Looking at health care system performance: Lessons from the Commonwealth Fund survey

Sukirtha Tharmalingam, Senior Policy Analyst, Health Council of Canada 

The Health Council of Canada has been pleased to be a key contributor to the design and funding of the annual Commonwealth Fund’s International Health Policy Survey (CMWF IHP survey) since 2009. Using the data collected in these annual surveys, we released a series of bulletins under the banner, Canadian Health Care Matters that focused on different aspects of public/patient and physician perceptions and experiences with our health care system.
The 2013 survey of the general public includes about 100 questions that address a comprehensive range of issues in our health care system.  The report we released today, Where you live matters: Canadian views on health care quality , lets us compare the performance of provincial health systems with that of 10 other high-income countries.  We also compare results from the 2013 survey to the same questions asked in 2004, 2007 and 2010.  We find that Canadians’ experiences with their health care system vary widely across the country and from our international counterparts. For example, if you are in BC, you may be happier knowing that your province outperforms all other provinces in getting a same-day or next-day appointment when needed – 41% of respondents say they can. However, even BC as the best performer lags far behind the other 10 other countries participating in this survey.  In the top performing country Germany, 76% of people surveyed report they can get a same-day or next-day appointment.  Over the past decade, Canada has shown little change in this aspect of access to care – hovering around the 40% range since 2004.  This and other comparisons we present in the bulletin serve to raise flags for others to probe further into the factors that contribute to the variations and trends we see.

Looking back and moving forward

With an eye to the future, there are a few insights and learnings that I would like to share based on working with the CMWF surveys for the last four years.
 
1. Canadians have something to say about their health care system performance and it matters! 

The findings we presented through these reports definitely resonated with Canadians.  This was evident to us through the interest they generated from national and local media and news agencies (the Toronto Star) and (the Globe & Mail), report downloads from our website, references to the statistics we presented, and the plethora of patient stories the reports brought forward.
[The cost of chronic illness] [Worrying about my future] [In search of support: the importance of communication in the heath care system]

2. There are recognizable challenges and limitations to a population based survey data

There are methodological challenges we face when analyzing and reporting on results from these surveys.  Achieving perfectly consistent and comparable survey data across the participating countries and even provinces within Canada is virtually impossible. Examples of some things to consider are variations in response rates, individual interpretation of the survey questions, representativeness of the population being surveyed, or one’s ability to recall an experience. However, tremendous efforts were taken to ensure that we developed questions that were unambiguous and could offer important insights on the health care system. We also employed statistical techniques to help us improve the interpretability of the results.

3. There are recognizable benefits to participating in a cross-sectional annual international survey that assesses health system performance from the perspective of those who interact with it. 

Although self-reported measures derived from population surveys can be challenged, we need to be wary that we are not dismissing results because we think they may not be comparable. There are benefits to these survey findings and the comparative lens (international, provincial, over time) they provide us. It allows us to understand what is being achieved in other countries of similar economic size and income and provokes us to think about where there are potential gains to be made in Canada.  For example, which countries have higher performance and what policy directions and strategies do they share with us? What aspects of the health system have improved over time; which have not?

As the Health Council prepares to wind down in March 2014, we are pleased that CIHI and CIHR-IHSPR have agreed to co-lead the Canadian contributions on future Commonwealth Fund surveys. We have enjoyed the opportunity to bring forward the results from this survey in recent years and have been pleased to collaborate with the health agencies in Alberta, Ontario and Quebec to expand sample sizes in their respective provinces. The self-reported experiences of those who are in direct contact with the health care system provide a unique and vital piece of information that can help to improve the delivery of health care. I hope that this important source of information will continue to play a role in supporting decisions by health care providers, managers, and policy makers. 

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The Home First philsophy - creating safe transitions for patients from acute care to home

Caroline Brereton, RN, MBA is a registered nurse and holds an MBA from Queens University. She is a graduate of the Rotman School of Management Advanced Health Leadership Program.
A senior healthcare executive with 15 years of leadership experience, Caroline became Chief Executive Officer of the Mississauga Halton CCAC in May 2010. Caroline has a vision for a system that is fully aligned to support the needs of patients.

