It All Begins with Home and Community Care

February 2023

What is home and community care?

Most older adults want to live in their homes and communities as long as they can. Home and community care can give them the support they need to live independently. Community support agencies and many municipalities are equipped to provide services that can make this happen. These services include supportive housing, transportation, meals on wheels, congregate dining, friendly visiting, security checks, adult day programs, homemaking, and personal support services. Not every person wants or needs every service but all older adults should be able to get what they need without having to worry about cost and availability.

Provincial policy that supports older Ontarians will drive the programs and services that let them remain safely and productively in their own homes. Comprehensive and adequate funding is a proactive way to keep a large number of Ontarians out of expensive institutions.

Care Watch’s recommendations

Care Watch welcomes the opportunity to contribute to Ontario’s Pre-Budget Hearings. Both urgent and long-range actions are needed to strengthen and expand home and community services so they can play an important role within the broader system of care for older adults. We recommend that the Ontario government commit to:

• a home-centred system of care
• funding care for older adults as a comprehensive, interdependent system, which begins with care in the home and also includes long-term care homes and hospitals
• making immediate investments in home and community services in the 2023 budget. These immediate investments include: (a) the strategic allocation of $425 million, previously announced in the 2022 Ontario budget, which would add 2.72 million hours of home care services; and (b) an additional $212 million to meet growing client needs, address the impact of inflation, and support innovative approaches to benefit clients and the health system
• adopting a five-year plan that significantly increases funding for home and community services in order to maximize access to these services by older Ontarians and decrease reliance on institutional care
• giving priority to community-based non-profit agencies to deliver services
• establishing a schedule, with timelines and accountabilities, to achieve equality in wages and benefits between personal support workers who work in home and community services and those who work in long-term care homes and hospitals
• developing and implementing a provincial strategy to recruit and retain enough personal support workers to meet the needs of the Ontario workforce
• anchoring home and community services as a key element within Ontario’s health planning and funding structures                                                             

The system should be home-centred.

Older adults who need support would prefer home and community services to institutionalization. Research by the National Institute on Ageing has shown that 96% of older adults would prefer to live at home if this support were available. 

Home and community services promote independence and dignified ageing. In addition, they have a large cost advantage, with lower capital and operating costs. The capital cost of home and community services pales in comparison to that of long-term care homes and hospitals. Indeed, the National Institute on Ageing estimates the cost of a new long-term care bed to be $250,000. The per client daily operating cost of home and community services is approximately half that of long-term care and one-seventh that of hospital care. When home and community services enable an older adult to avoid long-term care or hospital services, system costs are reduced and the system becomes more sustainable.

Current underfunding of home and community services has created large gaps in access, which are preventing home and community services from playing their proper role in the system of care for older adults.

The system is interdependent.

The system of care for older adults, comprising home and community services, long-term care homes, and hospitals, is interdependent. The functioning of each component affects, and is affected by, the functioning of the other two. When resource constraints prevent one component from effectively playing its full role, pressures are placed on the other components. The results are strain and major system dysfunctions. 

Because home and community care is underfunded, many older adults who need support can’t access these services and end up prematurely moving into long-term care homes. At least 8% of current long-term care home residents in Ontario would be able to live at home if adequate supports were available. In addition, older adults lacking support in the community are more likely to visit hospital emergency rooms frequently. Long waiting lists for home and community services often delay the discharge of older adults occupying hospital Alternative Level of Care beds, thereby extending hospitalizations.

Immediate action is needed.

Non-profit providers of home and community services are now under great strain stemming from high inflation, increasing client volumes, difficulties in recruiting and retaining personal support workers and other critical staff, and the lingering effects of the pandemic. The situation has become so serious that the Ontario Community Support Association reports that 76% of its non-profit provider organization members say they risk being forced either to cut services or expand their wait lists, with significant adverse consequences for client access to services.

A major infusion of funding is urgently needed to stabilize the budgets of non-profit providers and enable them to address the pressures they face, especially the shortage of personal support workers. Care Watch therefore strongly supports the recommendations of the Alzheimer Society of Ontario and the Ontario Community Support Association to immediately increase funding for home and community services.

