Challenges navigating publicly funded home care in Ontario, Canada: Perspectives from unpaid caregivers of persons living with dementia.

In Canada, persons living with dementia represent a sizable number of home care recipients. Although home care is not wholly publicly funded under provincial health insurance plans, some provinces like Ontario subsidize a maximum number of hours of home care provided by a personal support worker (PSW) on the basis of need. The public subsidization of home care may be interpreted as a mechanism of financial risk protection, enabling unpaid caregivers to maintain employment, income levels, and personal health. However, deficits in the availability of home care call into question how the organization of home care may be contributing to financial risk among unpaid caregivers. Inspired by qualitative phenomenology, this study describes the financial risks experienced by unpaid caregivers of persons living with dementia navigating publicly funded homecare in Ontario. Based on 24 interviews conducted between August-December, 2020, we found financial risk emerges across three dimensions: 1) receiving information about publicly funded home care that anticipates future care needs; 2) receiving flexible hours of support from a PSW; and 3) maintaining consistent access to quality support. Financial risks included turning to privately funded home care options, or taking time off work to provide care. Findings may inform local and international home care reforms aiming to protect caregivers from financial risk.

The Financial Risks of Unpaid Caregiving During the COVID-19 Pandemic: Results From a Self-reported Survey in a Canadian Jurisdiction.

As health service delivery shifts from institutions to the home, greater care responsibilities are being imposed on unpaid caregivers. However, gaps remain concerning how these responsibilities are contributing to caregivers' financial risk. This study describes results from an online survey conducted in late-2020 in Ontario, Canada, about the financial risks of unpaid, homebased caregiving throughout the first year of the COVID-19 pandemic. Among 190 caregivers, salient findings include difficulties paying for care expenses after the pandemic was declared than before (P = .002); more caregivers retiring or becoming unemployed during the pandemic than before (P = .013); and a significant relationship between paying out-of-pocket for a home care worker and experiencing a decrease in the availability of such support during the pandemic (P = .029). Overall, the financial stressors of caregiving during the pandemic contributed negatively to caregivers' mental health, with 64.2% noting could be partly offset by greater government and employment-based assistance in managing care expenses and productivity losses. Findings from this study will better inform policies that aim to protect unpaid caregivers from financial risk in pandemic recovery efforts and beyond. Results may also be useful in other welfare states where unpaid caregivers provide the majority of home care services.

Learning from the first wave of the COVID-19 pandemic: Comparing policy responses in Uruguay with 10 other Latin American and Caribbean countries.

A range of public health and social measures have been employed in response to the disproportionate impact of COVID-19 in Latin America and the Caribbean (LAC). Yet, pandemic responses have varied across the region, particularly during the first 6 months of the pandemic, with Uruguay effectively limiting transmission during this crucial phase. This review describes features of pandemic responses which may have contributed to Uruguay's early success relative to 10 other LAC countries - Argentina, Chile, Ecuador, El Salvador, Guatemala, Haiti, Honduras, Panama, Paraguay, and Trinidad and Tobago. Uruguay differentiated its early response efforts from reviewed countries by foregoing strict border closures and restrictions on movement, and rapidly implementing a suite of economic and social measures. Our findings describe the importance of supporting adherence to public health interventions by ensuring that effective social and economic safety net measures are in place to permit compliance with public health measures.

What Can Canada Learn From Accountable Care Organizations: A Comparative Policy Analysis.

Introduction: Accountable Care Organizations (ACOs), implemented in the United States (US), aim to reduce costs and integrate care by aligning incentives among providers and payers. Canadian governments are interested adopting such models to integrate care, though comparative studies assessing the applicability and transferability of ACOs in Canada are lacking. In this comparative study, we performed a narrative literature review to examine how Canadian health systems could support ACO models. Methods: We reviewed empirical studies (published 2011-2020) that evaluated ACO impacts in the US. Thematic analysis and critical appraisal were performed to identify factors associated with positive ACO impacts. These factors were compared with the Canadian context to assess the applicability and transferability of ACO models within Canada. Findings: Physician-led models, global budgets and financial incentives, and focus on collaborative care may optimize ACO impacts. While reforms towards alternative payments and team-based care are not unprecedented in Canada, significant further reforms to physician remuneration, intersectoral collaboration, and accountability for performance are required to support ACO-like models. Conclusion: This comparative study uncovered several insights on the applicability and transferability of ACOs to the Canadian context. Further comparative research outside the US is needed to infer the essential components of successful ACO models.

The federal government and Canada's COVID-19 responses: from 'we're ready, we're prepared' to 'fires are burning'.

Canada's experience with the coronavirus disease-2019 (COVID-19) pandemic has been characterized by considerable regional variation, as would be expected in a highly decentralized federation. Yet, the country has been beset by challenges, similar to many of those documented in the severe acute respiratory syndrome outbreak of 2003. Despite a high degree of pandemic preparedness, the relative success with flattening the curve during the first wave of the pandemic was not matched in much of Canada during the second wave. This paper critically reviews Canada's response to the COVID-19 pandemic with a focus on the role of the federal government in this public health emergency, considering areas within its jurisdiction (international borders), areas where an increased federal role may be warranted (long-term care), as well as its technical role in terms of generating evidence and supporting public health surveillance, and its convening role to support collaboration across the country. This accounting of the first 12 months of the pandemic highlights opportunities for a strengthened federal role in the short term, and some important lessons to be applied in preparing for future pandemics.

Comparison of outpatient coverage in Canada: Assistive and medical devices.

Outpatient technologies are important for maintaining health and overall quality of life, yet the degree of access and coverage of these technologies remains variable within and across jurisdictions. In Canada, assistive technologies are not included in universal health coverage, and are not subject to the Canada Health Act's criteria and conditions that provinces and territories must fulfill to receive the full federal cash contribution under the Canada Health Transfer. As such, the thirteen Canadian provincial and territorial governments make separate decisions on programs and coverage. Drawing on the WHO Universal Coverage Cube we compare who gets access, the types of technologies that can be accessed, and the level of coverage (total costs covered) in Canada. Overall, each Canadian jurisdiction had at least one publicly supported program. All relied on a 'health assessment' of an individual's need to determine eligibility. Income and eligibility for social assistance was used as eligibility criteria in 6 of the 13 jurisdictions. Mobility aids as well as audio, visual, and communication aids were included in all jurisdictions. While some programs offered full financial support for some technologies, forms of cost sharing were common. The results are discussed in the context of international experiences, demographic changes, and health system trends to highlight areas for policy learning.

Development of a web-based survey on the financial risks of unpaid caregiving: approach and lessons learned from a Canadian perspective.

Little is known about the financial risks of unpaid caregiving. This is, in part, due to challenges in identifying people who are caregivers and limitations in capturing all aspects of spending related to caregiving in existing approaches to public data collection. To fill these gaps, we developed a composite survey informed by validated instruments that assesses the types and magnitude of out-of-pocket expenditures caregivers incur in the provision of homebased care for someone living with a long-term health condition, and their impact across various domains of financial risk. This paper discusses the development of this survey currently in circulation in a Canadian province, and reflects on considerations in the engagement of unpaid caregivers in participatory research. Given its replicability and adaptability, this survey may inform future research in other developed or high-income settings and guide policy attention toward understanding how to protect unpaid caregivers from the financial risks of caring.

Achieving higher performing primary care through patient registration: A review of twelve high-income countries.

BACKGROUND: Patient registration with a primary care providers supports continuity in the patient-provider relationship. This paper develops a framework for analysing the characteristics of patient registration across countries; applies this framework to a selection of countries; and identifies challenges and ongoing reform efforts. METHODS: 12 jurisdictions (Denmark, France, Germany, Ireland, Israel, Italy, Netherlands, Norway, Ontario [Canada], Sweden, Switzerland, United Kingdom) were selected for analysis. Information was collected by national researchers who reviewed relevant literature and policy documents to report on the establishment and evolution of patient registration, the requirements and benefits for patients, providers and payers, and its connection to primary care reforms. RESULTS: Patient registration emerged as part of major macro-level health reforms linked to the introduction of universal health coverage. Recent reforms introduced registration with the aim of improving quality through better coordination and efficiency through reductions in unnecessary referrals. Patient registration is mandatory only in three countries. Several countries achieve high levels of registration by using strong incentives for patients and physicians (capitation payments). CONCLUSION: Patient registration means different things in different countries and policy-makers and researchers need to take into consideration: the history and characteristics of the registration system; the use of incentives for patients and providers; and the potential for more explicit use of patient-provider agreements as a policy to achieve more timely, appropriate, continuous and integrated care.

