Shining a Light: Examining Similarities and Differences in the Work Psychology of Health Support Workers Employed in Long-Term Care and Home and Community Care Settings.

Health Support Workers (HSWs) provide up to 80% of care to residents and clients in the long-term care (LTC) and home and community care (HCC) sectors but have received little research attention compared with the regulated professions. The authors explore similarities and differences in the work psychology of HSWs employed in LTC and HCC settings. Data were collected via survey from 276 LTC and 184 HCC HSWs. Descriptive statistics and path analyses were conducted. HSWs in LTC and HCC settings have significant, positive associations between organizational citizenship behaviors directed toward the organization (OCB-Os) and psychological empowerment, as well as intention to stay (ITS) and job satisfaction. For LTC sector HSWs, there are significant relationships between OCB-Os and quality of work life (QWL), ITS and work engagement, and individual performance and both job satisfaction and QWL. For the HCC sector, OCB-Os and ITS are significantly and directly related to organizational commitment. This study has implications for organizations interested in developing targeted interventions to improve the retention of HSWs.

Relationships between work outcomes, work attitudes and work environments of health support workers in Ontario long-term care and home and community care settings.

BACKGROUND: Our overarching study objective is to further our understanding of the work psychology of Health Support Workers (HSWs) in long-term care and home and community care settings in Ontario, Canada. Specifically, we seek novel insights about the relationships among aspects of these workers' work environments, their work attitudes, and work outcomes in the interests of informing the development of human resource programs to enhance elder care. METHODS: We conducted a path analysis of data collected via a survey administered to a convenience sample of Ontario HSWs engaged in the delivery of elder care over July-August 2015. RESULTS: HSWs' work outcomes, including intent to stay, organizational citizenship behaviors, and performance, are directly and significantly related to their work attitudes, including job satisfaction, work engagement, and affective organizational commitment. These in turn are related to how HSWs perceive their work environments including their quality of work life (QWL), their perceptions of supervisor support, and their perceptions of workplace safety. CONCLUSIONS: HSWs' work environments are within the power of managers to modify. Our analysis suggests that QWL, perceptions of supervisor support, and perceptions of workplace safety present particularly promising means by which to influence HSWs' work attitudes and work outcomes. Furthermore, even modest changes to some aspects of the work environment stand to precipitate a cascade of positive effects on work outcomes through work attitudes.

Factors Associated with Residential Long-Term Care Wait-List Placement in North West Ontario.

This article is based on a study that investigated factors associated with long-term care wait list placement in Ontario, Canada. We based the study's analysis on Resident Assessment Instrument for Home Care (RAI-HC) data for 2014 in the North West Local Health Integration Network (LHIN). Our analysis quantified the contribution of three factors on the likelihood of wait list placement: (1) care recipient, (2) informal caregiver, and (3) formal system. We find that all three factors are significantly related to wait list placement. The results of this analysis could have implications for policies aimed at reducing the number of wait-listed individuals in the community.

Organizational responses to accountability requirements: Do we get what we expect?

BACKGROUND: In health care, accountability is being championed as a promising approach to meeting the dual imperatives of improving care quality while managing constrained budgets. PURPOSES: Few studies focus on public sector organizations' responsiveness to government imperatives for accountability. We applied and adapted a theory of organizational responsiveness to community care agencies operating in Ontario, Canada, asking the question: What is the array of realized organizational responses to government-imposed accountability requirements among community agencies that receive public funds to provide home and community care? METHODOLOGY/APPROACH: A sequential complementary mixed methods approach was used. It gathered data through a survey of 114 home and community care organizations in Ontario and interviews with 20 key informants representing 13 home and community care agencies and four government agencies. It generated findings using a parallel mixed analysis technique. FINDINGS: In addition to responses predicted by the theory, we found that organizations engage in active, as well as passive, forms of compliance; we refer to this response as internal modification in which internal policies, practices, and/or procedures are changed to meet accountability requirements. We also found that environmental factors, such as the presence of an association representing organizational interests, can influence bargaining tactics. PRACTICE IMPLICATIONS: Our study helps us to better understand the range of likely responses to accountability requirements and is a first step toward encouraging the development of accountability frameworks that favor positive outcomes for organizations and those holding them to account. Tailoring agreements to organizational environments, aligning perceived compliance with behaviors that encourage improved performance, and allowing for flexibility in accountability arrangements are suggested strategies to support beneficial outcomes.

Caring for Caregivers: Challenging the Assumptions.

Informal and mostly unpaid caregivers - spouses, family, friends and neighbours - play a crucial role in supporting the health, well-being, functional independence and quality of life of growing numbers of persons of all ages who cannot manage on their own. Yet, informal caregiving is in decline; falling rates of engagement in caregiving are compounded by a shrinking caregiver pool. How should policymakers respond? In this paper, we draw on a growing international literature, along with findings from community-based studies conducted by our team across Ontario, to highlight six common assumptions about informal caregivers and what can be done to support them. These include the assumption that caregivers will be there to take on an increasing responsibility; that caregiving is only about an aging population; that money alone can do the job; that policymakers can simply wait and see; that front-line care professionals should be left to fill the policy void; and that caregivers should be addressed apart from cared-for persons and formal care systems. While each assumption has a different focus, all challenge policymakers to view caregivers as key players in massive social and political change, and to respond accordingly.

Caring for Caregivers: Bridging the Care Gap.