Specifically, we support the investments recommended by the Ontario Community Support Association in its 2023 pre-budget submission.

• the strategic allocation of $425 million previously announced in the 2022 Ontario budget, which would add 2.72 million hours of home care services to the system
• an additional $212 million in the 2023 Ontario budget to meet growing client needs, address the impact of inflation, and support innovative approaches to benefit clients and the system

A longer-term plan is needed.

Ontario should, over the next five years, put in place a reformed system of care for older adults that will maximize access to home and community services.

According to the Ontario Community Support Association, Ontario currently allocates 49% of its long-term care budget to home and community services and 51% to long-term care institutions. In contrast, Denmark, often regarded as a model of care for older adults, allocates 64% of its combined budget for home and community services and long-term care to home and community services and 36% to long-term care institutions.

Denmark has achieved a balance of services. We believe that Ontario should rapidly increase funding on home and community services over the next five years sufficiently to achieve a similar balance. This expansion of funding will give more adults access to home and community services and significantly reduce reliance on institutional care. We urge the Ontario government to aggressively pursue any opportunities to source additional funding for home and community services through current negotiations with the federal government on bilateral agreements about the transfer of federal funds to support health care services in Ontario. 

Non-profit service delivery is best.

Delivery by community-based non-profit providers needs to be prioritized in a longer- term plan to expand funding for home and community services. These community-based non-profits are embedded in their communities, and their knowledge of the community enables them to respond to the needs of clients. They also are able to devote all their resources to service provision and are not required to produce a return for shareholders. The most effective way to fund additional home and community services is through providing stable and reliable core funding, with increases tied to inflation, to these community-based non-profits.

Wage inequities have to be addressed.

A longer-term plan for funding home and community must remove inequities in compensation, especially those affecting personal support workers, who play a critical role in delivering home and community services.

According to the Ontario Community Support Association, personal support workers in home and community services are paid 17% less than those working in long-term care homes and 21% less than those working in hospitals. The government needs to create a rapid schedule, with timelines and accountabilities, to improve the salaries and benefits of workers in home and community services sufficiently to give them parity with their counterparts in other sectors. Any legislative or regulatory barriers to making the required adjustments in compensation should be removed.

Achieving equitable pay for personal support workers in home and community services is not only a matter of basic fairness, it is also an important step in addressing the problems of staff retention that have plagued providers of home and community services. Research by Katherine Zagrodney (pending publication) shows that achieving wage parity could reduce the rate of personal support workers leaving home and community services by 20%. That 20% would go a long way to alleviating current and future shortages.

A provincial human resource strategy is needed.

The current shortage of personal support workers is straining service provision at long-term care homes and hospitals as well as agencies providing home and community services. Strong action at the provincial level is needed.

The Ontario government needs to take steps to recruit and retain an adequate supply of personal support workers to meet the demands on the Ontario workforce. These steps should include: (a) enhanced support for training through the college system; (b) measures to remove any remaining barriers to integrating foreign-trained workers; (c) increased use of the Ontario Immigrant Nominee Program to recruit foreign-trained workers; and (d) measures to ensure that personal support workers are paid fairly and receive compensation that is competitive with other in-demand occupations.

Funds need to be anchored.

Ontario Health Teams, which are currently being rolled out by the Ontario government, will exercise fiscal and clinical responsibility for delivering home and community services, as well other health services, to more than 50 regional populations. When government flows provincial funding for home and community services to the health teams, there are three important requirements: (a) that funding is equitable across health teams and that it is earmarked specifically for home and community services; (b) that health teams are held accountable for using the new funding to maximize access, by older adults, to home and community services in the regions they serve; and (c) that they prioritize non-profit delivery of home and community services when they allocate funding and select providers.

Anchoring home and community services firmly within Ontario’s health care system gives older adults throughout Ontario increased and equitable access to these services. It responds to their preferences, is cost efficient, and promotes a sustainable health system. With these goals in mind, Care Watch is pleased to submit its recommendations.