HOME CARE IN QUEBEC AND ONTARIO:
STRUCTURE AND EXPENDITURES

INTRODUCTION

Over the past 20 years, home care expenditures in Canada have increased exponentially, at an average annual rate of 11.3%.  In 2000-2001, those expenditures (public and private) totalled nearly $3.5 billion.(1)  Between 1980-1981 and 2000-2001, home care expenditures as a percentage of overall health care spending in Canada rose from 1.2% to 3.5%.  This rapid growth can be attributed in large part to a number of significant changes affecting health care in Canada and Canadian society in general, in particular to the aging of the population.

Since home care is not considered a “medically required” service under the Canada Health Act, the structure and delivery of home care services differ from province to province, more so than in the case of medical and hospital services insured under the Act.  In fact, each provincial and territorial government currently administers its own home care program.

This paper is the second in a series of three(2) that provide an analytical overview of government-run home care programs in all Canadian provinces.  It focuses on home care in Quebec and Ontario and examines public home care programs in these two provinces in terms of:

Generally speaking, the term “home care” applies to a wide range of social and medical services provided to persons in their home, as opposed to care provided in private or public institutions.  Included in this category are such services as primary care, acute care, long-term care, palliative care and community support programs.  Home care may also include medical intervention, nursing care, various support services and help required by family members and informal caregivers, as well as a range of social, educational and health services enabling persons in need of assistance to live and function in the community, rather than in an acute or long-term care facility.(3)

More specifically, home care falls into one of the following three broad categories:(4)

QUEBEC

   A.  Responsibilities and Objectives

In Quebec, the Department of Health and Social Services is responsible for setting broad strategic directions and specific policies governing home care.  The general objectives of the department’s home care programs are as follows:

Quebec’s 18 regional health authorities determine what proportion of the total budget allocated to them by the department they wish to dedicate to home care.  Regional authorities set their own programming and performance objectives in accordance with the department’s overall policy.  However, regional authorities are not responsible for day-to-day program management or service delivery.  This task is delegated to 147 local community service centres (CLSCs) operated under the direction of the regional authorities.  CLSCs enjoy considerable latitude to adapt their programming to the specific needs of their clientele.  They are accountable to a board of directors as well as to the regional health authority to which they report.

   B.  Services

Each CLSC operates a “single window” access point that coordinates delivery of short-term and long-term home care services within its respective service area.  CLSCs are primarily responsible for the following:

CLSCs provide the following services to members of the public: 

   C.  Delivery and Eligibility

      1.  Service Delivery

In Quebec, CLSC staff provide the majority of nursing and professional services to clients, subject to resource availability.  However, delivery of professional and non‑professional services is frequently contracted out by the CLSCs to private agencies.  Home support services are essentially provided by private companies, specifically household service agencies.  Recipients’ use of contracted services and self-managed care programs is encouraged through the Tax Credit Respecting Home-Support Services for Seniors,(5) the Financial Assistance Program for Domestic Help Services(6) and Service Employment Paycheques.

      2.  Eligibility

Home care in Quebec is subject to the following eligibility criteria: 

Access to home care varies greatly from one CLSC to another.  Decentralization of services has enabled regional health authorities and CLSCs to adapt their services to the public, but as a result, some disparities persist.  Moreover, access to home care in Quebec is limited by the amount of financial resources allocated by the government to this sector.  Furthermore, CLSCs impose service quotas.  Strong demand has led to waiting lists for certain types of services in some regions.

Sources:  Health Canada, CARP’s Report Card on Home Care in Canada 2001, web sites of various provincial ministries, and Library of Parliament.

The home care sector in Quebec is experiencing a shortage of health care professionals.  Specifically, working conditions are less attractive than those of institutional workers, a situation that adversely affects the recruting of professionals and home support workers, and thus limits opportunities for providing home care.

   E.  Home Care Expenditures

      1.  Total Expenditures

According to Health Canada statistics, home care accounted for 2.91% of Quebec’s total health care expenditures in fiscal year 2000-2001.  The province’s spending in this sector was clearly below the national average.  The same is true of per capita expenditures, particularly per capita public spending, which was well below the national average.  However, per capita private spending on home care in Quebec was above the national average.  These discrepancies raise several questions.

