Chicken Soup and TLC.

Four out of five Canadians believe home care should be a free, universal health-care program, according to a 1999 survey by PricewaterhouseCoopers, but governments are still having trouble defining the term home care

A major problem in our health-care system has been the use of acute-care hospital beds to "warehouse" chronic-care - mostly elderly - patients. They clog up the acute-care beds because there aren't enough extended-care beds available. This tends to back up the whole system until you have patients being treated in ambulances, because they can't get into the emergency department, because the beds are full of patients who can't be transferred to a ward, because the ward beds are full of chronic-care cases.

On the other hand, hospital stays for many are growing shorter every year. And, the early discharge of patients has endangered the health of some Canadians denied immediate access to home care; this is what a survey released in October 1998 by the College of Family Physicians of Canada says. It's a result of too little public funding and it affects mainly the frail elderly who are put on waiting lists for home-care services. Often, they end up in emergency rooms suffering from health problems that could have been avoided with a better home-care system. Without the home care they need they can end up with fractures due to falls, dehydration, malnutrition, and complications from medication errors.

Fifty percent of doctors who responded to the survey said they thought their patients were at higher risk for future medical problems because they had been discharged too early from hospital. Eighty percent said they have noticed an increasing demand for home-care services over the previous five years, with 42% citing significant increases. Sixty-nine percent of family doctors across the country said the health or well-being of their patients had been adversely affected by inadequate access to home care.

Seventy-five percent reported that their patients were going home from hospital sicker than in the past. Such patients were often in need of more complex in-home medical care such as intravenous lines that need to be changed or monitored.

In some cases, hospital stays are being replaced entirely with what's called outpatient treatment. A patient goes into hospital for minor surgery and goes home immediately afterwards without ever occupying a hospital bed. This means that much of the focus on home care has been on post-acute-care treatment at home: visiting nurses who change dressings, deliver intravenous medication, or tend deathbeds. But, it's estimated that 80% of home-care services keep people - mostly seniors, but also chronically ill and disabled people - living in their homes. It involves such services as meals on wheels for seniors, homemakers who care for seriously incapacitated patients, programs to make sure schizophrenics take their medication, relief care for family caregivers who need time off.

Nevertheless, family members still are providing more than 80% of Canada's home care, and the tasks they perform grow heavier each day. A 74-year-old senior cares for his wife of 54 years; she's 76 and has Alzheimer's disease. He has devoted almost eight years to her care because she has become childlike and needs to be fed, changed, bathed, and watched constantly. Like many people who find themselves in similar situations, he didn't know where to turn for help, so he took on the challenge himself with little outside relief.

Canada's home-care system is yet to develop, and it's tough just to get basic information on health and social-services. According to one health-care executive, it's not unusual for people who suddenly find themselves with a sick family member to make a dozen phone calls and get absolutely no information.

The federal government says we need a national home-care program but doesn't know how such a program should work. At a national conference on home care in 1998 the Health Minister Allan Rock said a national program is "the most urgent element of modernizing and enhancing Medicare." But, the fact that he didn't have any plans to create one was disappointing to the 300 delegates attending the conference. Mr. Rock only suggested the possibility of developing a white paper, which would present for discussion legislation that the government plans to introduce. So far, the country's health ministers haven't even agreed on a common definition of home care.

Meanwhile, home-care services in Canada have been described as haphazard at best. They vary from province to province and town to town. Home care does not come under the Canada Health Act, which ensures equal access and public funding only for medically necessary services. So, while professional services such as nursing and occupational therapy in the home are typically provided free of charge, user fees are charged for many homemaking services. And, these are the services that many chronically ill or disabled people need in order to stay in their homes. These are the people for whom household cleaning and general maintenance could lead to serious injury and costly hospitalization.

According to one Statistics Canada study, more than 839,000 seniors in Canada who need health-related care at home are not getting it. Another federal study found that 70% of people who need help with the activities of daily living have no publicly funded help. And, those who turn to the open market find there are no standards for quality of care and no legislation to protect them, and it's expensive.

The quality of home care is a very real concern as private providers are replacing not-for-profit organizations such as the Victorian Order of Nurses (VON), underbidding them for home-care contracts. The VON is reluctant to lower its standards to be competitive. However, the decline in its business means it can't keep specialty teams for such things as pediatric care, mental health, and intravenous therapy. Some branches of the VON have faced bankruptcy.