The growing population of seniors across the province will continue to increase pressure on the health sector to provide health care at home, including community services to help seniors move from  hospital to home following acute treatment and programs to help residents remain safely at home for longer. We feel it acutely in our Mississauga Halton communities of South Etobicoke, Mississauga, Oakville, Milton and Halton Hills.  We experienced one of Ontario’s highest growth rates in population, a 12 per cent increase in population from 2006 to 2011.  The Mississauga Halton region is the second fastest growing population of seniors in Canada (projected 32.3 per cent increase in 75 to 84 year-olds and 71.1 per cent increase in seniors 85 and older, by 2013).

 In 2009, anticipating population growth, the Mississauga Halton CCAC, was the first to launch the Home First Philosophy. In collaboration with our region’s hospitals, Trillium Health Partners and Halton Healthcare Services, funding was provided by the Mississauga Halton LHIN.

The philosophy embodied our objective: to slow the growth of alternate level of care (ALC) rates in hospital, while at the same time supporting the province’s goal to increase access aging at home. It was ambitious; the number of ALC days nearly doubled from 9.3 per cent in 2007 to 17.5 per cent in 2008.
The Home First Philosophy was the foundation for a new suite of Wait at Home services and that was our approach to tackling the growing ALC rate. It is a team-based philosophy that promotes safe and timely care, services and supports, which helps to meet the health care needs of patients and families in the most appropriate setting. The Home First philosophy recognizes that the home environment is the best place for recovery and supports people in returning to their homes from hospital wherever possible. It also provides the necessary services to help older adults maintain their continued independence in the community.

Challenges and Hurdles
This new philosophy necessitated changes in workflow, culture and communication. When we introduced it to our patients, staff and partners, it was a huge culture shift in health care thinking for families and physicians.  Traditionally, patients applied to long-term care homes from the hospital.

Physicians were concerned about safety and risk to patients leaving hospital and returning home. We helped physicians understand the quality of care provided in the community through the Mississauga Halton CCAC. We explained our approach and introduced new services that would ensure patients, even those with complex care needs, would be safe at home while they applied for long-term care or recovered and realized they could stay at home safely with services from our CCAC.

Better Outcomes
Together, with our partners, we drove better results and we continue to bring proactive change to the health care system. With innovative efforts and focused teamwork, the consistently low ALC rates in Mississauga Halton is evidence of system integration as a key mechanism for delivering the right care, in the right place, at the right time.  In fiscal 2012/13 our ALC rate was seven per cent and 6.3 per cent in the previous year. This means that 93 per cent of hospital beds in our region were available to patients needing hospital care.

Staying in hospital after surgery or treatment is not in a patient’s best interest. There is an increased risk of infection; and patients become less independent the longer they stay in hospital.The Home First philosophy is an enormous cost savings to our health system. Every ten per cent  shift of ALC patients from acute care to home care results in a $35-million saving.  And most importantly, it provides better outcomes for patients where they are happier and more comfortable in a familiar setting and they tend to recover more quickly.
Recently, a patient’s son, who is caring for his 83-year-old father at home, told us:  “The Mississauga Halton CCAC made it so simple and smooth. You take care of everything – personal support workers, nurses, occupational and physical therapists, medical equipment and supplies.  They brought the hospital to our home.  Now my father is safe and secure, and getting the quality of life he deserves.  My father belongs here.  Without you, we could not do it.  It would have been impossible. It is a blessing to have my dad here.”
However, if a patient and family decide that long-term care is the right place to be, we help them through the process from beginning to end. We start by directing them to our long-term care website – http://mhccac-ltc.com/ –which provides information about wait lists and costs, as well as a virtual tour of our region’s 27 long-term care homes.

At the Mississauga Halton CCAC, we look at health care differently. We recognize health care at home is not the future; it is the reality of health care today.

*Watch the video on the Home First program, part of the Health Council's Wait Times video series.