* Provincial expenditures (excluding all federal spending under various programs)

Source:  Health Canada, Health Expenditures in Canada by Age and Sex, 1980-81 to 2001-02 – Statistical Annex, August 2001; Library of Parliament, Parliamentary Research Branch, for certain calculations.

It should be noted that home care expenditure estimates may not be completely accurate, since different agencies use different data compilation methods.  Caution should therefore be exercised when interpreting findings.  Data on home care expenditures incurred by Quebec’s health and social services network were extracted from the 2001-2002 report of Quebec’s Auditor General, and the figures do not correspond to Health Canada estimates.  For fiscal year 2000-2001, Health Canada estimated public expenditures of $382 million, whereas Quebec’s Auditor General reported expenditures of $547 million for 1999-2000, a difference of $165 million.  Since expenditures increase every year, the actual discrepancy between the two figures will probably turn out to be even greater.

The Quebec government invested nearly $487 million in CLSCs to ensure delivery of home care services.  Add to this figure $23 million in physicians’ fees for home visits, as well as $37 million in grants to community agencies and social economy enterprises for home support services.  Home care expenditures for 1999-2000 therefore totalled $547 million and accounted for 3.7% of public spending on health and social services.(9)

It should also be noted, however, that Health Canada’s spending estimates do not take into account tax expenditures.  This may explain, in part, the sizeable gap between per capita home care expenditures in Quebec and the national average, according to Health Canada’s compilation.

Quebec relies heavily on taxation to sustain and subsidize the purchase of home care and to promote home care as an option for seniors.  The Quebec government’s use of tax expenditures rather than larger tax credits in the home care sector meets four economic policy objectives, namely:

      2.  Tax Measures

The Quebec government has introduced three broad tax measures that target home care:  the Tax Credit Respecting Home-Support Services for Seniors, the Service Employment Paycheque and the Tax Credit Respecting the Housing of a Parent.

        a.  The Tax Credit Respecting Home-Support Services for Seniors(10)

Any person aged 70 or older may claim a tax credit equal to 23% of eligible expenses incurred for certain home support services.(11)  Unlike other tax credits, which must be claimed in the income tax return, the Tax Credit Respecting Home-Support Services for Seniors is granted each time services are provided and paid for.

Each time a person aged 70 or older incurs an expense for home support services, the amount of the credit offsets part of the cost of the service obtained.  Seniors can thus benefit throughout the year from a 23% reduction in the cost of home support services.  The annual ceiling on eligible expenses has been set at $12,000.  Seniors are therefore entitled to receive a maximum credit of $2,760, or 23% of $12,000.  To qualify for the tax credit, they must pay for eligible home support expenses by means of a Service Employment Paycheque (see below).

To be eligible for the tax credit, services must be provided in Quebec by a person who is neither the spouse nor a dependent of the recipient of the credit.  Services related to routine household tasks must be provided in respect of a dwelling, or the land on which it stands, of which the recipient of the credit, or his or her spouse, is the owner, tenant or sub‑tenant.

The following services are eligible for the tax credit:

The Quebec government expects to pay out $41 million to 50,000 seniors in 2002 by way of tax credits.

        b.  Service Employment Paycheque

In Quebec, the Service Employment Paycheque is a payment mechanism for persons who manage their own home care.  It simplifies the user’s job by assigning administrative responsibilities associated with the status of employer to a financial institution, specifically to the Services de paie Desjardins.  The person making the claim completes a form authorizing the Services de paie Desjardins to withdraw from his or her bank account the sums needed to pay for eligible home care expenses over and above the amount of the applicable tax credit.

        c.  Tax Credit Respecting the Housing of a Parent(12)

The Quebec government has introduced a refundable tax credit to compensate persons who take in a parent experiencing some loss of independence.  While the amount of the tax credit is modest compared to the real cost of caring for a parent, this provision recognizes the support given to a parent who can no longer live alone and who would otherwise have to rely on a public home care program.