Few home services are governed by the Canada Health Act. There are fears that this will lead to competition based mostly on lowering the price of care. That means that the quality of care is bound to suffer. A New Brunswick report says that home care workers are paid between $5.50 and $7.50 an hour; at that rate full-time workers are getting incomes well below the poverty line. And, many of these home-care workers are having to "perform nursing care," for which they are not trained. There is no overtime pay, except for statutory holidays, regardless of hours worked, no vacations, no health benefits, no sick leave, no pension plan, and virtually no travel allowance.

With such poor working conditions it's not surprising that it's a field with a high turnover rate: home-care workers quit when they have a little experience and move to better-paying jobs in institutions such as hospitals and nursing homes, which pay them twice as much. As one home-care executive said in 1998, "People who take care of our mothers ... are paid less than those who round up stray pets." He was commenting on two ads he had seen, one offering $18 an hour for an animal-control officer, the other for a personal-support worker at $10.10 an hour.

Home care promises to continue to be a hot political issue for many years to come. With an aging population, the growing strain on the health-care system, which already costs more than $86 billion a year, is expected to continue for decades.

SUGGESTED ACTIVITIES:

1. In 1995, Ottawa started slashing health-care funding to the provinces, and provincial governments paid the political price for hospital closings and long waiting lists that they blame on the cuts in transfer payments. In February 1999, the federal government announced an $11.5 billion increase over five years in transfer payments for health, restoring the money it had cut to fight the federal budget deficit. It's up to the provinces to deride how to spend it, and some say home care is a frill they don't need. What they say they do need is better acute-care programs. Find out how your province plans to spend the money.

2. Research what community home-care services are available to people in your region. Find out the quickest way to access them, and write to your local newspaper about your findings.

Websites

Canadian HomeCare Association - http:// www.cdnhomecare.on.ca/

Victorian Order of Nurses - http:// www.von.ca/english/front.htm

FACT FILE

About three million Canadians are providing home care for loved ones, some of them on a full-time basis; the physical, emotional, and financial strain is enormous.

RELATED ARTICLE: COST EFFECTIVENESS

According to a 1999 study, governments can cut treatment costs for elderly patients by as much as half by providing care in the community instead of in institutions, as long as their condition is stable. When patients are unstable and move frequently from home to hospital, it's more efficient to keep them in an extended-care facility.

The research showed that each patient cared for in the community rather than in a hospital saves the system an average of $8,000 a year. At the lowest level of care, where a person needed only non-professional help, it cost an average of $5,413 annually to care for a patient at home, compared with $12,504 in a facility. At the highest level of care, where a patient has a functional disability that requires nursing care almost around the clock, the average cost was $33,579 at home and $41,023 in an institution.

Nationally, governments spend $2.5 billion a year on home care, about 4% of public-health spending. That's a growth rate of about 20% a year over the last two decades. But, they spend $7 billion a year on long-term care facilities, and $26 billion on acute-care hospitals.

About 113 of every 1,000 seniors receive home-care services, up from 87 per 1,000 in 1983. But, admission to long-term care facilities has dropped from 72 per 1,000 to 50. Admissions to extended-care facilities over the 16-year period held steady at about 17 per 1,000.

The services are costing Canadians a bundle. A 1999 survey showed that Canadians who get long-term services, such as seniors and disabled people, are spending an average of $407 a month on home care and another $138 for prescription drugs. Those who need post-acute home care, usually after surgery, spend almost double that amount, at $202 a week.

RELATED ARTICLE: THERE IS A DOCTOR IN THE HOUSE

Some of your parents can probably remember the days when, as children, the doctor actually visited them at home when they were sick, There was no getting out of bed to go to the donor's office. And, some people think we should return to the days of housecalls. Toronto doctor David Thow is one of them

In a letter to the Globe in Mail in 1998, Dr. Thow declared that "housecalls are alive, if not welt, and we need to see more of them." He's part of a minority 1% of physicians in Toronto who offer home visits, and he says you don't have to search far for the mason: a typical house call brings in $50 and takes about an hour; in the same time a doctor can see five or six patients at the office and make $125.

Dr. Thow works at a community health centre that pays its doctors an annual salary rather than paying them on a fee-for-service basis, This, he says, "encourages doctors to take the time necessary to get to know their patients, rather than churning them out like links in a sausage factory. In the long run, the thinking goes, you end up with people who are physically and mentally healthier."

He says he usually sees 12 to 15 patients a day in his office and makes about 80 home visits a year, mostly to the frail elderly, who he says are most in need of housecalls - they are often sick, alone, and on fixed incomes.

"The governing powers that be - in Ontario, specifically the Ontario Medical Association and the College of Family Physicians - would serve us better by promoting the concept of home visiting," he writes. "And our government could help by paying a competitive wage for this valuable service."