needs major improvement,
including better internal communication at the CCAC and external communication with
clients and agencies.
Strategies that make managed competition less disruptive to the care of clients and to the
homecare labour force are also needed. Job turnover creates problems not only for
clients but also for agencies, who must spend money on recruitment and training of new
staff. Possibilities here include lengthening the time that contacts are awarded from the
current length of two to three years. Adequate staff support and training during the
implementation of a transition are needed. Lengthening the transition period and
ensuring that active communication strategies (including joint visits) occur between new
and old service providers would also help clients and their caregivers. Longer-term
clients are much more likely to be affected by contract changes than post-acute care
clients who leave the homecare system within 60 to 90 days. Changes for vulnerable
clients should be carefully planned and require more communication among workers.
Additional Resources
Presentations have been made at professional meetings (e.g., Association of CCACs,
Ontario Community Support Association, Canadian Home Care Association) as well as
meetings of researchers. Four papers have been written for publication in academic
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journals and one paper to be published in conference proceedings. Copies of papers as
well as the report of our policy workshop will soon be available on the CHEPA web site,
www.chepa.org.
Further Research
Many questions arise from this research. They include:
1. Does continuity of care, as described by our stakeholders, make a difference in
the outcomes of homecare?
2. How can a variety of communication strategies be used to enhance continuity of
care? Do they influence care outcomes?
3. How can we measure continuity of care in a reliable, valid way?
4. Can we foster greater collaboration among agencies within the competitive
bidding model? Is this possible when you depend on collaboration but are forced
to compete?
5. What are effective ways for CCACs to monitor the continuity of care that their
clients are receiving?
6. To what extent do subsequent changes in managed competition, including the
bidding process address the concerns raised about its implementation?
7. What effects will new governance arrangements for CCACs have on quality of
service provision?
Several types of studies are needed to address the knowledge gaps that remain. Some
studies, which examine the effects of differences in or changes in aspects of care
continuity on client outcomes, require careful documentation of the interventions tried
and the outcomes achieved. Information for comparison groups that do not receive the
intervention should be used wherever possible (e.g., questions one and two).
Measurement issues (question three) must be studied using designs that will allow the
assessment of the reliability, validity and responsiveness of the measures. Other studies
of the effects of policy changes (questions four to seven) are likely best addressed by
using a combination of record review, in-depth interviews and focus groups with
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stakeholders and selected quantitative measures tailored to the specific policy change. It
would be useful to look for variations in how the policy was implemented and see if these
variations have differing effects.
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References
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Sheets. www.hc-sc.gc.ca, accessed July 10, 2001.
2. Coyte, P. (2000) Home Care in Canada: Passing the Buck.
www.hcerc.utoronto.ca/papers/02elect.htm, accessed July 10, 2001, Vol.14.
3. MacAdam, M. (2000) Home Care: It’s time for a Canadian Model. Health Care
Papers; 1(4): 9-36.
4. Dumont-Lemassen, M., Donovan, C., & Wylie, M. (1999) Provincial and
Territorial Home Care Programs: A synthesis for Canada. Ottawa: Health
Canada. www.hc-sc.gc.ca, accessed July 10, 2001.
5. Anderson, M., & Parent, K. (2000) Care in the home: Public responsibility-private
roles? Paper prepared for the Dialogue on Health Reform. Kingston, Ontario,
Queen’s University.
6. Williams, A.P., Barnsley, J., Leggat, S., Deber, R., & Baranek, P. (1999)
Longterm care goes to market: Managed competition and Ontario’s reform of
Community-based services. Canadian Journal on Aging; 18(2): 125-133.
7. Witmer, E. (2000) Bringing healthcare closer to home: One province’s approach
to home care. Healthcare Papers; 1(4): 98-102. www.healthcarepapers.com.
Additional Bibliography
Aronson J & Neysmith S. (2001) Manufacturing social exclusion in the home care
market. Canadian Public Policy; 27(2): 151-165.
Baranek P, Deber R & Williams AP. (1999) Policy trade-offs in “home care”: the
Ontario example. Canadian Public Administration; 42(1): 69-92.
Flynn R, Pickard S & Williams G. (1995) Contracts and the quasi market in community
health services. Journal of Social Policy; 24(4): 529-550.
Government of Ontario, Press Release, November 7, 2001. Government moves to
strengthen Community Care Access Centres.
www.newswire.ca/government/ontario/english/releases/ November 2001/07/04893.htm,
accessed April 5, 2002.
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Government of Ontario, Press Release, June 26, 2001. Minister takes action to stabilize
Community Care in Hamilton.
www.newswire.ca/government/ontario/english/releases/June 2001/26/C7545.htm,
accessed April 5, 2002.
Haggerty, J., Reid, R., McGrail, K., & McKendry, R., (2001) Here, there and all over the
place: Defining and Measuring Continuity of Health Care. Discussion paper prepared for
the Canadian Health Services Research Foundation, the Canadian Institute for Health
Information and the Federal/Provincial/Territorial Advisory Committee on Health
Service. University of British Columbia, Health Policy Research Unit, Centre for Health
Services and Policy Research. HPRU 2001:10D.
Shapiro E. (2000) Reaching a federal provincial consensus on home care. Health Care
Papers; 1(4): 85-90. www.healthcarepapers.com.
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