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Feedback on Proposed Home & Community Care Regulations

July 16, 2021
A VHA Personal Support Worker holds a client's hand

Ontario Ministry of Health (MOH) is working on new regulations regarding providing home care in Ontario. As part of the regulation development process, VHA was invited to provide feedback on the draft regulations.

You can download a PDF version of the MOH’s PowerPoint slides below:

Update on Proposed Home and Community Care Regulations under the Connecting Care Act, 2019

PDF, PowerPoint slides

We are pleased to share that VHA has submitted the following response:

Scope of Services, Service Maximums (slides 9 – 11)

Do you have feedback on any aspects of the proposed approach set out on slide 10?

We are pleased to see the additional scope of home and community care services and believe that the newly added offerings will provide significant increased benefit to the populations receiving care at home and in the community. We wish to provide the following additional comments for your consideration with respect to slides 9 – 11.

  1. Many of the ‘new’ community support services (and some of the existing) also fall within the professional services category. These include bereavement services, behavioural supports, education, prevention & awareness, chronic disease management, aphasia, palliative care and foot care, among others. To better align with the Ministry’s goal to refrain from sorting services into ‘home care’ and ‘community care’, we suggest re-naming the “Community Support Services” category to simply “Support Services” and confirming that ‘professional service’ providers may also deliver those ‘support services’, as applicable. This adjustment will empower HSPs and OHTs to offer the basket of services more flexibly and to provide better integration of care. It may also allow for more efficient use of health human resources (HHR), which is critical as HHR is already limited.
  2. Certain key services appear to be missing, such as, case management. The case management function is an essential and heavily relied upon service by the populations who need it. Omitting case management will create increased challenges for those individuals and may negatively impact their ability to access and utilize home and community care services that would otherwise be available to them and are available to the rest of the population. It is recommended that case management be added to the scope of home and community care services and that its placement within the categories be flexible. Meaning, the organization most suited to provide the case management, based on the particular client circumstance, shall be the one to do so. It is also recommended that more clarity be provided under the Occupational Therapy and Physiotherapy headings to confirm that such services will include occupational therapy and physiotherapy assistants (OTAs and PTAs). In many instances, support from OTAs and PTAs may be more appropriate for clients and can enable more efficient use of resources.
  3. We propose eliminating the “Personal Support Services” category and recognizing those services under the “Professional Services” category. This move would offer an acknowledgement of the value and professionalism of the work performed by personal support workers, even though they are not regulated health professionals. It would also help to elevate their role within the larger health system and better recognize their contribution to a client’s care needs.

Client/Patient Eligibility Criteria (slides 12 – 13)

Do you have feedback on any aspects of the proposed approach set out on slide 11?

We applaud the move to eliminate service maximums and recognize this as a positive change for clients and caregivers and for improving overall population health outcomes. It will be critically important for the service allocation guidance policies, to be developed in place of service maximums, to be consistently applied across the system to ensure equity of access – regardless of where one resides or who their HSPs and/or attributed OHTs may be. In addition, it will be necessary to ensure that the client’s wishes are properly considered alongside the objective criteria, such as, clinical evidence, best practices, public safety and efficient management of resources. It is strongly recommended that providers who are currently delivering home care services and clients/caregivers who are currently receiving home care services are consulted regarding the development of these policies.

For the proposed new services of Traditional Healing and Indigenous Cultural Supports:

  • Do you have feedback on whether client/patient eligibility criteria should be defined provincially in regulations, or left to be determined more locally (and if they should be defined provincially, what they should be)

    To ensure equity of access to services across the system, we believe that eligibility criteria should be set provincially. We recommend engaging with traditional healers and indigenous community members and groups to define the provincial eligibility criteria to be applied.

  • Do you have any other feedback on these proposed new services?

    We were thrilled to see the addition of these important new services and the Ministry’s acknowledgment of the need to provide traditional healing and Indigenous cultural supports.

Care Coordination (slides 17 – 20)

Do you have feedback on the proposed requirements for care coordination functions on slide 17?

Care Coordination is a vital function for people who require this service. However, not all clients require extensive coordination of services, and many clients/caregivers would instead prefer the assistance of a system navigator and/or care navigation services to augment their health care journey experience. What we have heard from clients/caregivers as to what they want/need is as follows:

  • I have simple/easy access to care when and where needed – one number to call myself or someone to help make the link for me
  • It is clear to me what my choices are for care and how much care I will receive. I have flexibility to design care delivery in a way that works for me.
  • When my care needs are complex, I will have one person whose job it is to help me through all phases of my care.

What is important to the people of Ontario receiving home and community care is what is important to be reflected in the regulations. As such, further clarity on what is meant by “care coordination” or clarity to allow an HSP or OHT to define coordination with clients/families/caregivers is key. Care coordination for the sake of managing the HSP or SPO delivering the care is not what is needed and often results in a disruption to the seamless flow of care by creating an unnecessary middle layer. Further, coordination as it relates to oversight occurs in-house for most HSPs and SPOs and thus an external source doing the same work is a duplication of services for many. We recommend implementing a flexible and streamlined approach to care coordination that empowers frontline health care professionals and service providers to respond to client and family needs, within an appropriate accountability structure.

An additional and critical concern is the definition of an HSP which appears to exclude SPOs delivering home care services for an OHT. This creates a barrier to SPOs who may be unable to sit as an equal partner at the table for OHT development and ongoing roll out and expansion of services offered through the OHT. The detrimental effect of this is to minimize the voice of the specialty of home care in designing a truly client centered care trajectory where each component is valued and respected for the importance it plays in people’s lives and a safe and effective integrated health care journey. The impact of continuing the contracted service model and barring SPOs from being equal partners in OHT decision making, is detrimental to clients and families who receive home care because it not only puts the SPOs at arms length but puts our clients and families and their needs at arms length too.

It is also noted that SPOs are not listed to be included in the Ministry’s transition work to develop a staged implementation plan. It is strongly recommended that those who provide the home care services to clients are consulted and included regarding the transition of home care service functions to the OHT.

In addition, more guidance on the use of digital strategies and connecting health records for SPOs is needed to support improved care coordination, timely communication, and increased integration.

Do you have feedback on the factors to be considered when planning care on slide 18?

The proposed approach to developing a care plan is well thought out. It has some clear and realistic elements for consideration when planning care around client/caregiver wishes. We are pleased to see that slide 18 provides for the co-design of care in a manner that includes consideration of other essential factors, such as, equity, best practices, and resource allocation. This is in contrast with the statements on slide 17 that appear to be based solely on a client’s wishes and needs to be updated with similar language as per slide 18. It will also be imperative to establish clear guidelines to prevent racism and discrimination toward front-line staff so that those elements are not improperly framed as “preferences”.

A barrier to improving the quality of care is that the regulations only speak to the need for a care plan in relation to home and community care services. This once again siloes care for the people of Ontario. A care plan that is flexible and identifies care along the client trajectory will be key, especially as it relates to safe and transparent transitions from in-patient care to home and community care and upon discharge to independence or other longer-term care or educational needs. Therefore, changes to regulations for home care cannot be successfully completed without a thoughtful and organized review of regulations impacting all team members within an OHT and development of a fulsome coordinated view of the client experience across the spectrum of care that they receive. A client’s preference to age in place should be firmly supported and the relative costs/benefits or provided enhanced supports at home should be considered against other health settings (ex. emergency department, LTC etc.).

We believe that it is impossible to properly ‘modernize’ one sector of healthcare without looking at modernizing all sectors. In looking at only one critical sector of the OHT’s broad spectrum of care without the others continues to perpetuate the siloed approach to providing care that Ontarians have become accustomed to receiving but have requested that we change. This further siloed approach is in stark contrast to the design and intention of OHTs and to some of the learnings we have been fortunate to have during this global pandemic.

Are there any rules or parameters in addition to what is set out on slide 19 that the ministry should consider regarding an HSP or OHT’s assignment of care coordination functions?

The proposed approach on slide 19 assumes that SPOs delivering home care services are not team members of the OHT but rather “contractors” to the OHT. This is not the case in many OHTs and should not be the case if the aim is to create a truly integrated system. SPOs are the home care specialists and their direct unique experience is needed for the OHT to develop seamless care coordination with improved system navigation that eliminates duplication in the home and community care setting and maintains the client-centred approach to care.

The requirements that an SPO must meet when assigned to perform care coordination functions are reasonable and appropriate. It is suggested that these requirements be included for all HSPs/OHTs performing the function and not just SPOs. We recommend provincial standards for care coordination be developed to ensure quality and consistency of services. If all organizations are held to the same standards, there can be more flexibility for an OHT to determine, at the local level, how the coordination function will be performed and to readily engage those closest (i.e, those providing the service and the client/family receiving service) in developing/evaluating and revising the plan.

Bill of Rights, Locations of Service, Eligible Providers, Methods of Delivery (slides 21 -25)

Do you have any feedback on the proposed items on slides 21-25?

We were pleased to see the enhancements to the Bill of Rights on slide 21.

With respect to slide 23, Locations of Service, it is noted that clinics were omitted from the description of current state and are not referenced in the proposed approach. We believe that clinics provide a valuable solution for many clients and should be continued.