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Canadian Home Care Priorities for Seniors: What Can We Learn From Australia? Your questions answered

In May, our international webinar, Canadian Home Care Priorities for Seniors: What Can We Learn From Australia?, sparked many more questions than we were able to answer in one hour, so we asked our panelists to address your questions directly.

Here, one of our panelists, Pamela Fralick, President and CEO of the Canadian Healthcare Association, answers your question about underserved and vulnerable populations. If you want to see all the answers from all three panelists, or the presentations from the webinar, click here.

Q: Can you identify any specific strategies in working with the Aboriginal population and aging strategies in relation to this?

A: At the federal level, Health Canada launched the First Nations and Inuit Home and Community Care (FNIHCC) program in 1999. The program provides various health-related home care, including case management and nursing care. In addition, the Assisted Living program, administered by Aboriginal Affairs and Northern Development provides support services to elderly or disabled First Nations persons living on reserves. Services provided include homemaker, foster care and institutional care services.

Throughout Canada, provinces and territories vary in the extent to which they provide home care services to Aboriginal People. Challenges lie in providing adequate home care to these populations and ameliorating the differences between the provincial home care program and the on-reserve federally-funded programs. The differences can make it difficult to offer consistent care delivery.

From 2008 to 2010, the Victorian Order of Nurses undertook a National Aboriginal Health Initiative through which several culturally relevant resources were developed.

Canadian Home Care Priorities for Seniors: What Can We Learn From Australia? Your questions answered

In May, our international webinar, Canadian Home Care Priorities for Seniors: What Can We Learn From Australia?, sparked many more questions than we were able to answer in one hour, so we asked our panelists to address your questions directly.

Here, one of our panelists, Nadine Henningsen, Executive Director of the Canadian Home Care Association, answers your question about provincial versus federal responsibility. If you want to see all the answers from all three panelists, or the presentations from the webinar, click here.

Q: There used to be a federal Minister of State responsible for caregiving.  Would you say that caregiving is now considered a 'provincial' issue (aside from CPP changes and the Aboriginal population)?

A: Both the federal and provincial governments in collaboration with NGOs and other stakeholders across Canada are actively working on initiatives to support caregivers.  

These actions may be a part of a distinct strategy to support all caregivers (as seen in Manitoba’s Caregiver Act) or targeted to caregivers providing support for the frail elderly and included in policy to support continuing care and healthy aging.   Specifically, the jurisdictions are moving forward on key elements of the Canadian Caregiver Strategy (proposed by the Canadian Caregiver Coalition), such as:

1. Safeguard the health and wellbeing of family caregivers through identification of caregiver needs and provision of flexible respite options. Note: This is a provincial issue and activity.
2. Minimize excessive financial burden placed on family caregivers by providing direct payment, where caregivers receive allowances, compensation or reimbursement for expenses and / or tax credits, pension credits, and dropouts from pension. Note: This is a federal activity with the Compassionate Care Benefit and Caregiver Tax Credit.  Provinces have advanced this with unique programs.
3. Enable access to user-friendly information, education, resources and counseling. Note: This is a provincial focus, with Federal Government research grants to support access to information (e.g., Caregiver Policy Lens & Caregiver Toolkit).
4. Create flexible workplace environments that respect caregiving obligations including labour policy, workplace policies, labour standards and Employment Insurance policies such as the Compassionate Care Benefit. Note: There’s limited activity in this area. 
5. Invest in research on family caregiving as a foundation for evidence-informed decision making. 
6. Note: Federal government – through HRSDC – 2009 Call for Proposals (listing of approved projects here. Provincial activity varies by jurisdiction. 

Canadian Home Care Priorities for Seniors: What Can We Learn From Australia? Your questions answered

In May, our international webinar, Canadian Home Care Priorities for Seniors: What Can We Learn From Australia?, sparked many more questions than we were able to answer in one hour, so we asked our panelists to address your questions directly.

Here, one of our panelists, Jeff Fiebig, Manager of Program Development with the ACH Group in Adelaide, answers your question about home care packages in Australia.

