HOME CARE IN THE ATLANTIC PROVINCES:
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 do 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 first in a series of three(2) that provide an analytical overview of government-run home care programs across the provinces.  It focuses on home care in the four Atlantic provinces and examines public home care programs in each province in terms of:

HOME CARE

Generally speaking, the term “home care” applies to a wide range of social and medical services provided to persons in their homes, 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) 

NEWFOUNDLAND AND LABRADOR

   A.  Responsibilities and Objectives

In Newfoundland and Labrador, the Department of Health and Community Services determines overall funding for home care in the province and allocates resources among the various regions.  The department is also responsible for establishing strategic directions and policies, and for monitoring programs.  Day-to-day program management and responsibility for service delivery are delegated to six regional Health and Community Services Boards.  These boards have considerable flexibility in adapting their programs to the specific needs of their regional clients.

The objectives of home care programs in Newfoundland and Labrador are as follows:

   B.  Services

Each regional board operates a “single window” access point that coordinates delivery of short-term and long-term home care services.  The boards are responsible for general services associated with:

The following services are offered to members of the public:

   C.  Delivery and Eligibility

      1.  Service Delivery

In Newfoundland and Labrador, professional services such as nursing care, rehabilitative care and nutritional counselling are delivered to clients in their homes primarily by employees of the regional boards.  However, services are frequently contracted out.  In the case of home support services, subcontracting and clients’ self-management of services are widespread, as these delivery options are considered more economical and allow clients to choose the services they need.  Clients may receive an allowance with which to purchase services directly from private providers.

      2.  Eligibility

Home care in Newfoundland and Labrador is subject to the following eligibility criteria:

   D.  Service Coverage and Co-payment Charges

In Newfoundland and Labrador, as in the other provinces, the regional delivery of services has made it possible to adapt them to the needs of the population, but it has also created some disparities.  Services offered may vary from one region to another depending on priorities, the available human resources and the needs of the clientele.

Generally speaking, access to home care is limited by constraints at two levels.  First, budgets allocated to home care are modest, which obliges the regional boards to give priority to the neediest clients – those with the least income, or those without family support or volunteer assistance.  Second, the increasing requirement that beneficiaries share the costs of services – in particular, home support services – in proportion to their income, also has the effect of limiting access to care.  Moreover, the province has established monthly service utilization quotas for each beneficiary (limiting the number of hours or dollar cost of services); this does mean, however, that a greater number of clients can benefit from the available public resources.

Sources:   Health Canada, CARP’s Report Card on Home Care in Canada 2001, Newfoundland and Labrador government web site, and Library of Parliament.

In Newfoundland and Labrador, as elsewhere in Canada, the home care sector suffers from a shortage of health professionals.  Working conditions are less attractive than those offered in institutions, and this does not facilitate recruitment.  This situation limits opportunities for providing home care.

   E.  Home Care Expenditures

      1.  Total Expenditures

Despite the steep increase in expenditures over the past 20 years, the home care sector is still characterized by volunteer work and the involvement of family and friends in providing assistance to disabled persons or those with decreasing independence.  The prevalence of unpaid work in this field means that home care expenditures are limited and also difficult to define accurately.

In Newfoundland and Labrador, home care expenditures accounted for 3.56% of total health care expenditures during fiscal year 2000‑2001, which is in line with the Canadian average.  Per capita expenditures were slightly lower than the Canadian average.  This gap does not necessarily translate into a lesser level of service for the province’s inhabitants, since labour costs are lower than in most other provinces.

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

Sources:   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

According to data for 2000‑2001, Newfoundland and Labrador allocated 74% of its home care expenditures to services for seniors (65 years of age or older).  Statistics Canada’s demographic projections for the province indicate that seniors will make up 22.5% of the population in 2021, as opposed to only 11.6% in 2000 – an increase of 94%.  In the coming years, the aging of the population and the resulting demand for home care services will probably compel the province 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.

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

PRINCE EDWARD ISLAND

   A.  Responsibilities and Objectives

In Prince Edward Island, as in Newfoundland and Labrador, Regional Health Authorities – there are five in the province – are responsible for the day-to-day management of the public home care support program.  For its part, the provincial Department of Health and Social Services determines the level of home care funding for the province as a whole, allocates resources to the regional health authorities and is responsible for the broad strategic directions and policies, and for monitoring programs.

