Sunday, November 21, 2010

Home Care; pitfalls and benefits

Another great show at White Coat Black Art. All about Home Care in the big city
Theoretically, Home Care should be delivered in your home. Respite Care is another topic. If it is not, then it should not be called home care. Out Patient services, perhaps.

Another point made by one interviewee, is that in the past (1989) she had thrice-daily visits by a nurse. After her discharge in 2009, after breast cancer surgery, in hospital 3 days, she is sent home and told to get herself to a wound clinic for her 'Home Care'.

A recent study, showed...

Among home care patients, per-patient use of home care and acute care did not change significantly over the time periods. The pattern of average nursing and PSW hours per week used in the last 12 weeks of life did not change a year after the strategy implementation, averaging 3.8 nursing hours per week and 3.8 PSW hours per week over the study period. The proportion of in-hospital deaths remained stable at approximately 38% over the study period. Approximately 16% of patients had an ED visit and 32% had a hospitalization in the last two weeks of life across time periods. Similarly the proportion of patients who had zero, one or greater than one ED visit or hospitalization remained constant across time periods.

These days, with bed shortages (see Bed Blockers), they send you home as quickly as possible. This is a good thing. It means you can sleep in your own bed. You can avoid the Superbugs and infestations that plague our institutions, and it gets you on your feet quickly. This is an issue for seniors, as well as those with other health issues. (See my posts on Hospitalisation, Hospital Discharge of Seniors, Bed Blockers)

My concern with Home Care, is that services are not delivered equally across this province of Ontario. I imagine it is the same in other provinces, but this is where my expertise lies.

In Ontario 'Home Care' has changed from services being delivered at home, to contracted services by Transfer Payment Agencies that are coordinated by the Community Care Access Centre (CCAC). With a reluctance by politicians to increase health care budgets, taxpayers reluctant to pay for health care, and a philosophy of providing Home Care for seniors, CCAC is cutting back services.

Risks of Home Care
There is no coordination of services.
A hospital discharges you and your Case Manager (a nurse) doesn't necessarily speak to the care providers after initial contact.
In the city, 'Home Care' can be provided at a clinic, where specialists (e.g., wound specialist, palliative care nurses) need not spend time travelling to various patient's homes.

In my mother's case, Home Care meant 4 hours per day, by a nurse, in rural Ontario, who was replacing her regular nurse in a staff shortage. Mom died the next day. We are short nurses in the province by about 17 - 20%, I've heard told.

No one talked to me about how close the end was. Her physician visited and asked me if she wanted to die at home. I told him she did. He did not tell me that the end was nigh. I had no idea that she would die within 24 hours. he wasn't a geriatrician. He ordered oxygen and left. There was no coordination, explanation, nor information provided to me, the primary caregiver.

Dad was suffering from a urinary tract infection. It went undiagnosed, even after an ER visit. He missed Mom's funeral. We (my brother and I) were desperately trying to figure out why Dad clearly had delirium, thinking it was dementia.

I believe that the Home Care movement is a good one, but there are risks for those not on an equal footing. The *Compassionate Care Benefits Program (EI benefits) has an impact on caregiver (read women's) pensions. Doctors are reluctant to predict longevity for terminal, palliative care patients.

Disparities and barriers to receiving good health care
Dad, resting after Mom's death
  • Between rich and poor. Those comfortably off, or with extra benefits, hire for-profit firms to provide extra nursing/PSW care. This eases caregiver burden.
  • Between rural and urban services.
  • Those with transportation, those without.
  • Those whose caregivers have the education, time and energy to provide care.
  • Pain Management kits are not extolled by all CCAC delivery teams, especially in rural Canada.
  • Myths about pain control abound. 
  • Palliative Care Nurse specialists are few and far between. In long-term they are summarily absent.
  • There are huge PSW, nurse, and physician shortages in rural areas. 


Caregivers (primarily women) suffer financially. Even with the government's program

*However, to be eligible for compassionate care benefits, a medical doctor or practitioner must issue a certificate stating that the family member has a serious medical condition with significant risk of death within 26 weeks and that he/she requires the care or support of one or more other family members.

No comments: