Determinants and Outcomes of Privately and Publicly Financed Home-Based Nursing

Key Implications for Decision Makers

This study aimed to assess determinants of publicly and privately financed home-based nursing and personal support service utilization. The relationship between publicly and privately financed home-based nursing and personal support services and quality of care, as well as the costs to the system and to care recipients, were also evaluated.

  • By characterizing the distribution of publicly and privately financed care, critical issues such as inequalities in access to homecare and quality of care can begin to be addressed. Furthermore, to be in a position to assess the relative effects of health reforms, an accurate depiction of the financing and caregiving responsibilities assigned to care recipients and their families is required. The results of this study can be used to develop a systematic measurement strategy which can then be implemented to evaluate local, provincial, or national predictors and outcomes of home-based nursing and personal support care.
  • By assessing determinants and outcomes of privately and publicly financed home-based services, issues concerning access to services, societal costs, and the quality of healthcare will be highlighted. Identifying which individuals face a greater burden for private financing would reveal whether the principles of the Canada Health Act regarding reasonable access to medically necessary services without financial barriers to utilization is maintained in the homecare context. Decision-making around the allocation of resources in a financially constrained environment may be facilitated through an accurate depiction of the homecare context in which healthcare services are provided. Furthermore, by characterizing the utilization of home-based nursing, gaps in knowledge may be recognized and areas for future investigation may be prioritized.

Executive Summary

Purpose: This study aimed to assess determinants of publicly and privately financed home-based nursing and personal support service utilization. The relationship between publicly and privately financed home-based nursing and personal support services and the quality of care, as well as the costs to the system and to care recipients were also evaluated.

Methods: The research team at the University of Toronto collaborated with six community care access centres across Ontario to recruit study participants. Two types of participants were recruited: 1) care recipients who were expected to receive short-term nursing services (less than 60 days) (Group S); and 2) those who had been receiving nursing and/or personal support service on a continuing basis (more than 60 days with no more than a one-week break in servicing within the 60-day period) (Group C). Potential participants were at least 18 years of age or older, fluent in English, and were receiving publicly financed home-based nursing and/or personal support services; those who were receiving palliative care were not eligible for the study. Participants participated in a telephone interview on a weekly basis for four weeks; each interview lasted on average 15 minutes.

Data were collected using the following instruments: 1) the Ambulatory and Home Care Record was used to collect information on public costs incurred by the healthcare system; out-of-pocket expenditures for medications, health professional appointments, and travel expenses; and time loses incurred by care recipients and family caregivers; 2) the Older Americans' Resources and Services' Activities of Daily Living Scale measured level of activities of daily living functioning; 3) the Canadian Community Health Survey's chronic conditions module assessed co-morbidity; 4) the Quality of Care Survey assessed participants' perceived quality of nursing and personal support care; and 5) a demographic form. The Ambulatory and Home Care Record was administered weekly and the Activities of Daily Living Scale and demographic form were used during the first interview. The Canadian Community Health Survey was used in the third interview and the Quality of Care Survey was administered during the last interview.

Physician and laboratory unit prices and the cost of clinic and emergency room visits were determined using the Ontario Health Insurance Schedule of Benefits. Medication costs were derived using the Ontario Drug Formulary. The costs of home-based health professional visits were valued using the homecare agencies' rates. For the cost data, three distributions of total resource expenditures comprising publicly financed, privately financed, and informal care were computed. Appropriate measures of central tendency and dispersion were computed to describe the distributions, and 95 percent confidence intervals were derived. Multivariate regressions were used to assess the relationships between health service utilization determinants and various sources of cost of care.

Results: Five hundred twenty-six participants completed the study. Group S and C participants were similar in demographic characteristics, except for marital status and education level. Overall, the mean cost of care for a four-week period for Group S and Group C participants was $7,243 and $8,054 respectively, with time spent providing and receiving care accounting for the majority of costs. Eighty-six percent of in-home services (nursing, personal support, physiotherapy, etc.) that short-term clients received were publicly financed, whereas 97 percent of this type of service that continuing care clients received were publicly financed.

Overall, the results showed an increase in public expenditure was associated with an increase in private expenditure (t = 4.85, p < 0.0001). Private expenditures werehigher for the very elderly, younger care recipients with chronic conditions, males, and care recipients who had many chronic conditions, regardless of age. Private expenditures werelower for females. In addition, a 10-fold increase in public expenditures was associated with a 10-percent increase in private expenditures for someone who had excellent or good functioning for activities of daily living.

The median scores for the quality of nursing and personal support care survey were 84/100 and 79/100 respectively. Regressions analyses demonstrated 1) there were systematic variations among community care access centres in the perceived quality of nursing care, while holding other factors (age, gender, income, education level, employment status, daily functioning, co-morbidity, urban/rural residence, rurality, and amount of nursing/personal support service received) constant; and 2) perceptions of quality of personal support care were higher for rural access centres.

Linkage, Exchange, and Dissemination Activities: Representatives from the Ontario Association of Community Care Access Centres and the six partner access centres were involved in all stages of the study. Each centre received regular updates on the progress of recruitment activities and ongoing communication among all partners was maintained. Study updates were disseminated through electronic newsletters to administrators, government

agencies, academics, healthcare professionals, and students. Study findings were presented at two health policy and economic conferences in 2005. We are currently in the process of planning further dissemination activities. An abstract is under review to present a symposium at the Ontario Association of Community Care Access Centres Annual Conference in June 2006. In addition, three manuscripts are in preparation for publication.

Implications: The results of this study can be used to develop a systematic measurement strategy which can then be implemented to evaluate local, provincial, or national predictors and outcomes of home-based nursing and personal support care. By assessing determinants and outcomes of privately and publicly financed home-based services, issues concerning access to services, societal costs, and the quality of healthcare will be highlighted. By assessing the

determinants of home-based nursing services, such as age and socioeconomic status, issues regarding the inequitable access to home-based care may be examined and addressed by decision makers. Furthermore, gaps in knowledge may be recognized and areas for future investigation may be prioritized.