AMy home is not my home Improving Continuity of Care in Homecare

Transcription

1 AMy home is not my home Improving Continuity of Care in Homecare December 2001 Christel A. Woodward, PhD Julia Abelson, PhD Brian Hutchison, MD, MSc Funding provided by: Canadian Health Services Research Foundation Ontario Ministry of Health and Long Term Care

2 Principal Investigator: Christel A. Woodward, PhD, Professor Centre for Health Economics and Policy Analysis Department of Clinical Epidemiology and Biostatistics McMaster University, 1200 Main Street West Hamilton, Ontario L8N 3Z5 Telephone: (905) , ext Fax: (905) This document is available on the Canadian Health Services Research Foundation web site ( For more information on the Canadian Health Services Research Foundation, contact the foundation at: 11 Holland Avenue, Suite 301 Ottawa, Ontario K1Y 4S1 Telephone: (613) Fax: (613) Ce document est disponible sur le site web de la Fondation canadienne de la recherche sur les services de santé ( Pour obtenir de plus amples renseignements sur la Fondation canadienne de la recherche sur les services de santé, communiquez avec la Fondation : 11, avenue Holland, bureau 301 Ottawa (Ontario) K1Y 4S1 Courriel : communications@fcrss.ca Téléphone : (613) Télécopieur : (613)

3 AMy home is not my home Improving Continuity of Care in Homecare Christel A. Woodward, PhD 1 Julia Abelson, PhD 1 Brian Hutchison, MD, MSc 1, 2 1 Department of Clinical Epidemiology and Biostatistics, McMaster University 2 Department of Family Medicine, McMaster University Acknowledgments: We would like to thank the Hamilton Community Care Access Centre and community homecare agencies in Hamilton for their assistance in carrying out this study. We especially appreciate the support for this research provided by our research advisory group. The participation of the Hamilton Community Care Access Centre homecare clients is gratefully acknowledged.

4 Table of Contents Key Implications for Decision Makers... i Executive Summary... ii Context...1 The Homecare Sector in Ontario...2 The Homecare Sector in the City of Hamilton...3 Implications of the Research Findings...4 Improvements in Communication...4 Service Provision...4 Contracts and the Contracting Process...5 Human Resources...6 The Approach...6 Results...7 What do key stakeholders see as important components of continuity of care in homecare?...7 What problems exist with care continuity...11 What facilitates continuity of care?...12 What challenges are there to overcome?...13 What kinds of clients are most affected by lack of care continuity?...16 What are the effects of managed competition?...19 What strategies can be pursued to improve continuity of care under managed competition?...21 Additional Resources...22 Further Research...23 References...25 Additional Bibliography...25

5 Key Implications for Decision Makers $ In the mid-1990s, Ontario s homecare sector underwent dramatic changes in the way services are organized and paid for, as a system of managed competition was introduced. $ The main barriers to continuity of homecare lie in problems with staff and a lack of information. $ Problems with continuity of care can occur when care plans are being designed and evaluated and when services are being delivered by homecare workers. $ The systems for monitoring service contracts and service delivery are inadequate, resulting in duplication and poor continuity. $ There is a high turnover rate in the homecare sector, due to lower wages and benefits than the institutional sector. $ Homecare clients should have consistent service providers to maximize efficiency and improve care continuity when service providers know how the home is organized, they can work more quickly and efficiently. $ Service providers must consistently have the appropriate knowledge and skills to effectively do their jobs. $ Co-ordination of services to meet the care plan for homecare recipients is necessary for continuity of care. $ The competitive bidding process means Community Care Access Centres and service providers cannot work collaboratively, which hinders continuity of care. $ Better communication among stakeholders is required. Communication especially during transition periods is inadequate between case managers and service providers, resulting in poor continuity of care. i

6 Executive Summary Context The management of homecare services changed following the 1995 election of a new provincial government in Ontario. Forty-three not-for-profit transfer agencies called Community Care Access Centres (CCACs) were created to manage homecare and act as purchasers of services for homecare clients. CCACs were directed by volunteer community boards overseeing the introduction of competitive contracting for homecare service provision. At the same time, hospital downsizing led to patients being discharged sooner, sicker, and more likely to need homecare during their recovery at home. In this environment, we examined what continuity in homecare means for different stakeholders, including longer-term clients, case managers, service providers, and community physicians. We also examined the problems with care continuity that clients experienced, the implementation of the competitive contracting model, and the impact of competitive contracting on continuity of care and the consistency of homecare personnel for clients in one Ontario community. The Implications There are many implications of our findings for policy makers, case managers, and service providers. Policy makers must think of the homecare sector in terms of the broader healthcare system, and they need to pay greater attention to the factors that promote continuity of care. Requests for proposals process should be changed so that CCACs can better compare information from service providers, and better mechanisms are needed to monitor how well the service providers follow contract terms, including guarantees regarding communication strategies and consistency of personnel. As well, longer contracts would provide greater stability for both clients and the homecare workforce. ii

7 Case managers and service providers should consider lengthening the contract overlap period to ensure knowledge about clients is passed on to new workers. More effective, active communication between service providers and case managers is necessary, and case managers should have lighter case loads to allow sufficient time for case planning and review. As well, monitoring systems should be developed to ensure high consistency of care. One possible way to alleviate problems would be to use primary provider teams and backup teams to reduce the number of workers visiting a client. Another would be to stop using short appointments for homemaking services, as fewer, longer appointments are a more efficient use of time. The Approach Over the two years of the study, we used a variety of research approaches to develop an understanding of continuity of homecare and the issues surrounding it. In particular we: conducted key stakeholder interviews; surveyed clients; examined client care provision records; studied sections of agencies service delivery proposals; and discussed our findings and implications with our advisory group. The Results Continuity of care in homecare has two dimensions that interact with each other to promote continuity: case management and service provision. Case management includes negotiating a care plan with clients and their families, and then monitoring and reevaluating the plan to ensure efficiency. It also involves co-ordinating services to effectively meet the care plan. Service provision includes ongoing service delivery by providers who consistently have appropriate knowledge and skills to meet the clients needs. There must be ongoing, accurate observations of the clients conditions. Most importantly, clients and their caregivers must develop trusting relationships, and the various members of the care team must communicate well with each other. Clients also believe consistent timing in their care appointments facilitates continuity of care. iii

8 There are several problems with both case management and service provision that interfere with continuity, however, and there are aspects of the competitive bidding process used in the Ontario homecare sector that exacerbate the difficulties in achieving continuity of care. Some of the barriers to continuity include human resource problems, inadequate communication among stakeholders (particularly during transition periods), differing client needs (which make it impossible to have a one size fits all care plan), the diversity of the community care sector, and inadequate systems for monitoring service contracts and delivery. Two strategies facilitate and support homecare continuity: effective communication among all stakeholders and consistent personnel. Current communication strategies are primarily passive, except when working directly with the client, and clients who require multiple visits per week generally have less consistency in personnel. The home as a setting for care also presents novel challenges to care delivery that contribute to the need for greater care continuity and/or make it more difficult to deliver care continuity. These include a different idea of what is acceptable to clients regarding service provision than if they were in an institution, and the need for knowledge about how the home is organized to deliver services effectively. An additional difficulty is that the healthcare team is not in one setting where they can meet regularly, and most communication among team members is likely to be passive. iv

9 Context Homecare, the provision of an array of a health and social services designed to support living at home, is the most rapidly expanding sector of the Canadian healthcare delivery system. Although resources allocated for homecare have increased rapidly, funding increases have not matched the growing need for homecare. For example, inflation-adjusted homecare expenditures by the Ontario Ministry of Health and Long-Term Care grew by 70.9 percent between 1991 and 1999; yet they were still seen as inadequate. Three trends have influenced the rapid growth in homecare expenditures. First, the financial constraints faced by Canadian hospitals during the 1990s led to earlier discharge of people recovering from surgery or acute illnesses, who were more likely to enter the homecare system. Second, demographic changes due to increased life expectancy mean that there are more frail, elderly people who need ongoing health services and support to remain in their homes. Third, a growing segment of the population has chronic illnesses and physical disabilities. These people are living longer, often at home, where they require some nursing and other support services. These factors have created pressure on the homecare sector to deliver services to a growing number of clients with a wide range of needs. Service delivery may be an acute-care substitute for a short period, or it may be a long-term care substitute or a method for maintaining functioning levels or slowing deterioration in health over an extended period of time. The structure of homecare systems differs across provinces. Four models are used to deliver publicly funded homecare: public provider (all providers are public employees); public professional and private home support (public employees provide professional care, and home support care is contracted to private agencies); mixed public and private (public employees provide case management, and services are provided by either private or public employees); and contractual (publicly funded services are delivered by a mix of 1

10 for-profit and not-for-profit agencies who are awarded the right to deliver services through a competitive bidding process). This latter model, currently used in Ontario, was studied. The Homecare Sector in Ontario In 1996, the Ontario government established Community Care Access Centres (CCACs), which are mandated to assess potential homecare clients and arrange delivery of homecare services through a range of community for-profit and not-for-profit private agencies (Witmer, 2000). The CCACs provide a case-management function for homecare clients. In their role as government transfer agencies they contract out service delivery through a process that involves competitive bidding by agencies for service delivery rights, based on requests for proposals issued by local CCACs. This competitive bidding process was developed in the hope that they would promote effective, highquality services delivery at the best (cheapest) price. The measurement of quality in homecare is in its infancy, which complicated the implementation of the bidding process. Consensus about what quality in homecare means or how it should be defined or evaluated does not exist. There are no standardized quality indicators for homecare. We do not know whether homecare that we would subjectively consider high quality produces better outcomes than usual care, because no consensual definition of these terms exists. To develop sound measures, the processes and outcomes involved in homecare need to be carefully defined to allow their precise measurement. For example, continuity of care is usually seen as a good thing that is important to care quality. Yet, how it operates in the homecare setting and its contribution to homecare outcomes are not known. The introduction of managed community care attempted to even the playing field and allow a greater range of provider agencies to enter the homecare service delivery market, including for-profit companies. Prior to the introduction of the 1996 reforms, not-forprofit organizations dominated the provision of professional services such as nursing and therapy while the provision of homemaking services was shared between not-for-profit 2

11 and for-profit agencies. Unionized workforces dominated not-for-profit organizations, while non-unionized workforces dominated the for-profit agencies. Companies (either for-profit or not-for-profit) that established homecare businesses after 1995 were exempted from pay equity laws by which existing companies had to abide. The new agencies therefore, theoretically, had an advantage over their competitors on the pricing side of the equation. The Homecare Sector in the City of Hamilton The Hamilton CCAC, one of the largest in Ontario, serves a population of about 500,000 and was one of the last to be established, in October The first competitive bidding process was initiated soon after the CCAC s establishment, and the first service contracts were awarded in November 1998 for approximately one-third of all nursing and homemaking services provided in the region to clients living in the downtown core area of the city. A second bidding process took place in 1999 to award nursing service contracts for the remainder of the CCAC s client population. In the first contracting process, one agency received a contract for 73 percent of homemaking services provided to the core area. A single agency (new to the community) gained the remaining 27 percent of market share. On the nursing side, a single agency received a contract for 80 percent of services delivered, while the remaining 20 percent went to another agency. Major questions addressed in this study include: 1. What do key stakeholders see as important components of continuity of care in homecare? 2. What problems exist with continuity? Are there barriers to and facilitators of continuity? 3

12 3. What are the effects of managed competition on continuity of care? 4. What kinds of clients are most likely to be affected by lack of care continuity? What kinds of clients require high continuity of care? What strategies can be used to improve continuity of care in homecare under managed competition? Implications of the Research Findings Several strategies to improve continuity of care in homecare were identified. These strategies relate to improvements in communication, service provision, contracts and funding, and human resource policies. Improvements in Communication More effective communication strategies are required to ensure that care plans are developed through consultation with clients (and caregivers, where present) and are delivered with consistency. Communication should be ongoing among all stakeholders. More direct, active communication between stakeholders is required. Each service provider tends to communicate actively with the client; however, for communication among the care team, passive communication is relied on too heavily. Improved and expanded use of communication technologies are needed that ensures that active communication that provides feedback to the person communicating occurs. More effective communication is required about the bidding process and its results within the CCAC and among CCACs, providers and clients. Service Provision The case loads of case managers must allow sufficient time for care planning, case monitoring and reassessment. Service provision must start with a careful assessment of needs through consultation with the client and all stakeholders. The key caregiver of a client should be involved in the care planning and implementation process. Special attention should be given to ensuring that a high level of care continuity is maintained for vulnerable clients such as the frail elderly, those suffering from dementia, mental health 4

