November 23, 2016

Who we are: Care Watch, a not-for-profit, volunteer-run advocacy organization led by senior citizens, advocates for quality home and community services in Ontario. Specifically, Care Watch advocates for home and community services that are: seamlessly integrated, well-coordinated, securely funded, and led by non-profit, community-based agencies.

Response respecting the Bill 41 – Patients First Act

Care Watch appreciates the opportunity to review and comment on Bill 41 – The Patients First Act [1]. Care Watch approaches its analysis from the perspective of the social determinants of health and that policies that support and advance the well-being of senior citizens will, in the long term, assist all Ontarians. Given an understanding of the social determinants of health, ensuring the well-being of all Ontarians requires intervention in multiple public service systems, and not just the health care system.

On the whole, few can disagree with the proposed intent of a Patients First philosophy and Care Watch supports approaches that place the needs of individual service recipients (not just “patients”) and their caregivers at the focus of a service system. However, Bill 41 is more about providers than patients or consumers. If fact, it still puts Providers First.

Amendments to the Local Health System Integration Act, 2006

1. Expanded Role of Local Health Integration Networks (LHINs) and Objectives

Care Watch acknowledges the enlarged role of LHINs in expanding and, hopefully, improving the planning, coordination and delivery of local health care services in accordance with provincial plans and priorities. We particularly welcome the amended objectives [2] to “…promote health equity, reduce health disparities and inequities, and respect the diversity of communities”, including meeting the requirements of the French Languages Services Act, in the planning, design, delivery and evaluation of services.

We acknowledge incorporation of previous Community Care Access Centre (CCAC) functions [3]:

• To provide health and related social services and supplies and equipment for the care of persons in home, community and other setting, and to provide goods and services to assist caregivers in the provision of care for such persons;
• To manage the placement of persons into long-term care homes, supportive housing programs, chronic care and rehabilitation beds in hospitals, and other programs and places where community services are provided under the Home Care and Community Services Act;
• To provide information to the public about, and make referrals to health and social services; and,
• To fund non-health services that are related to health services,
• in order to ensure the effective and efficient management of publicly funded human, material, capital and financial resources.

Care Watch also supports the inclusion of “public interest” considerations in decision-making by the government, the Minister and LHINs. In addition to key considerations mentioned in section 35, (that is, the quality of management and administration of LHINs and health service providers, the proper management of the health care system in general, the accessibility of health services on a geographic basis, the quality of care and treatment of patients and availability of financial resources), Care Watch would add the promotion of equity and the mitigation of health inequities.

However, a truly equitable home and community care policy must:

• be based on the same principles as the Canada Health Act (CHA) principles of public administration, comprehensiveness, universality, portability and accessibility; and,
• be supported by a funding commitment that originates in the tax system and includes earmarked or designated funding that is quarantined against leakage to the acute care service system.

Regrettably, these principles are not clearly embedded in the legislation and there is no clear indication of how home care and community support services will be sustainably funded and protected.

2. Planning for Local Health Services

Care Watch supports the incorporation of planning for primary care services within local health system planning, including planning respecting physician and nursing resources. The availability of accessible, consistent and comprehensive primary care services province-wide has long been a concern and would benefit from systematic analysis and intervention, notwithstanding the claim that 94 per cent of Ontarians now have a primary health provider.

We also support the incorporation of population health concepts and analyses to inform LHIN strategic planning and the requirement for LHINs to engage and seek advice from local Medical Officers of Health and Boards of Health that exist within each LHIN region [4]. Population health analysis should facilitate understanding of and strategies to incorporate the social determinants of health within planning for health care services. Such underlying analyses are essential to ensure the sustainability of home and community care services delivered at local, regional and provincial levels.

However:

• Bill 41 fails to address the criteria or key considerations for how LHIN sub-regions will be selected, governed and operated. For example, in addition to HealthLink services, will factors such as geography, population density and dispersal, transportation infrastructure and accessibility, local health worker labour pools and service delivery costs also be considered?
• Bill 41 fails to address the criteria for selecting and establishing local service coordinators. From prior experience, Care Watch predicts that local service coordination responsibility will be delegated predominantly to local hospitals and that home care and community support 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 continues to advocate that multi-disciplinary primary health and/or community care agencies assume local service coordination responsibilities and be funded appropriately to successfully carry out such functions. Care Watch is also in favour of more local governance and input to service planning, which is unlikely to occur if large hospital or health care corporations dominate local service coordination.
• Bill 41 fails to address service planning by local home care and community support services by ensuring that they are specifically included in LHIN/Sub-Region strategic planning and coordination processes. Local home care and community support agencies also need to be funded appropriately to participate in regional strategic planning. The continued focus on medical services, ignoring the social determinants of health, is detrimental to the overall sustainability of Ontario’s home care and community support service systems. The greatest cost and service efficiencies are provided through home care and community support services rather than just illness-care and medical services, which while important, represent only a portion of health determinants. Home care and community support services maintain seniors in the community; prevent ER visits; and allow seniors to remain in their homes and community rather than having to move to LTC prematurely or take up an ALC bed.