The objectives of Prince Edward Island’s home care program are as follows:

The program also provides post-hospitalization home care (up to 30 days).

   B.  Services

Each regional board has established a “single window” access point that coordinates delivery of both short-term and long-term home care services.  The regional boards are responsible for general services related to:

Services delivered to members of the public are as follows:

   C.  Delivery and Eligibility

      1.  Service Delivery

In Prince Edward Island, professional services such as nursing care, rehabilitative care and nutritional counselling are delivered to clients in their homes by regional health authority employees, and occasionally by subcontractors.  With regard to home support services, there is widespread reliance on subcontracting and clients’ self-management of services.  Home support services must be paid for by the client, who may receive financial assistance, depending on his/her income, to purchase services directly from private providers.

      2.  Eligibility

Home care in Prince Edward Island is subject to the following eligibility criteria:

   D.  Service Coverage and Co-payment Charges

In Prince Edward Island, regional health authorities can adapt their services to clients’ needs.  However, given the province’s geography and the prevalence of the public sector in delivering professional care, actual regional variations are minimal.  The availability and skill levels of human resources are important considerations that may at times influence the delivery of services.

Priority is given to the neediest clients – those with the least income, or without family support or volunteer assistance.  Professional services are free to all recipients, but clients contribute a large share of the cost of home support services.

Sources:      Health Canada, CARP’s Report Card on Home Care in Canada 2001, Prince Edward Island government web site and Library of Parliament.

   E.  Home Care Expenditures

      1.  Total Expenditures

In Prince Edward Island, home care expenditures accounted for 2.48% of total health care expenditures during fiscal year 2000‑2001, which is considerably below the Canadian average.  Per capita expenditures were also substantially lower than the Canadian average.  The reasons for this situation are unclear.  However, as in Newfoundland and Labrador, this gap does not necessarily translate into a lesser level of service for the province’s inhabitants, since labour costs are lower than those in most other provinces, and the Island’s small size may increase cost-efficiency by permitting more service intensity.  Moreover, community spirit and support from friends and family are probably stronger in environments such as Prince Edward Island.

The Prince Edward Island model is not as “medicalized” as that of other provinces, and home support services are mostly paid for by the beneficiaries, as shown by the level of per capita private expenditures.  In 2000‑2001, 32.8% of home care expenditures in Prince Edward Island were paid for by the private sector – the highest percentage in the country, after that of Quebec.  Finally, as concerns professional care, it can be difficult to measure the exact amount of time devoted to home care in regions where personnel also perform other tasks.

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

Sources:   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

According to data for fiscal year 2000‑2001, Prince Edward Island devoted 78% of its home care expenditures to persons 65 years of age or older.  For those 85 years of age or older, private expenditures accounted for 40% of total expenditures, the highest percentage in the country.

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

 NEW BRUNSWICK

   A.  Responsibilities and Objectives

The home care model in New Brunswick is unique in Canada because of the importance it gives to home care as a more economical alternative to hospitalization, in addition to the more traditional roles of home care.  The New Brunswick model is “medicalized” to the point that many consider it as a “home hospitalization” program.

In New Brunswick, the Hospital Services Branch of the Department of Health and Wellness establishes general directions, and allocates funds to eight regional boards that are authorized to deliver home care programs and services.  Each regional board is also responsible for managing hospitals, community health centres and the regional unit of the Extra-Mural Program (EMP), the main component of the province’s home care system. This division of responsibilities is designed to strengthen coordination of client care among the hospital, the home and the community.  It is widely regarded as essential to the effectiveness of the EMP, and therefore of the home care delivery model.

The EMP has the following mandate:

   B.  Services

Each regional EMP has established a “single window” access point that coordinates the delivery of short-term or long-term home care.  Reporting to the regional board, the EMP provides general services related to:

The following services are provided to the public:

C.  Delivery and Eligibility

      1.  Service Delivery

In New Brunswick, all professional service providers (nursing care, rehabilitative care and nutritional counselling) work for the EMP.  Non-professional home care services (visiting homemaker services) are provided to some extent by contract workers from community organizations operating in partnership with the EMP.  In the case of home support services, the client may receive financial assistance, depending on his/her income, to purchase services from private suppliers.

      2.  Eligibility

Home care in New Brunswick is subject to the following eligibility criteria:

Under the EMP, a physician’s recommendation is mandatory except for rehabilitative services.