If you want to see all the answers from all three panelists, or the presentations from the webinar, click here.

Q. Can you elaborate on the Australian home care packages - are these based on funding/services/functionality?

A: Current access to all “higher level” services is loosely based on individual functionality, a rationed system of places (114 places per 1000 of population aged 70 plus)along with capitation grants for some services (low level HACC services, socialisation etc). Here is the best description of the current system.
Under the Living Longer, Living Better Reforms there is proposed:

• Common entry levels between Residential and Community Care
• Common means testing and fees
• A universal approach to quality, standards, and more.

“Compassion fatigue” and caregiver burnout

An article in last week’s National Post discussed “compassion fatigue” – a health risk that family caregivers too often experience.

The article describes the high potential for caregiver burnout, saying as the length of time of caregiving increases, the risk of burnout does as well. Dr. Jacqueline Brunshaw, the author of the article, provides tips for caregivers to protect their own health, like understanding the challenges of the situation, celebrating the good times had with the family member, and asking for help.

Caring for a high-needs senior in particular may stretch family caregivers beyond their capacity when there is only limited outside support. We have recently reported on the state of home care in Canada, both in Seniors in need, caregivers in distress, and our Progress Report 2012. We found that about 40-50% of seniors with the most complex health needs have distressed caregivers who report they are finding it difficult to continue to provide care, and that they have feelings of stress, anger, and depression.Home care is an integral part of the health care system, and in order to help ensure the best quality of life for seniors and avoid “compassion fatigue” by their caregivers, it must be supported and enhanced.  

Dr. Brunshaw lists 10 signs of caregiver burnout. If you recognize them in yourself or someone else, you may wish to discuss them with a professional:

1)    Feeling unusually tense, irritable or agitated with others
2)    Being irritable and angry towards the ill/disabled individual
3)    Feeling sad, tearful or dissatisfied with life in general
4)    Feeling exhausted and overwhelmed
5)    Withdrawal from friends and enjoyable activities due to loss of desire and/or energy
6)    Lowered immunity: getting sick more often and taking an unusually long time to recover
7)    Increased need for medications and/or use of drugs or alcohol
8)    Feeling out of control in attempts to manage your usual daily routine, with no sense of how to regain that control any time soon
9)    Trouble sleeping and/or disturbing dreams
10)  Change in appetite

Conference Board of Canada report echoes Health Council findings on home care

In our recently released report, Seniors in need, caregivers in distress: What are the home care priorities for seniors in Canada, we found that many seniors with complex needs are not getting the level of care they require and many of their family caregivers are becoming distressed. 

The Conference Board of Canada’s new report, Home and community care in Canada: An economic footprint estimates the economic impact of home and community care in Canada. The report highlights the implications for businesses of their employees doubling as family caregivers, and the potential spending implications of shifting care from institutions to homes. The report estimates that the total spending on home and community care in 2010 ranged from $8.9 billion to $10.5 billion, accounting for approximately 5% of total health spending in Canada. About 3 million Canadians are estimated to have given some level of unpaid care in 2007, providing over 1.5 billion hours of home support and community care.

Research into the cost-effectiveness of integrated home care programs would facilitate policy development and improvement of care for seniors, as there is a lack of recent economic data in this area.

The Conference Board of Canada has provided some important information for governments, policy makers, and the public in terms of the financial implications of an aging population that wants to be cared for at home. The Conference Board echoes our finding that family caregivers provide the highest proportion of care, but that distressed family caregivers may have additional economic implications.

Canadian governments are recognizing that an aging population along with rising health care costs requires a greater focus on home and community care. We have profiled some innovative practices in our report that are examples of effective home care policies and programs. We encourage others to adapt and expand what’s already working to ensure that seniors and their family caregivers can live healthy and comfortable lives at home.

By: Shilpi Majumder, Policy Lead, Health Council of Canada

Home Care - We need to translate findings into real solutions

Kevin Mercer is the Chief Executive Officer of the Waterloo Wellington Community Care Access Centre in Kitchener, Ontario. He is the Editor-in-Chief of Healthcare Management Forum and was a member of the expert panel for Seniors in need, caregivers in distress: What are the home care priorities of seniors in Canada?