13 problems, acquired brain injuries, or serious mobility impairments, and people who are in the terminal phase of life or have caregivers who are at risk for burnout. Their care must be handled very carefully, especially during transitions created by managed competition. Agencies should consider using a primary provider with a small team and a regular backup team to avoid frequent visits by personnel who do not know the client, the way the home is organized, or the client s care needs. The care team should be aware of how many other different services and providers are also visiting the client s home. CCACs and agency managers should rethink the use of one short appointment (one hour or less) for homemaking as they are often an inefficient use of time. Fewer, longer appointments allow homemakers to get more work done. Contracts and the Contracting Process The requests for proposals used must spell out the information to be contained in a bid precisely enough to agencies that those reviewing the contract can make decisions based on comparable data from each bidding agency. Contracts and the contracting process must address agency capacity issues and critical mass. Contracts must be of sufficient volume to allow agencies to sustain themselves. Extending the length of contracts is also needed to add stability to the system and help stabilize the human resource pool. Some specialization in contracts to ensure that vulnerable groups are served appropriately should be sought. Requests for proposals should require agencies to describe how they will ensure a high level of care continuity to such vulnerable groups. After new contracts have been awarded, the hand-over period between agencies/personnel must be long enough to ensure appropriate, smooth transitions. When managed competition forces agencies to rely on part-time staffing to the detriment of full-time employment, the longterm stability of the workforce is jeopardized. Including requirements for active communication and use of innovative communication strategies in requests for proposals will ensure that these important features are part of agency contracts. Better strategies are needed for monitoring contracts, once awarded, to ensure that agencies comply with the terms of their contracts. 5

14 Human Resources Several strategies could be used to better support the homecare human resource pool available and lessen the turnover in this field. Besides longer contracts, possible measures to stabilize the human resource pool for homecare include ensuring that there are more full-time employment opportunities available in the homecare sector. More workers would be attracted to and remain in this sector if their wages and benefits were similar to other sectors. Ensuring that the necessary educational opportunities are in place to train workers appropriately is also important. Standards for unregulated workers are needed to raise clients level of trust in this category of worker. Policy makers need to consider homecare within the whole healthcare system. For example, one systemic solution to the homecare human resource problem is a common human resource pool. This approach would help stabilize the human resources available to homecare. However, the homecare human resource pool currently operates in isolation from the health human resource pool for the primary and institutional care sectors in Ontario. By integrating homecare into the rest of the healthcare system, homecare would find its way onto decision makers radar screens and, therefore, have a better chance of being considered in healthcare policy decisions. The Approach We collected both quantitative and qualitative data in this study using a mixed-methods design. We also benefited from the knowledge and experience of our research advisory group of homecare managers and decision makers. We used qualitative methods to understand how continuity of care was conceptualized by managers, clients, caregivers and workers in the homecare system who were associated with the Hamilton CCAC. They also told us about their experiences with the bidding process. In total, 65 people who had different vantage points regarding the homecare system were interviewed. To understand more about the types of information agencies provided to the CCAC to make decisions when awarding contracts, we studied a section of agencies responses to the requests for proposals (their answer to the question in the request about how they 6

15 would ensure consistency of service providers). Supplemental information was sought from the agency about how they defined three key concepts: team, continuity of care and primary nurse. We were interested in learning about the consistency of homecare personnel, the reasons for changes in personnel, the factors that affected the consistency of personnel for a client, and whether the consistency of service personnel improved after transfers from one agency to another. To better understand these issues, we reviewed service provision records for all nursing and homemaking homecare agencies involved with 600 clients 200 from the city core where transfer of nursing and homemaking services occurred after the first round of competitive bidding, and 400 from the surrounding area where transfer of nursing services occurred after the second round of competitive bidding by agencies. The records were sought for the twelve-month period during which new, competitive contracts were awarded. Information about reasons for provider changes, not available in administrative records, was sought from clients and our advisory group. We surveyed a random sample of longer-term clients to determine whether the information that we had previously gained from client interviews was also the experience of current clients. We had many meetings with the agencies in the community to discuss our findings, their implications, how these might be applied, and what further research might be needed. Results What do key stakeholders see as important components of continuity of care in homecare? Continuity of homecare exists when the services delivered are co-ordinated and follow the objectives of a care plan developed for and with the client (and caregiver, when appropriate). The services occur in an uninterrupted fashion, changing as the needs of the 7

16 client change and objectives of the care plan are met or revised. The people delivering services consistently demonstrate the appropriate knowledge and skills to carry out the care plan, provide accurate ongoing observation of the client s condition, and have established good rapport with the client and good working relationships with other members of the care team with whom they must work to deliver the services needed (See Table 1). Clients included consistency of timing of service delivery as part of continuity of care. The slightly different nuances provided by our different types of reporters are summarized in Table 2, including their perceptions regarding how well continuity of care has been implemented. Table 1: Dimensions of Continuity in Homecare Managing Care Care Planning, Monitoring and Review Care Co-ordination Description A care plan is developed that is negotiated with the client and caregiver and provides the services needed to meet the care plan s objectives. The delivery of care is monitored and adjustments are made to the care plan as needed to ensure its objectives are met or revised to meet changing client needs. All relevant care required by the client is arranged and delivered without delays and disruptions in service. Service Provision Continuous Service Delivery Consistent, Appropriate Knowledge and Skills Ongoing, Accurate Observation Trusting Relationships Effective Teamwork Uninterrupted service occurs as planned. Service providers consistently demonstrate the knowledge and skills needed to deliver care to the client. Knowledge and skills of three types are needed: related to the client and caregiver; related to the care required; and related to the home. The client s condition is continuously monitored. Changes in the client s condition are noted and reported to the appropriate service providers and case manager. A relationship of trust is established with the client (and caregiver). Members of the team delivering healthcare and managing its delivery have good working relationship. 8

17 Table 2: Continuity of Homecare: Perceptions of Various Stakeholders in Ontario Managing Care Continuity Development, Monitoring and Review of Care Plan Stakeholder Type Client/family caregivers Service providers Case Manager Physicians may or may not feel consulted; some clients unaware of care plan or interpret it as a list of services provided involved in negotiation of how things are done in the home with client and family and implementation of care plan; must translate it into action and may modify it develop care plan for publicly funded services; report sometimes plan not wellformulated due to hospital discharge pressure, little time for monitoring and reassessment Co-ordination some report good co-ordination; others report poor follow-through may be unaware of other services obtained play key co-ordination management role sometimes not involved to extent they feel is needed Service Provision Continuous Service Delivery report that service is usually delivered; few missed appointments and interruptions reported work with scheduler at agency to ensure care is consistently delivered see continuous service delivery as their priority Appropriate Knowledge and Skills report wide variation in worker s skill and knowledge level that affects the quality of care they provide, particularly homemaking and personal support; complain about need to convey the same information again and again homemakers require the most knowledge about how the house is organized, client likes and dislikes, background; sometimes need technical skills; need to know what client can do for self to support independence recognize that workers may vary; see selves as helping to communicate knowledge regarding client, care needs and household indicate this is a major area of complaint from their patients, particularly differences in skills and knowledge Ongoing Observation nurses comment more frequently about this aspect of their work than homemakers, provide reassurance to client that improvement is occurring, alert physician to problems see themselves as also monitoring the client by telephone calls and reports from service providers suggest frequent changes in nursing personnel do not allow good monitoring; cause unnecessary concern and duplication of services 9