3. Provincial Service Standards

Care Watch concurs that Ontarians should be able to have confidence in the expertise of both individuals and organizations that provide home and community care services, and the quality of service and care that they provide. Therefore, we generally support provisions for the establishment, publication and implementation of service quality standards [5] and, where required, the Ministry’s or LHINs’ authority to issue general or particular policy and operational directives with which LHINs or service providers must comply, notwithstanding the lack of enforcement mechanisms.

However, we point out that standards for the provision of home care and community support services have not received comparable attention:

• Health Quality Ontario, or a comparable provincial agency, is not working on service standards for home care and community support services beyond medically necessary services;
• Efforts to replace the former, ineffective and underfunded screening and registry mechanism for personal support workers (PSWs) have been, at best, minimal; and
• Health Quality Ontario’s focus has been reduced to reporting on “patient” (rather than consumer or service recipient) health status and experiences, leaving out concerns for seniors who while lacking complex medical conditions still require support to age safely at home and in their community.

Failure to address home care and community supports does not foster or support long-term system sustainability.

4. Inter-Service and Provider Communication

Care Watch appreciates that the Bill is intended to improve communication among local family doctors, nurse practitioners, inter-professional health care teams, hospitals, and home and community care agencies to ensure a smoother patient experience.

Unfortunately, the legislation alone cannot ensure effective communication and information exchange by providers. Sufficient mechanisms to facilitate such communication and better patient transitions between primary, home and community, acute, mental health and addictions, and long-term care systems are not clearly evident within Bill 41. For example, there is no requirement or mechanisms to ensure that service provider systems that collect and store patient service data are compatible and can communicate with each other to ensure that patient information is quickly accessible and seamlessly transferable.

5. Portability of Services across LHIN jurisdictions

Care Watch supports provisions that foster the portability of home care and community support services across LHIN and Sub-LHIN regions. We endorse sub-section 19 that allows the funding of health service providers in other LHIN regions [6] and sub-section 20 that prohibits restrictions on patient mobility [7]. However, proposed amendments to the Home Care and Community Services Act do not clearly establish that service funding and provision apply to the individual recipient (patient/caregiver) rather than a service delivery agency. Patient mobility is, by definition, limited or restricted if the receiving region lacks comparable services that are required.

In this regard, Bill 41 also fails to address issues and mechanisms relating to the development of appropriate and sustainable local labour pools for the delivery of home and community care services.

Amendments to the Home Care and Community Services Act

LHIN provision of Homemaking and Community Care Services [8]

Care Watch notes that the LHINs have been given (the previous CCAC’s) authority to provide or arrange provision of prescribed “homemaking and community care services” to individuals in accordance with their service plan. We also note that while other approved agencies may require and accept payment from clients for such services, the LHIN shall neither require nor accept payment for such services, unless it is deemed to be an “approved agency”. Consequently, the terms and conditions under which community care services will be subject to patient co-payment or purchase are unclear.

Also, since it appears that the Minister may deem a LHIN to be an “approved agency”, Care Watch questions the capacity of the LHINS to both fund and directly deliver home care and community support services. Issues of conflict of interest are evident. How will complaints be received and weighed if LHIN service recipients have to complain to their service provider if they cannot get the services they need or were promised; if service providers are abusive or just inefficient/ineffective; or if service transitions are difficult and delayed? The division of labour between the LHIN, Patient Ombudsman, Minister and Ontario Ombudsman is not clear and does not assure service recipients of fair, effective or timely responses to complaints.

Conclusion

Care Watch commends the Minister of Health and Long-Term Care for leadership in reforming the health planning system to better develop, plan, administer and manage health care services, and for attempts to improve linkages to home care and community support services. We are aware, however, that successful results are dependent upon the political, financial and human resources of the partners and stakeholders deployed to systematically implement and enforce the proposed changes.

Submitted by Care Watch Ontario, Josephine Grayson, Chair

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Footnotes:

[1] Bill 41, An Act to amend various Acts in the interests of patient-centred care (return to text)

[2] & [3] Section 5, Bill 41 (return to text)

[4] Section 15, Bill 41 (return to text)

[5] Subsection 11, Bill 41 (return to text)

[6] Sub-Section 19(1), Bill 41 (return to text)

[7] Sub-Section 20.1, Bill 41 (return to text)

[8] Section 28, Bill 41 (return to text)

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