   D.  Service Coverage and Co-payment Charges

In New Brunswick, all residents are entitled to home care.  Coordination by regional boards means that, despite the regional delivery of services (there are 30 service points in the province), services are reputed to be uniform throughout the province.

Access to professional EMP services is free, which makes sense given that the EMP’s acute care component more or less substitutes for the care offered in medical or hospital facilities in other provinces.  Nonetheless, access is limited by budget constraints and the availability of human resources.  The extent to which home support services are free depends on the beneficiary’s income, and their use is subject to a ceiling.  The government takes into account any private insurance that the client may have in calculating the level of financial assistance.

Sources:    Health Canada, CARP’s Report Card on Home Care in Canada 2001, New Brunswick government web site and Library of Parliament.

   E.  Home Care Expenditures

      1.  Total Expenditures

New Brunswick’s unique approach to home care translates into a percentage of total health care expenditures that is much higher than that of the other provinces.   Home care accounted for 7.55% of total health care expenditures in fiscal year 2000‑2001 – more than twice the Canadian average.  Per capita expenditures were also more than twice the Canadian average.

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

Sources:   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

More than 20 years ago, New Brunswick designed a health care model centred on home care.  Premised largely on the concept that the aging of the population would significantly affect hospitalization costs, this model – which was ahead of its time a generation ago – remains very relevant today.

According to data for fiscal year 2000‑2001, New Brunswick allocated 45% of its total health care expenditures and 76% of its total home care expenditures to services for seniors (65 years of age or older).

Statistics Canada’s demographic projections for the province indicate that seniors will make up 22.2% of its population in 2021, as opposed to 13.9% in 2000 – an increase of 60%.

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

NOVA SCOTIA

   A.  Responsibilities and Objectives

In Nova Scotia, the Department of Health’s home care program (“Home Care Nova Scotia”) is responsible for issues relating to planning, strategic direction, funding, human resources and the quality of home care throughout the province.  Day-to-day program management is the responsibility of care coordinators who work in hospitals and in the community.  Nova Scotia is one of the only provinces where the regional boards, the District Health Authorities, do not have a major role in delivering home care.

The objectives of the Home Care Nova Scotia program are essentially as follows:

   B.  Services

The Home Care Nova Scotia program is structured around a “single window” access point with a toll-free number.  Under the program, case distribution for the entire province is coordinated centrally, but case assessment and management and the delivery of home care services, both short-term and long-term, are decentralized to the local level.

Services delivered to members of the public include:

   C.  Delivery and Eligibility

      1.  Service Delivery

In Nova Scotia, the delivery of most home care services (nursing care, home support) is subcontracted to private agencies by the provincial Department of Health.  The subcontracting applies to acute care provided at home, as well as to longer-term care.

      2.  Eligibility

Home care in Nova Scotia is subject to the following eligibility criteria:

   D.  Service Coverage and Co-payment Charges

Nova Scotia provides a wide range of home care services.  All professional services are free with the exception of respiratory care, which is cost-shared by the beneficiary according to his/her financial resources.  Home support services are also paid for in part by beneficiaries.  The value of all services received by a beneficiary is subject to a monthly ceiling that reflects the cost of providing the same services in an institution.

Sources:      Health Canada, CARP’s Report Card on Home Care in Canada 2001, Nova Scotia government web site and Library of Parliament.

   E.  Home Care Expenditures

      1.  Total Expenditures

In Nova Scotia, home care expenditures accounted for 4.28% of total health care expenditures in fiscal year 2000‑2001 – higher than the Canadian average.  Private per capita expenditures were slightly higher than the Canadian average.

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

Sources:   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

According to data for fiscal year 2000‑2001, Nova Scotia allocated close to 77% of its home care expenditures to services for seniors (65 years of age or older).  Statistics Canada’s demographic projections indicate that seniors will make up 21.3% of the province’s population in 2021, compared with 13.2% in the year 2000 – an increase of 61%.

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

CONCLUSION

Among the various home care organization models in the Atlantic region, the New Brunswick model has many features of interest to other provinces.  Home care in that province is highly medicalized and is a central component of the provincial health care system.  All things being equal, this approach to home care benefits from access to more resources than home care programs elsewhere in Canada.

APPENDIX

DEFINITIONS AND METHODOLOGY

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