Home Care In The Atlantic Provinces: Structure And Expenditures

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:

to prevent hospitalization;

to reduce the length of a patient’s stay in an acute care facility through providing post-hospitalization support and care;

to provide an alternative to stays in long-term care institutions.

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:

management of the regional home support program;

management of human and financial resources;

case assessment, coordination and management;

management of professional services (nursing care, rehabilitative care, etc.);

client placement in long-term care facilities in the event of significant loss of independence.

The following services are offered to members of the public:

nursing care;

rehabilitative care (physiotherapy, occupational therapy, speech therapy, social work, respiratory care);

services related to daily activities (for example, help with dressing, personal hygiene, meal preparation and getting around inside and outside the home);

civic support services (for example, accompanying a person on outings, providing help with filling out forms and with budget management);

respite services for informal caregivers;

palliative care;

services related to routine household tasks (for example, cleaning of living areas, maintenance of household appliances, laundry, grocery shopping and similar errands, minor exterior maintenance).

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.

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

proof of residence in the province;

assessment of care required prior to the delivery of any services;

lack or scarcity of informal caregivers to assist the prospective recipient;

suitability of the home for service delivery;

consent of the prospective recipient or of his/her legal representative.

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.

Home Care Costs:
Public Sector Coverage and Co-payment Charges

Coverage – professional services

Coverage – home support services

Co-payment charges

One or two visits per day. The frequency of visits may be reduced if the client lives in a remote area.

Ceiling set at $2,268 a month for seniors and at $3,240 a month for disabled persons.

Professional care is free. The contribution required from a beneficiary towards the cost of home support services is based on his/her monthly income (maximum: $2,100). Supplies are free in cases involving acute care, except for medication.

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.

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.

Home Care Expenditures, 2000-2001

Public Sector Expenditures*

Private Sector Expenditures

Total Expenditures

Home Care as a Percentage of Total Health Care Expenditures (%)

Newfoundland and Labrador

Total expenditures
(millions of dollars)

Per capita expenditures (dollars)

45.5

84.53

12.8

23.80

58.3

108.33

3.56

–

All provinces

Total expenditures
(millions of dollars)

Per capita expenditures (dollars)

2,690.9

87.51

764.3

24.86

3,455.2

112.37

3.54

–

* 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.

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.

Home Care Expenditures by Age, 2000-2001

0-64 years

65+

85+

Total

Newfoundland and Labrador

Total expenditures (millions of dollars)

Per capita expenditures (dollars)

Percentage of total health care expenditures allocated to home care (%)

Private sector expenditures as a percentage of total home care expenditures (%)

15.3

32.14

1.65

21.57

43.0

683.94

6.03

22.04

12.4

1,899.71

7.25

28.01

58.3

108.33

3.56

21.97

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

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:

to prevent or reduce institutionalization;

to assist persons with diminishing abilities to maintain a certain level of independence so that they can continue to live in their community;

to supplement the support provided by family and loved ones to persons with diminishing abilities.

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

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:

case assessment, coordination and management;

professional services management (nursing care, rehabilitative care, etc.);

management of home support services;

management of human and financial resources;

client placement in long-term care facilities in the event of significant loss of independence.

Services delivered to members of the public are as follows:

nursing care;

rehabilitative care (physiotherapy, occupational therapy, speech therapy, social work and respiratory care);

a dialysis program;

services related to daily activities;

civic support services;

respite services for informal caregivers;

palliative care;

services related to routine household tasks.

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.

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

proof of residence in the province;

assessment of care required prior to the delivery of any services;

lack or scarcity of informal caregivers to assist the prospective recipient;

suitability of the home for service delivery;

consent of the prospective recipient or of his/her legal representative.

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.

Home Care Costs:
Public Coverage and Co-payment Charges

Coverage – professional services

Coverage – home support services

Co-payment charges

Professional care is free. Maximum 4 hours a day or 28 hours a week of professional or non-professional care and services.

Maximum 4 hours a day or 28 hours a week of professional or non-professional care and services.

For home support services, cost-sharing is proportional to the beneficiary’s income. Subsidized hourly wage. Supplies, equipment and medication are paid for by the beneficiary.

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

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.

Home Care Expenditures, 2000-2001

Public Sector Expenditures*

Private Sector Expenditures

Total Expenditures

Home Care as a Percentage of Total Health Care Expenditures (%)

Prince Edward Island

Total expenditures
(millions of dollars)

Per capita expenditures (dollars)

6.6

47.85

3.2

23.36

9.8

71.21

2.48

–

All provinces

Total expenditures
(millions of dollars)

Per capita expenditures (dollars)

2,690.9

87.51

764.3

24.86

3,455.2

112.37

3.54

–

*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.