18 Managing Care Continuity Trusting Relationships Stakeholder Type Client/family caregivers Service providers Case Manager Physicians quality of relationship with service providers more important to some than others, e.g., if provider is a source of social support; major incompatibility may lead to request for provider change; clients trust nurses more quickly than homemakers; lack of relationship is depersonalizing seen as necessary to carrying out their responsibilities in the home; negotiating how and sequence of service delivery requires tact; report some clients will cancel visit rather than have a stranger come to do the visit need to establish client s confidence and trust; report that clients value relationship with service providers; some clients may feel vulnerable to being taken advantage of Teamwork Among Service Providers Consistent Timing* report service providers often do not know each other and may be unaware of other services coming to the home important, especially for homemaking services, as it supports routines in activities of daily living; unable to plan day effectively if visits are at differing times each day * Only clients see this as central to care continuity important to working together effectively homemakers indicate that when assigned the same person consistently, they are more likely to be able to support clients wishes for consistent timing; nurses report that urgent care needs of other clients may interfere with schedule and delay regularly scheduled visits must establish rapport with members of the care team not seen as part of homecare continuity, but some acknowledge clients prefer this indicate that need some prior experience with nurse to be able to judge the importance of observations made report that lack of consistent timing of nursing care is a complaint of their patients 10

19 What problems exist with care continuity? Problems exist with both the management of care continuity and with service provision. Issues in the management of care continuity. Case managers reported they were more likely to be reactive than proactive in dealing with their clients needs. They carried large case loads and lacked adequate time for care planning, monitoring, review, and coordination. Care co-ordination existed mainly for services directly paid for by the CCAC and tended not to include other community services. Case managers who were stationed at hospitals reported insufficient time to develop an appropriate care plan for clients who were discharged very rapidly. Some clients were not aware of their care plans, and service providers sometimes were unaware of or did not follow the service plan well. Although services, once begun, were usually consistently delivered, gaps in service delivery occurred due to waits for needed services or failure to follow through on services promised to the client. Issues in Service Delivery. Clients often expressed concern about the need to re-explain their situation and care needs to new service providers who 1) sometimes did not possess the skills to meet their needs, and/or 2) did not know how their households were organized and required extensive explanation and direction. Sometimes, lack of ongoing, accurate observations or limited trust in service providers knowledge led primary care physicians to see patients to reassure themselves or their patients and their families. Clients reported some homemakers were poorly trained and did not provide the care they were supposed to deliver. A few clients complained that things had been stolen from or broken in their home, but with the rapid turnover in workers they could not tell who had done it. The absence of rapport between some clients and service providers made care delivery less than optimal. Some clients refused to have a service provider visit if their regular worker(s) were unavailable, even when they desperately needed the service (e.g., received palliative care). 11

20 What facilitates continuity of care? The two major strategies used to provide continuity of care are communication and consistent personnel. They are the vehicles by which care planning, monitoring, and review, care co-ordination, continuous service delivery, consistent knowledge and skills, ongoing, accurate observation of changes (or lack of change), and good rapport and working relationships can be achieved. Communication patterns within homecare are complex. Good communication may be achieved through a variety of methods, including face-to-face meetings, telephone calls, voice messages and written messages left in the home. Excellent communication allows a care plan to be developed and implemented that best meets the needs of the clients and their family caregivers. It also assists the case manager in monitoring how well the plan is implemented and allows rapid readjustment of the care plan and services provided when a client s needs change. It is required to ensure that the care received is well-coordinated. Good communication ensures that service providers are aware of what is happening and changes that have occurred. It permits sharing of knowledge about the client and caregiver, the care required and how it can best be delivered in this household. It is needed to build effective partnerships with clients and their families and the other members of the care team. Consistent service personnel were valued highly because they dramatically reduced the complexity of communications required and improved service providers ability to make accurate observations across time, important to both physicians and case managers. All of the aspects of care continuity were supported by consistent personnel. Consistent personnel gain detailed tacit knowledge of clients and their care needs. They understand the context in which the needed care is delivered, the client s home. If you get to know the person who is coming to help you, I think it is a far better arrangement. Certainly it is a better arrangement for the person who is doing the helping, because they not only get to know you and how you like things done but they get to know where the equipment is. You 12