First of all, if it hasn’t been said, it needs to be said – kudos to the Health Council of Canada for recognizing the importance of home care and publishing this report.  After working for 20 years in home and community care, you realize that despite the compelling research on the value and the importance of home care, policy papers and policy shifts have not kept pace with the directional advice of the research.  As a society, we have remained committed to a health care model developed predominantly in the 1950s.

The Health Council of Canada’s Seniors in need, caregivers in distress: What are the home care priorities of seniors in Canada? reminds us on the one hand how far we have advanced with home care services and on the other hand how far we have to go.  We have a long ways to go and some very vulnerable people are depending on us to do it.  This report puts a face to the policy issue and redefines “home care” from a “nice-to-have” substitute to acute care and long term care to an essential prerequisite to maintaining the health of both seniors and the caregivers.  We have made assumptions about the availability and the capacity of caregivers at home.  The report reminds us that these are flawed assumptions and we need to recognize the caregiver burden and provide more assistance.  The report tells us that the caregiver situation in terms of the ageing population is going to continue to grow.  The negative effects, if remedies are not implemented, are going to be felt in the health system and in the work force.  Caregivers are going to increase in numbers and so are the distress levels if action is not taken and soon.

In many respects, the Health Council report provides a picture that many of us have understood intuitively for many years.  Our front line staff, the advocates for seniors and caregivers, has articulated very well the caregiver burden they witness as they try to assist home care clients and families.   However, the empirical evidence has never been as clearly demonstrated as it has in this report.  Thanks to Dr. John Hirdes and his team of researchers, the RAI-HC data has been assessed and a scientific validation of the caregiver burden is provided.  The value of the RAI assessment data in this report is instructive in helping us appreciate the needs of home care clients.  Governments have often challenged the field to provide the data that supports claims of increased acuity demands in the community.  This report provides the evidence as illustrated in this quote.

“About one-third of the seniors in our analysis of home care recipients have high needs, often involving both physical disability and cognitive impairment such as dementia.  Despite this, they may receive only a few hours more of publicly funded home care each week than seniors assessed with moderate needs.”

The challenge for all of us now is to translate the findings in this report into real solutions for vulnerable home care clients and their caregivers.  At least in Ontario a commitment to home care of a 4 percent per year budget increase for the next three years is a step in the right direction. 

This is positive news and if there was any question as to the need, one just needs to read Seniors in need, caregivers in distress: What are the home care priorities of seniors in Canada?  A very timely report.

PLEASE NOTE: On May 9th, the Health Council of Canada held a webinar Canadian Home Care Priorities for Seniors: What Can We Learn From Australia? with our special panelists:

• Jeff Fiebig, Manager, Program Development of the ACH Group in Adelaide, Australia
• Pamela Fralick, President and Chief Executive Officer of the Canadian Healthcare Association
• Nadine Henningsen, Executive Director of the Canadian Home Care Association

The webinar expanded upon many of the issues presented in our recent report, Seniors in need, Caregivers in distress: What are the home care priorities for seniors in Canada?

You can download the PowerPoint presentation or listen to the webinar.

Home care: it's about people, families, and their perspectives – not ours

Dr. Paul Holyoke is the director of Saint Elizabeth’s research department, which has an extensive applied research portfolio across five themes:  client experience and person-centred care, health system innovations, use of evidence, clinical interventions in home care, and innovative research methodologies.   

This report emphasizes how important it is for older Canadians to be able to remain in their homes.  As the focus shifts more to home care, we need to realize that people don’t simply want facility-based care at home. 

In a research project funded by Saint Elizabeth and the Canadian Health Services Research Foundation, I talked with home care clients and heard what makes a difference for them.  This video from the project captures in their own words what they want in home care. They tell us care should be personalized, flexible and delivered at a pace that responds to people’s needs and preferences. Care should honour and enrich people, their homes, their family members and caregivers, their memories of the past and their hopes for the future.  In short, people want and need more than help with activities of daily living. 