Expanding health care coverage in Canada: a dramatic shift in the debate.

The coronavirus disease 2019 (COVID-19) pandemic has shifted the health policy debate in Canada. While the pre-pandemic focus of policy experts and government reports was on the question of whether to add outpatient pharmaceuticals to universal health coverage, the clustering of pandemic deaths in long-term care facilities has spurred calls for federal standards in long-term care (LTC) and its possible inclusion in universal health coverage. This has led to the probability that the federal government will attempt to expand medicare as Canadians have known it for the first time in over a half century. However, these efforts are likely to fail if the federal government relies on the shared-cost federalism that marked the earlier introduction of medicare. Two alternative pathways are suggested, one for LTC and one for pharmaceuticals, that are more likely to succeed given the state of the Canadian federation in the early 21st century.

The rollout of the COVID-19 vaccination: what can Canada learn from Israel?

This commentary compares Israel's COVID-10 vaccination response to the much slower and less successful vaccination campaign in Canada. Although Canada did start with some structural disadvantages relative to Israel including less centralized and coherent emergency planning and a more complex demographic geography, there are, nonetheless, some important policy lessons Canada can draw from Israel. These include a more strategic use of national leadership in the vaccination campaign and the greater use of primary care resources and providers.

Social Democratic Solidarity and the Welfare State: Health Care and Single-Tier Universality in Sweden and Canada.

Although it is not generally done, it is useful to compare the history of the evolution of universal health coverage (UHC) in Canada and Sweden. The majority of citizens in both countries have shared, and continue to share, a commitment to a strong form of single-tier universality in the design of their respective UHC systems. In the postwar era, they also share a remarkably similar timeline in the emergence and entrenchment of single-tier UHC, despite the political and social differences between the two countries. At the same time, UHC was initially designed, implemented, and managed by social democratic governments that held power for long periods of time, creating a path dependency for single-tier Medicare that was difficult for future governments of different ideological persuasions to alter.

Canada: examen du système de santé

La présente analyse du système de santé du Canada examine les évolutions récentes dans l’organisation et la gouvernance, le financement de la santé, la prestation de soins de santé, les réformes de santé et le rendement du système de santé. L’espérance de vie est élevée, mais a atteint un plateau entre 2016 et 2017 en raison de la crise des opioïdes. Les inégalités socioéconomiques en matière de santé sont importantes, et les écarts marqués et persistants dans les résultats en matière de santé entre les Autochtones et les autres Canadiens représentent un grand défi pour le système de santé, et la société de façon plus générale. Le Canada est une fédération : les provinces et territoires font l’administration de systèmes de couverture de santé pour leurs résidents (appelés « régimes d’assurance-maladie »), alors que le gouvernement fédéral fixe des normes nationales, notamment par la Loi canadienne sur la santé, et est responsable de la couverture de santé de sous-groupes précis. Les soins de la santé sont principalement financés par l’État, avec environ 70 % des dépenses de santé financées par des recettes fiscales générales. Pourtant, les régimes d’assurance-maladie ont des lacunes importantes, comme les médicaments d’ordonnance en dehors de l’hôpital, les soins de longue durée, les soins de santé mentale, et les soins dentaires et de la vue, ce qui explique le rôle important des régimes d’assurance-maladie privés liés à l’emploi et des paiements déboursés par les patients. Le bassin de médecins et d’infirmières est inégal à l’échelle du pays, avec des pénuries chroniques dans les régions rurales et éloignées. Les réformes récentes comprennent une tendance vers le regroupement des régions sanitaires en structures de gouvernance plus centralisées à l’échelle provinciale ou territoriale, et un passage graduel vers l’autonomie des soins de santé par les Autochtones. Il y a également eu une lancée vers l’introduction d’un programme national de couverture des médicaments d’ordonnance (régime d’assurance-médicaments), mais la pandémie de COVID-19 de 2020 pourrait occasionner un virage dans les priorités, vers d’autres problèmes importants du système de santé, comme la mauvaise qualité et la surveillance réglementaire du secteur de soins de longue durée. Le rendement du système de santé s’est amélioré au cours des dernières années, selon les taux de mortalité à l’hôpital, la survie au cancer et les hospitalisations évitables. Des défis majeurs – comme l’accès à des services non couverts par l’assurance-maladie, les délais d’attente pour une consultation avec un spécialiste et les interventions chirurgicales non urgentes, ainsi que la fragmentation et la mauvaise coordination des soins – continueront toutefois de préoccuper les gouvernements dans leur quête d’amélioration du rendement du système de santé.