Any resident of the province of Quebec may claim a tax credit of $550 for each parent who lived with him or her in a dwelling of which that person, or his or her spouse, was the owner, tenant or sub-tenant.

The parent concerned may be the claimant’s or his or her spouse’s father, mother, grandfather, grandmother or other direct ancestor, or uncle, aunt, great-uncle, great-aunt or their spouses.

The parent concerned must meet the following conditions:

      3.  Expenditures by Age

According to the data for 2000-2001, 72% of Quebec’s home care expenditures were incurred for services targeting individuals 65 years of age or older, a percentage similar to the national average.

In the coming years, the aging of the population and the resulting demand for home care services will compel provinces either to spend considerably more on home care or to withdraw fully or partially from this field and turn responsibility over to the private sector.  In 2000-2001, the private sector’s share of home care expenditures was much greater in Quebec than elsewhere (38.2%, compared to the national average of 28%).  Favourable tax measures for individuals incurring home care expenses are one reason for the strong presence of the private sector in this field.

Source:  Health Canada, Health Expenditures in Canada by Age and Sex, 1980-81 to 2000-01 – Statistical Annex, August 2001, and Library of Parliament.

ONTARIO

   A.  Responsibilities and Objectives

The Ontario Ministry of Health is responsible for setting major strategic and policy directions and guidelines for public tendering of home care services, medical supplies and related equipment.  However, the day-to-day management of the public home care program has been delegated to 43 Community Care Access Centres (CCACs).  CCACs are independent, not‑for-profit agencies administered by a board of directors that is accountable to the ministry.  Located throughout the province, CCACs serve as the point of entry to the home care program and are responsible for the following: 

CCACs provide the following home care services to the public: 

CCACs provide at-home acute care in the following fields:  chemotherapy and radiotherapy, pediatrics, obstetrics, and medicine and surgery.

   C.  Delivery and Eligibility

      1.  Service Delivery

In Ontario, all home care (from nursing care to homemaker services) beyond assessing the client and setting up a home care program geared to that client is delivered by the private sector.  However, the private agencies that deliver services to clients are paid by the province’s 43 CCACs, pursuant to the terms of service agreements concluded through a public tender process.

      2.  Eligibility

Home care in Ontario is subject to the following eligibility criteria:

Access to home care in Ontario is primarily dictated by the level of financial resources available, as well as by service quotas.  As in Quebec, heavy demand has resulted in waiting lists for certain services in some regions.

Sources:  Health Canada, CARP’s Report Card on Home Care in Canada 2001, web sites of various provincial ministries, and Library of Parliament.

As in Quebec, the home care sector in Ontario is experiencing a shortage of health professionals.  Moreover, working conditions that are less attractive than those enjoyed by institutional workers have compounded the problem of recruiting home care workers.  This situation has also resulted in longer waiting lists.

   E.  Home Care Expenditures

      1.  Total Expenditures

Ontario allocated over $1.5 billion to home care during fiscal year 2000-2001, an amount equivalent to 3.94% of its total health care expenditures and slightly above the national average.  Ontario is also among the leaders in terms of provincial per capita home care expenditures.

* Provincial expenditures (excluding all federal spending under various programs)

Source:  Health Canada, Health Expenditures in Canada by Age and Sex, 1980-81 to 2000-01 – Statistical Annex, August 2001; Library of Parliament, Parliamentary Research Branch, for certain calculations.

      2.  Expenditures by Age

Ontario’s population is younger than that of Quebec or the Atlantic provinces.  This situation is reflected in the figures for home care expenditures by age group.  In 2000-2001, Ontario spent 73% of its home care budget on clients 65 years of age and over, compared to 74% for all provinces.  During the same period, 23% of total home care expenditures in Ontario were incurred in respect of clients 85 years of age and over, compared to the national average of 26%.

In the coming years, the aging of the population will put even stronger upward pressure on the funding and delivery of home care in Ontario and in other provinces.  Ontario will need either to increase its home care expenditures significantly, or to withdraw fully or partially from this field and turn responsibility over to the private sector.  Ontario is one of the few provinces in which access to public home care programs is not a function of the client’s ability to pay for services.  Therefore, at some point in the future, despite the magnitude of its tax revenues as compared to other provinces, Ontario may also have to introduce co-payment charges for home care services.

It is also possible that longer waiting lists within the public system (where services are provided by private agencies) will result in wealthier Ontarians turning directly to private agencies.  In 2000-2001, the private sector accounted for 19.8% of total home care expenditures in Ontario, compared to the national average of 22.1%.

Source:  Health Canada, Health Expenditures in Canada by Age and Sex, 1980-81 to 2000-01 – Statistical Annex, August 2001, and Library of Parliament.

CONCLUSION

Over the years, Quebec and Ontario have introduced highly sophisticated public home care programs.  The two provinces offer a broad range of services through their public community services networks that are firmly established at the regional and local levels.

Despite greater efforts on the part of the public sector to meet growing needs, the private sector currently plays a leading role in the delivery of home care services funded through public programs in both provinces.  In fact, this is a unique feature of the home care models in Ontario and Quebec.

The private sector plays a different, and perhaps more important, role in Quebec than in Ontario, in terms of the criteria used.  Almost 40% of home care expenditures in Quebec (excluding the value of tax credits) are incurred by the private sector, twice the figure for Ontario.  In Quebec, the private sector is involved in all aspects of the delivery of home care, even though the public sector remains the leading provider of professional services.  However, what makes the Quebec model unique is the use of tax expenditures, as opposed to budgetary expenditures, to promote access to home care.  This approach makes it possible to gear public assistance to client resources and thus to leverage private expenditures.

APPENDIX I

DEFINITIONS AND METHODOLOGY

The following are definitions of the various terms used throughout this document.

APPENDIX II

OVERVIEW OF THE QUEBEC GOVERNMENT’S
FINANCIAL ASSISTANCE PROGRAM
FOR DOMESTIC HELP SERVICES

How Does the Program Work?

Persons using domestic help services provided by a social economy enterprise that has been accredited for program purposes may receive financial assistance to offset part of the hourly rate charged by the enterprise.  Two types of financial assistance are available.

A person’s income and family situation are used to determine an exemption threshold.  Where this threshold is exceeded by more than $15,000, no variable financial assistance is granted.

The maximum total financial assistance granted per hour of service provided is $10 ($4 in basic financial assistance and $6 in variable financial assistance).

The person pays only the difference between the rate charged by the enterprise and the financial assistance granted.

What Domestic Services Are Covered?

Some businesses do not offer all the above services.

 Persons aged 18 and over who are residents of Quebec within the meaning of the Health Insurance Act are eligible for the program.

 However, persons receiving compensation for domestic help services under a public plan (Commission de la santé et de la sécurité du travail, Société de l’assurance automobile du Québec, Veterans Affairs, etc.) are not eligible for the program.

Who Is Eligible for Basic Financial Assistance?

Any person eligible for the program may receive basic financial assistance, regardless of family income.

Who Is Eligible for Variable Financial Assistance?

However, persons receiving compensation for domestic help services under a private plan, or receiving a direct allowance (CLSC) are eligible only for basic financial assistance.

Financial Parameters Used to Calculate Variable Financial Assistance

To calculate any variable financial assistance payable, it must be determined what portion of family income exceeds the exemption threshold, which varies with family size.

The exemption thresholds are:

For example, the exemption threshold for a couple with two children is calculated as follows:

$12,000 + $2,400 + $2,400 = $16,800

Where family income exceeds the exemption threshold, the maximum variable financial assistance of $6 is reduced by 20 cents for every full $500 by which family income exceeds the threshold.  Variable financial assistance is therefore calculated as follows:

$6 - ( [Family income - exemption] x $0.20 )
$500

The following table shows the income levels below which variable financial assistance of $6 is granted, as well as the income levels at or above which no variable financial assistance is granted.