It’s essential to listen to these perspectives and ensure home care is truly client-centred, not task-centred. While all services in the home, whether personal care, home support, nursing or rehab, need to follow a care plan as a guide to achieving goals, we must recognize that people’s needs, priorities and preferences frequently can change. All home care providers require the flexibility and support to respond to the most important needs as expressed by people themselves, day by day.

The growing focus on home care is a great opportunity for us to share our knowledge, apply person-centred approaches, and reflect people’s preferences and perspectives in all we do.  If we accomplish this, we’ll optimize the potential of this shift for everyone.

PLEASE NOTE: On May 9th, the Health Council of Canada held a webinar Canadian Home Care Priorities for Seniors: What Can We Learn From Australia? with our special panelists:

• Jeff Fiebig, Manager, Program Development of the ACH Group in Adelaide, Australia
• Pamela Fralick, President and Chief Executive Officer of the Canadian Healthcare Association
• Nadine Henningsen, Executive Director of the Canadian Home Care Association

The webinar expanded upon many of the issues presented in our recent report, Seniors in need, Caregivers in distress: What are the home care priorities for seniors in Canada?

You can download the PowerPoint presentation or listen to the webinar.

Family - the invisible backbone of the health care system

Nadine Henningsen is the Executive Director of the Canadian Home Care Association.

Home is the place that in so many ways defines who we are; it is, in the words of the Pulitzer prize winning journalist John Ed Pearce “...a place you grow up wanting to leave, and grow old wanting to get back to.“ How true this is, especially when we think about aging and how we want to live out our lives – independently and with dignity; surrounded by our loved ones in the comfort of our home. Thanks to the great strides made in the development and growth of home care programs across Canada, this vision is very much a reality.

The aging process inevitably brings both physical and mental challenges as one must often deal with a number of chronic diseases as well as complex emotional situations such as the death of a spouse or loved one. Although publicly funded home care programs are essential to providing vital clinical and social supports to seniors, an integral part of aging at home is the involvement of family caregivers. Family caregivers – a spouse, children, siblings and even friends and neighbours - are the invisible backbone of the health care system. Without family caregivers, receiving care in the home would not be a viable option.

Congratulations to Health Council of Canada for their recognition and sound recommendations for both home care and family caregivers. We look forward to working with the Council and governments across Canada to advance home care as a vital component of an integrated health care system that is responsive to all Canadians.

Centre Stage: Where Seniors and Caregivers Belong

Shirlee Sharkey is president and chief executive officer of Saint Elizabeth, a leading national health care organization. Saint Elizabeth delivers five million health care visits annually and employs almost six thousand people providing nursing, rehabilitation, personal support, research and consulting services.

Home care is in the spotlight as economics, aging and consumerism push care closer to home. A timely new report from the Health Council of Canada showcases a range of examples, from across Canada and internationally, of promising approaches in home care.  I agree we need to broaden the reach of these positive advances, shifting from pockets of innovation to more mainstream implementation.  At the same time, we must use the opportunities for care in the home to help the entire system leap forward by optimizing the strengths of individuals, families and communities. 

A quick win might be to simply increase funding, expecting more of the same to provide better results. And it will – to some degree. Existing home care services encompass everything from highly complex care, such as home dialysis and chemotherapy, to chronic disease management, to personal and home support. More funding will enable these services to reach more people.  However, this approach will keep us responding to people and their needs reactively, often after a life-changing event takes place, rather than proactively filling the gaps in an individual’s health journey. Other countries conduct needs assessments with seniors in their homes and communities after the age of 75 in order to get ahead of the care curve.

For optimal investment we need to shift the lens from providers to seniors and their families, bringing health care to where they are.  The greatest value of care in the home will come from supporting people where and how they need us, throughout their lives. 

To achieve this vision we need to deeply understand the health and life circumstances of individual seniors and their caregivers.  Only then can we offer choices that best suit their needs, preferences and environment.  Seniors and family caregivers will take centre stage, while we step back to provide the props and backdrops.