Provincial legislative and regulatory standards for pain assessment and management in long-term care homes: a scoping review and in-depth case analysis.

BACKGROUND: Among Canadian residents living in long-term care (LTC) facilities, and especially among those with limited ability to communicate due to dementia, pain remains underassessed and undermanaged. Although evidence-based clinical guidelines for the assessment and management of pain exist, these clinical guidelines are not widely implemented in LTC facilities. A relatively unexplored avenue for change is the influence that statutes and regulations could exert on pain practices within LTC. This review is therefore aimed at identifying the current landscape of policy levers used across Canada to assess and manage pain among LTC residents and to evaluate the extent to which they are concordant with evidence-based clinical guidelines proposed by an international consensus group consisting of both geriatric pain and public policy experts. METHODS: Using scoping review methodology, a search for peer-reviewed journal articles and government documents pertaining to pain in Canadian LTC facilities was carried out. This scoping review was complemented by an in-depth case analysis of Alberta, Saskatchewan, and Ontario statutes and regulations. RESULTS: Across provinces, pain was highly prevalent and was associated with adverse consequences among LTC residents. The considerable benefits of using a standardized pain assessment protocol, along with the barriers in implementing such a protocol, were identified. For most provinces, pain assessment and management in LTC residents was not specifically addressed in their statutes or regulations. In Alberta, Saskatchewan, and Ontario, regulations mandate the use of the interRAI suite of assessment tools for the assessment and reporting of pain. CONCLUSION: The prevalence of pain and the benefits of implementing standardized pain assessment protocols has been reported in the research literature. Despite occasional references to pain, however, existing regulations do not recommend assessments of pain at the frequency specified by experts. Insufficient direction on the use of specialized pain assessment tools (especially in the case of those with limited ability to communicate) that minimize reliance on subjective judgements was also identified in current regulations. Existing policies therefore fail to adequately address the underassessment and undermanagement of pain in older adults residing in LTC facilities in ways that are aligned with expert consensus.

Do health systems cover the mouth? Comparing dental care coverage for older adults in eight jurisdictions.

Oral health is an important component of general health, yet there is limited financial protection for the costs of oral health care in many countries. This study compares public dental care coverage in a selection of jurisdictions: Australia (New South Wales), Canada (Alberta), England, France, Germany, Italy, Sweden, and the United States. Drawing on the WHO Universal Coverage Cube, we compare breadth (who is covered), depth (share of total costs covered), and scope (services covered), with a focus on adults aged 65 and older. We worked with local experts to populate templates to provide detailed and comparable descriptions of dental care coverage in their jurisdictions. Overall most jurisdictions offer public dental coverage for basic services (exams, x-rays, simple fillings) within four general types of coverage models: 1) deep public coverage for a subset of the older adult population based on strict eligibility criteria: Canada (Alberta), Australia (New South Wales) and Italy; 2) universal but shallow coverage of the older adult population: England, France, Sweden; 3) universal, and predominantly deep coverage for older adults: Germany; and 4) shallow coverage available only to some subgroups of older adults in the United States. Due to the limited availability of comparable data within and across jurisdictions, further research would benefit from standardized data collection initiatives for oral health measures.

Mapping variability in allocation of Long-Term Care funds across payer agencies in OECD countries.

INTRODUCTION: Long-term care (LTC) is organized in a fragmented manner. Payer agencies (PA) receive LTC funds from the agency collecting funds, and commission services. Yet, distributional equity (DE) across PAs, a precondition to geographical equity of access to LTC, has received limited attention. We conceptualize that LTC systems promote DE when they are designed to set eligibility criteria nationally (vs. locally); and to distribute funds among PAs based on needs-formula (vs. past-budgets or government decisions). OBJECTIVES: This cross-country study highlights to what extent different LTC systems are designed to promote DE across PAs, and the parameters used in allocation formulae. METHODS: Qualitative data were collected through a questionnaire filled by experts from 17 OECD countries. RESULTS: 11 out of 25 LTC systems analyzed, fully meet DE as we defined. 5 systems which give high autonomy to PAs have designs with low levels of DE; while nine systems partially promote DE. Allocation formulae vary in their complexity as some systems use simple demographic parameters while others apply socio-economic status, disability, and LTC cost variations. DISCUSSION AND CONCLUSIONS: A minority of LTC systems fully meet DE, which is only one of the criteria in allocation of LTC resources. Some systems prefer local priority-setting and governance over DE. Countries that value DE should harmonize the eligibility criteria at the national level and allocate funds according to needs across regions.

Collaborative Governance for Integrated Care: Insights from a Policy Stakeholder Dialogue.

INTRODUCTION: Integrated care is a goal of many health care systems. However, operationalizing and implementing integrated care remains challenging especially in continuously evolving policy environments. We report on a policy symposium held in 2017 focused on operationalizing a particular integrated care policy in the context of policy evolution in Ontario, Canada. METHODOLOGY: Forty-five participants attended the symposium including government employees, health care leaders, researchers, clinicians, and patient representatives. The symposium included presentations from representatives of each group and breakout sessions. Two trained observers recorded observational field notes. RESULTS: We report four recommendations and fourteen sub-recommendations which arose regarding the implementation of the policy. We highlight four important tensions which characterize challenges regarding its implementation, and discuss the recommendations in the context of Collaborative Governance. DISCUSSION: We outline how the recommendations could be strengthened by collaborative governance and identify where this framework could support governance and leadership challenges associated with implementing integrated care. We describe the unique challenges posed by working towards these goals in an evolving policy environment. CONCLUSION: We draw on collaborative governance to generate insights for leaders implementing integrated care and conclude by addressing the importance of maintaining collaborative governance initiatives under circumstances of unstable policy environments.

Canada: Health System Review.

This analysis of the Canadian health system reviews recent developments in organization and governance, health financing, health care provision, health reforms and health system performance. Life expectancy is high, but it plateaued between 2016 and 2017 due to the opioid crisis. Socioeconomic inequalities in health are significant, and the large and persistent gaps in health outcomes between Indigenous peoples and the rest of Canadians represent a major challenge facing the health system, and society more generally. Canada is a federation: the provinces and territories administer health coverage systems for their residents ( referred to as "medicare") , while the federal government sets national standards, such as through the Canada Health Act, and is responsible for health coverage for specific subpopulations. Health care is predominantly publicly financed, with approximately 70% of health expenditures financed through the general tax revenues. Yet there are major gaps in medicare, such as prescription drugs outside hospital, long-term care, mental health care, dental and vision care, which explains the significant role of employer-based private health insurance and out-of-pocket payments. The supply of physicians and nurses is uneven across the country with chronic shortages in rural and remote areas. Recent reforms include a move towards consolidating health regions into more centralized governance structures at the provincial/ territorial level, and gradually moving towards Indigenous self-governance in health care. There has also been some momentum towards introducing a national programme of prescription drug coverage ( Pharmacare) , though the COVID-19 pandemic of 2020 may shift priorities towards addressing other major health system challenges such as the poor quality and regulatory oversight of the long-term care sector. Health system performance has improved in recent years as measured by in-hospital mortality rates, cancer survival and avoidable hospitalizations. Yet major challenges such as access to non-medicare services, wait times for specialist and elective surgical care, and fragmented and poorly coordinated care will continue to preoccupy governments in pursuit of improved health system performance.