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.

Home Care Expenditures by Age, 2000-2001

0-64 years

65+

85+

Total

Prince Edward Island

Total expenditures (millions of dollars)

Per capita expenditures (dollars)

Percentage of total health care expenditures allocated to home care (%)

Private sector expenditures as a percentage of total home care expenditures (%)

2.2

18.22

1.0

31.82

7.6

422.06

4.3

33.09

2.6

1,130.91

4.9

39.82

9.8

71.21

2.5

32.80

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

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:

to provide an alternative to hospitalization;

to facilitate early release from hospital;

to provide an alternative to institutionalization, or delay it;

to provide long-term care;

to provide rehabilitative services;

to provide palliative care;

to facilitate the coordination and delivery of home care 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:

planning and case assessment, coordination and management;

management of professional services (nursing care, rehabilitative care, etc.);

management of short-term home support services;(5)

management of human and financial resources.

The following services are provided to the public:

nursing care;

rehabilitative care;

services related to day-to-day activities;

civic support services;

respite services for informal caregivers;

palliative care;

services related to routine household tasks.

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.

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

proof of residence in the province;

assessment of care required prior to the delivery of any services;

lack or scarcity of informal caregivers to assist the prospective recipient;

suitability of the home for service delivery;

consent of the prospective recipient or of his/her legal representative.

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

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.

Home Care Costs:
Public Sector Coverage and Co-payment Charges

Coverage – professional services

Coverage – home support services

Co-payment charges

All professional services are available and free under the Extra-Mural Program (EMP) acute care component.

Coverage is available but is paid for by beneficiaries. The EMP has a small budget for short-term services, notably for palliative care.

The beneficiary pays the full cost of long-term professional and home support services. The government provides financial assistance ($2,040 per month) geared to income, assets and family make‑up. The government takes the beneficiary’s private insurance into account in calculating assistance.

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

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.

Home Care Expenditures, 2000-2001

Public Sector Expenditures*

Private Sector Expenditures

Total Expenditures

Home Care as a Percentage of Total Health Care Expenditures (%)

New Brunswick

Total expenditures
(millions of dollars)

Per capita expenditures (dollars)

146.6

193.76

30.7

40.56

177.3

234.32

7.55

–

All provinces

Total expenditures
(millions of dollars)

Per capita expenditures (dollars)

2,690.9

87.51

764.3

24.86

3,455.2

112.37

3.54

–

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

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%.

Home Care Expenditures by Age, 2000-2001

0-64 years

65+

85+

Total

New Brunswick

Total expenditures (millions of dollars)

Per capita spending (dollars)

Percentage of total health care expenditures allocated to home care (%)

Private sector expenditures as a percentage of total home care expenditures (%)

41.8

63.42

3.21

16.75

135.5

1,388.99

12.95

17.50

41.5

3,587.32

15.27

22.32

177.3

234.32

7.55

17.31

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

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:

to prevent or reduce hospitalization and institutionalization;

to assist persons with diminishing abilities to maintain a certain level of independence so that they can continue to live in their community.

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:

nursing care;

rehabilitative care;

respite services for informal caregivers;

palliative care;

respiratory care;

services related to daily activities;

services related to routine household tasks.

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.

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

proof of residence in the province;

assessment of care required prior to the delivery of any services;

lack or scarcity of informal caregivers to assist the prospective recipient;

suitability of the home for service delivery;

consent of the prospective recipient or of his/her legal representative.

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.

Home Care Costs:
Public Sector Coverage and Co-payment Charges

Coverage –
professional services

Coverage –
home support services

Co-payment charges

Services covered include nursing care, rehabilitative care and respiratory therapy.

Available for low-income beneficiaries.

For acute care, the maximum value of care provided is $4,000 per month.
For long-term care, the maximum value of services provided is $2,200 per month.
Home support services and respiratory therapy are charged at $6 an hour, to a maximum of $360 per month. The beneficiary pays for supplies between visits.

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

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.

Home Care Expenditures, 2000-2001

Public Sector Expenditures*

Private Sector Expenditures

Total Expenditures

Home Care as a Percentage of Total Health Care Expenditures (%)

Nova Scotia

Total expenditures
(millions of dollars)

Per capita expenditures (dollars)

93.1

98.89

25.1

26.64

118.2

125.53

4.28

–

All provinces

Total expenditures
(millions of dollars)

Per capita expenditures (dollars)

2,690.9

87.51

764.3

24.86

3,455.2

112.37

3.54

–

* 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.