While drawing on different perspectives, the insightful responses of our commentators all highlight the increasingly crucial role of informal, and mostly unpaid caregivers. They also raise key questions. The first question, "how should we refer to caregivers," pushes us to acknowledge the diversity of caregiver characteristics, contexts and roles. The second, "how should we understand the caregiver 'problem'," reminds us that although often thought of as an individual matter, caregiving is a public policy issue requiring broader systems thinking and approaches. The third, "what should we do about it," draws attention to the importance of building and strengthening social networks to support caregivers and bridge a "growing care gap." We offer the example of Japan which, as part of its national dementia care policy, is now encouraging the development of inter-generational dementia-friendly communities.

Home and community care sector accountability.

This paper focuses on accountability for the home and community care (HCC) sector in Ontario. The many different service delivery approaches, funding methods and types of organizations delivering HCC services make this sector highly heterogeneous. Findings from a document analysis and environmental scan suggest that organizations delivering HCC services face multiple accountability requirements from a wide array of stakeholders. Government stakeholders tend to rely on regulatory and expenditure instruments to hold organizations to account for service delivery. Semi-structured key informant interview respondents reported that the expenditure-based accountability tools being used carried a number of unintended consequences, both positive and negative. These include an increased organizational focus on quality, shifting care time away from clients (particularly problematic for small agencies), dissuading innovation, and reliance on performance indicators that do not adequately support the delivery of high-quality care.

Chicken little? Why the healthcare sky does not have to fall.

If the healthcare sky is falling, it is because we have not yet grasped the opportunity to do better. Here we comment on three points in Chappell and Hollander's lead article. First, rather than looking to new federal-provincial mechanisms, which do not currently appear on the political agenda, we propose that federal and provincial governments honour their current commitments, including an extension of the 2004 First Ministers' agreement, set to expire in 2013-2014, that flows federal healthcare dollars to the provinces. Second, we concur that small things (e.g., transportation and medication management) matter in big health systems. Access to a full range of services in integrated systems of care permits cost-effective "downward substitution" instead of more costly, and often inappropriate "upward substitution" to hospital and institutional care. Finally, given the current political climate of fiscal constraint, it is helpful to consider the lessons of successful local initiatives such as supportive housing, which can integrate care "from the ground up" including essential primary and preventive care. Rather than seeing an aging population as the harbinger of healthcare doom, we suggest seeing it as a motivator to rethink, refresh and innovate.

Balancing institutional and community-based care: why some older persons can age successfully at home while others require residential long-term care.

Why can many older persons with relatively high needs age successfully at home, while others with similar needs require residential long-term care (LTC)? How can healthcare investments best be balanced to ensure that older persons have access to the most appropriate, cost-effective care?

Aging at home: integrating community-based care for older persons.

Integrating community-based health and social care has grabbed international attention as a way of addressing the needs of aging populations while contributing to health systems' sustainability. However, integrating initiatives in different jurisdictions work (or do not work) within very various institutional and structural dynamics. The question is, what transferable lessons can we learn to guide policy makers and policy innovators at the local level? In this paper, we consider "aging at home" as a policy option in Ontario, and beyond. In the first section, we focus on the problem, in effect, what not to do. Here, we briefly review findings from national and international research literature and from our own research in Ontario that identify the costs and consequences of non-systems of care for older persons. In the second part, we turn to solutions, in effect, what to do. Drawing on our recent scoping review of the international literature, we identify three guiding principles, as well as a number of recommendations, for integrating care for older persons, knowing that important details of how to put such initiatives "on the ground" will be provided by other contributors to this journal edition.

From Denmark to Deep River: integrating care in small and rural communities in Ontario.

Integrating community-based health and social care for older persons is said to help individuals maintain high levels of independence, well-being and quality of life and contribute to health systems sustainability by moderating the demand for costly emergency services and inappropriate hospital care. Rural settings, however, pose challenges distinct from those in urban areas. Using North Renfrew Long-Term Care Services as a case study, this paper discusses the principles and practices of a small, rural community service agency located in Renfrew County, Ontario, that provides to its scattered populations a range of services across the care continuum. Services include community support programs, supportive housing and long-term care beds as well as an innovative 24-Hour Flexible In-Home Support Pilot program adapted from the ground breaking "night patrol" system in Denmark.

'Working at the margins' or 'leading from behind'? A Canadian study of hospital-community collaboration.

Collaboration between hospitals and community organisations has been promoted over the past 20 years by various levels of government, hospital associations, health promotion advocates, and others at the state/province, national and international levels as a way to improve the 'efficiency of the system', reduce duplication, enhance effectiveness and service coordination, improve continuity of care, and enhance community capacity to address complex issues. Nevertheless, and despite a growing literature on interagency collaboration, systematic documentation and empirical analysis of hospital-community collaboration (HCC) is almost completely lacking in the literature, particularly as regards collaborations that address the determinants of health beyond the hospital walls. In this paper, we describe the methodology and key findings from a research study of HCC. The Hospital Involvement in Community Action (HICA) study undertook detailed qualitative case studies (in four urban, suburban, rural and northern locations) and a telephone survey (of 139 community organisations in a large urban centre) in order to learn about the range of collaborations and working relationships that exist between hospitals and community agencies in the province of Ontario (Canada), and the factors that influenced (enabled and/or hindered) HCC. Particular attention was paid to barriers and enablers at three nested levels of context (policy, hospital and community) and, drawing primarily on the qualitative case studies, it is this aspect that is the focus of this paper. That such collaborations continue to be widespread despite a generally unfavourable policy environment and hospital institutional culture that poses significant barriers, suggests that the extent to which HCC flourishes (or exists at all) crucially depends on the presence and ongoing enthusiasm/commitment of one or more 'champions' within the hospital, and the commitment of both parties to overcome the marked cultural differences between hospital and community. We conclude with a discussion of implications for policy and practice.