January 12, 2016

On December 17, 2015, Dr. Eric Hoskins, Ontario’s Minister of Health and Long-Term Care released a new Discussion Paper “Patients First: Proposal to Strengthen Patient-Centred Health Care in Ontario.” While espousing principles of patient choice and health equity, this paper provides a high level outline of proposed restructuring of the planning, funding and delivery of health services, to achieve service integration, increased efficiency and improved health outcomes. All of these objectives are highly desirable, but, to paraphrase an old saying, the “devil will be in the details”.

Restructuring Discussions

Care Watch welcomes and applauds the Province’s willingness to engage system users, especially seniors, and service providers in discussion regarding the future of home and community care services, and looks forward to full participation in restructuring discussions and decision-making processes.

Care Watch also appreciates the “patients first” principle underlying the Discussion Paper, despite the Paper’s almost total focus on the organization of and support required by “clinical” care providers. The proposed maintenance of client choice in service and service providers is essential in a client-centred system. We anticipate that a variety of legislative mechanisms and culture-change strategies will be needed to guarantee user choice.

However, to get the best system change outcome for Ontarians, the Ministry should ensure that restructuring discussions are also accessible to and include the voices of seniors, family caregivers, and non-health community-based organizations which also provide critical home and community care services.

Expansion of LHIN Mandate and Responsibilities

Care Watch acknowledges the potential efficacy of transferring current CCAC functions to the LHINs and the proposed expansion of the LHINs’ mandate to include primary care planning and performance management; home and community care management and service delivery; and the development of formal linkages with population and public health planning, in order to improve system planning and accountability, funding equity, delivery standards and client outcomes. Integration of the primary health care sector (e.g., community health centres, Aboriginal health access centres, and family health and nurse practitioner teams) within the ambit of the LHINs is required to provide critical local anchors for the continuum of healthcare.

Care Watch is concerned that despite repeated references, the Discussion Paper does not identify community social and support services as being part of either primary health care or the continuum of care. Services which support autonomous living for seniors, people with disabilities and persons with chronic illnesses – like transportation, home-making, meals-on-wheels, adult day programs and respite care – are critical to the success of any home and community care plan.

Additionally, the scope and complexity of the anticipated system change cannot be achieved all at once. The Ministry needs to identify priorities for incorporating and integrating the various existing sectors and proceed in a phased manner along agreed time lines. Care Watch advocates that the primary health care and community social and support services sectors be addressed in the earliest phase. The Ministry should also second senior staff from the home and community sector to inform and augment its analysis of needed changes.

Local Service Coordination

Care Watch supports the proposal that home care coordinators be housed at the LHIN subregion level and deployed into community settings. However, the Paper is silent on how the sub-LHIN areas will be selected, governed, and operated. Repeated reference to “patients”, “health care” providers and “clinical” services and leadership demonstrates that medicalized paradigms still dominate the government’s discourse and priorities in designing and delivering home and community-based services to seniors and people living with disabilities who, in fact, strive to maintain their autonomy in their own homes and communities.

Based on prior experience, Care Watch worries that local service coordination responsibility will be delegated predominantly to local hospitals and that home and community care services will consequently become even more medicalized and expensive.

Based on cost alone, Care Watch disagrees with the apparent perception that hospitals are appropriate lead agencies for “home and community care coordination”, and advocates that multi-disciplinary primary health and/or community care agencies assume local service coordination responsibilities and be funded appropriately.

Integrated Funding

In order to remain affordable, Ontario’s health system needs to respond to the demographic implications of an ageing population. An antiquated model oriented to acute care is clearly no longer sustainable; it cannot meet the needs of people living with chronic health conditions. Service users live in the community and that is where services must be provided. However, hospitals and acute care services consume the lion’s share of health budgets. The influence of the acute care sector, with its powerful advocates, easily drowns out the voice of the community services sector.

Based on experience, Care Watch opposes the proposed “bundling” or integration of funding that encompass hospitals, primary health care, and community care sectors and services. Care Watch advocates that instead of bundling funding, the government establish a protected budget envelope that is dedicated solely to home and community care services; a budget envelope that cannot easily be reallocated elsewhere, even when increasing hospital, physician or pharmaceutical costs stretch existing resources.

Increased Investment in Home and Community Care

System reorganization requires intensive planning, support and evaluation, especially during transition periods. These activities require investment. Perhaps in the long run the savings generated by eliminating the CCAC structure may be sufficient to support the enhanced responsibilities of LHINs and other organizations, but this is unlikely to be true in the short term. It is unclear what new funds will be provided to support the change process.

Care Watch recommends that the Ministry set aside funding to assist community agencies to undertake the necessary research, planning and organizational changes required for successful system restructuring.

Significant Missing Details

Multiple system reviews have identified gaps and inconsistencies in accessibility and service provision across the province.

A significant missing detail in the Ministry`s Discussion Paper is consideration of the range of services to be delivered within the restructured home and community care system. Redefining government and provider relationships and accountability outside the context of required services and supports will not, in the long term, produce better outcomes for Ontarians.

Multiple reports have also highlighted the difficulties that seniors and caregivers have navigating the health care system.

While having “services closer to home in sub-LHIN areas” may mean smaller bureaucracies, we do not yet understand what mechanisms will be put in place to improve system navigation and wait times for home and community care.

Care Watch

Care Watch is a not-for-profit, volunteer-run advocacy organization led by senior citizens. We work with policy makers and those who influence policy to raise issues relevant to older people. We believe that we – the senior citizens of Ontario – must have a say in how services are organized, delivered and evaluated. Care Watch advocates for quality home and community services that are:

• Seamlessly integrated with primary, secondary and tertiary health services;
• Effectively coordinated;
• Securely funded; and,
• Led by not-for-profit, community-based agencies.

Media contact: Michèle Harding, Board of Directors