Similarly, with respect to transitional personal support services being provided in Long Term Care Homes, we believe this will provide a very positive benefit to both clients and system partners. We note that behavioural issues may not be the only reason why this approach can be useful and would recommend the practice be enabled under broader circumstance, as appropriate. At the same time, we must be mindful of the HHR and labour issues that this expansion can present and recommend that the regulations specifically address those labour components (for example, related employer) and that the Ministry move to reduce salary gaps among front-line providers who work in different environments (i.e., home care, CSS, LTC and acute care).

We also believe that allowing home and community care services to be provided in hospital is a critical component of the effective integration of care. Currently, a client’s first visit may happen in the hospital prior to discharge. This process allows for a more seamless transition to home and provides an improved client experience. For pediatric clients, visits are often continued while in hospital to allow for better familiarity and continuity of care. Plans for conducting virtual visits while clients are in hospital are being explored for these same beneficial reasons as well as to prevent or lessen decline while the client is in hospital and to reduce the length of stay, were possible. We are concerned that the exclusionary language being proposed in the regulations may result in the deterioration of the client experience and more difficult transitions. We recommend putting guidelines in place but not a strict prohibition against service in hospital.

With respect to slide 25, Methods of Delivery, it was great to see the affirmation and continuation of virtual care services, which have been shown through the pandemic to be an effective and safe way to provide care for those who are able to receive it. It is suggested that written communications and secure email also be included within the description of virtual care as this is particularly helpful to non-verbal clients who are suitable candidates for virtual care services.

Charges for Services (slide 26)

Do you have any feedback on the proposed items on slide 26?

It is noted that currently available co-payment options for homemaking services has not been referenced. Clarity as to how co-pay options would continue to apply in those circumstance is needed.

Plans to Prevent Abuse, Complaints, Appeals, Patient Ombudsman (slides 27-30)

Do you have any feedback on the proposed items on slides 27-30?

We are in support of the additional measures being taken to prevent, recognize and address abuse. We recommend adding mental abuse to the types of abuse and the training and education. We also recommend stipulating the consequences of abuse with mechanisms to enforce, as necessary. We have no feedback on the process for complaints, appeals or the role of the Patient Ombudsman.

Self-Directed Care, Residential Congregate Care, Other Related Amendments (slides 31 – 35)

Do you have any feedback on the proposed items on slides 31-35?

As acknowledged by the Ministry, HSPs and SPOs are capable of and already manage care coordination as implemented through the self-directed care model. Many clients prefer the self-directed care option as it allows them to engage most directly in the management of their care, increases communication efficiency and streamlines their services. It is recommended that self-directed care be considered as a more widespread option for clients rather than a last resort.

Other Feedback

Do you have any other feedback on the proposed regulations?

The Ministry’s work being done on the proposed regulations is highly commendable and a needed exercise. VHA Home HealthCare appreciates the opportunity to provide feedback and to partake in this important process. The Ministry’s presentation offers a welcome high-level overview describing the “what” of future home and community care services. However, at this time, the mechanism(s) for implementation have not yet been addressed. These mechanisms represent the “how” and are the details that need to be most carefully considered to ensure the effective and safe provision of quality care at home. To be able to offer the most informed and valuable feedback, and to assist the Ministry in achieving the goals of the quadruple aim, we look forward to the opportunity to continue to provide feedback as these essential details are developed.

We believe that a more comprehensive approach to consultation is needed as these details are developed. This comprehensive approach requires strong engagement with clients, families and caregivers as they sit at the centre of any changes to be designed. Secondly, it requires the direct engagement and feedback from home care providers working with Ontario Health Teams to share learnings to date from working within a new model of integrated care. We firmly believe that directly involving the home care service providers and the client/caregiver voice in this development is the essential ingredient to improving the system and achieving our collective vision of strengthening innovative service delivery, increasing accountability for performance, and better enabling efficient and integrated quality care that the people of Ontario deserve.

No feedback can be offered in respect of the imposition of new costs or enabling costs savings because the proposed regulations are silent on funding and the planned costing model remains unknown at this point.

What we do know, through experience amidst the COVID-19 pandemic, is that different organizations from across the spectrum of care are able to effectively and innovatively work together through the OHT model. Indeed, the OHT work done to date, particularly in respect of COVID-19 response activity and vaccinations, has successful demonstrated the OHTs ability to deliver innovative, efficient, and quality health care services. We are enthusiastic about the opportunities that lie ahead and looking forward to the continued development and ‘modernization’ of our health care system as a whole.

The Ontario Community Support Association (OCSA) and a number of Ontario Health Teams VHA is a member of have also provided feedback on these proposed regulations. Please find the responses below from the OCSA and the East Toronto Health Partners Ontario Health Team.

Read the response from the Ontario Community Support Association (OCSA)

Read the response from East Toronto Health Partners (ETHP)

Read VHA’s original submission on these regulations from July 2020