Are chronically ill patients high users of homecare services in Canada?

OBJECTIVES: Chronically ill patients often need healthcare and supportive services, with formal homecare services an important source of community-based assistance. Although people diagnosed with 1 or more chronic diseases are thought to be the most common homecare clients, and perhaps the highest users of homecare services, few studies have analyzed homecare services utilization by specific clients. A study was done to determine if a relationship exists between chronic illness and homecare services utilization. STUDY DESIGN: Descriptive-comparative, secondary analysis of population homecare data. METHODS: Three years (2003-2004, 2004-2005, and 2005-2006) of complete homecare client and services utilization data for 1 Canadian province were obtained and tested using 5 definitions of chronic illness to determine which clients among all 149,378 were high users in terms of annual homecare hours and service visits or episodes. RESULTS: Two definitions revealed clients with a disproportionately large share of homecare hours and service episodes: a) clients classified by homecare case managers as "long-term" and b) clients with service spans of ≥90 days. Definitions involving medical diagnoses and International Classification of Diseases, Ninth Revision, Clinical Modification codes or chapters did not reveal high users. Age and gender also did not predict services utilization. CONCLUSIONS: The comprehensive pre-service assessment completed by homecare case managers was the most successful at distinguishing people with substantial homecare service needs-people who could then be described as chronically ill. This assessment should be studied to develop a standardized minimum data tool for consistent and fair assessments.

The rapidly changing location of death in Canada, 1994-2004.

This 2008 study assessed location-of-death changes in Canada during 1994-2004, after previous research had identified a continuing increase to 1994 in hospital deaths. The most recent (1994-2004) complete population and individual-level Statistics Canada mortality data were analyzed, involving 1,806,318 decedents of all Canadian provinces and territories except Quebec. A substantial and continuing decline in hospitalized deaths was found (77.7%-60.6%). This decline was universal among decedents regardless of age, gender, marital status, whether they were born in Canada or not, across urban and rural provinces, and for all but two (infrequent) causes of death. This shift occurred in the absence of policy or purposive healthcare planning to shift death or dying out of hospital. In the developed world, recent changing patterns in the place of death, as well as the location and type of care provided near death appear to be occurring, making location-of-death trends an important topic of investigation. Canada is an important case study for highlighting the significance of location-of-death trends, and suggesting important underlying causal relationships and implications for end-of-life policies and practices.

The possibilities and the realities of home care.

BACKGROUND: An analysis of a provincial home care dataset, comparing home care client, service, and providers in 1991/92 through 2000/01, was undertaken to describe changes over the decade, and permit a more informed discussion of home care in relation to Canadian health policy developments and health system reforms. METHODS: After data were obtained upon request from Alberta's Ministry of Health and Wellness, descriptive and comparative statistical analyses were undertaken using the SPSS computer program. Logistic regression was used to compare multiple client characteristics in the first and last years. RESULTS: Home care clients doubled and the mean hours of care per client increased substantially, although the duration of care provision declined. The mean age of clients also declined. Home care continued to be primarily provided by Home Support Aides, with self-managed care increasing dramatically. Sustained geographical differences in home care were noted. CONCLUSION: Although home care has much potential for enabling early discharge from hospital, and for maintaining or improving health, few population-level studies of home care trends exist. In Alberta, although formal home care hours increased, home care expansion was not uniform across the province. Home Support Aides continued to be the primary care provider. In the face of substantial hospital downsizing, these observations could imply that the provision of home care has been off loaded to families. Moreover, home care increases do not appear to be related to an aging population.

Long-term-care residents: concerns identified by population and care trends.

OBJECTIVE: Despite rising concern over population aging, few descriptions exist of long-term-care (LTC) residents, the people who are normally the oldest and the most dependent persons. This study sought to describe a LTC resident population and trends in this population. METHODS: A descriptive-comparative quantitative analysis of all data (1988-1999) from a provincial (Alberta) LTC resident database was undertaken. FINDINGS: Over the 10-year period, there was a significant increase in care needs. In the 1988, the mean Requirement Score was a "C" (indicating low to medium level care was required); by the 1999, the mean score was "E" (medium to high level care). There were both a substantial reduction in residents with low care needs and an increase in residents with high care needs. Although the mean age of LTC residents increased from 80.5 to 82.5, residents under age 65 had higher care needs. General linear modelling also revealed younger age was a significant influence in regard to higher care needs, along with larger (versus smaller) LTC admission to death also declined significantly from 6.9 to 3.4 years. Although this study may only confirm what is suspected about LTC residents, it should raise discussion over the impact of limited LTC beds on families, community-based health services, and acute care hospitals; and the implications of more dependent residents on LTC facility and personnel planning [corrected]

Evaluating institutionalization by comparing the use of health services before and after admission to a long-term-care facility.

Despite concern over increased health services utilization with population aging, few studies describe health services utilization by long-term-care (LTC) residents. An investigation was designed to compare health services use before and after LTC admission. Comprehensive 1988 to 1999 data for all LTC residents (N = 47,510) in Alberta, Canada, were obtained. Utilization comparisons involved equal pre/post timeframes. Only non-hospital physician services increased post-LTC admission. Home care was not provided after admission (51% had been recipients). Hospital and ambulatory services use declined, with these patterns stable for 5 years pre- and post-LTC admission. When hospital or ambulatory care was sought by LTC residents, they were not disadvantaged in the type or scope of care as compared to the care received prior to LTC admission. These findings should raise interest in the services provided by LTC facilities and the outcomes of long-term, facility-based care. LTC services could be beneficial for people with advanced age and dependency.

Twentieth-century social and health-care influences on location of death in Canada.

Providing the right care, in the right place, to dying persons is hampered by a lack of understanding of where death and dying normally take place and ignorance about what influences location of death. This paper reports the findings of a multidisciplinary historical investigation of 20th-century influences on location of death in Canada. It builds on a study that found a hospitalization-of-death trend in Canada over much of the 20th century but a reduction in hospital deaths beginning in 1994. This study found 2 key influences on location of death: (1) health-care and health-system developments that consolidated care in hospitals while also raising and sustaining public expectations of beneficial if not curative hospital care--the rising hospital-death rate throughout the 20th century can thus be considered an outcome of the shift of illness care from the home to the hospital; and (2) reduced availability of home-based caregivers. A number of developments limited the availability of home care for chronically ill and terminally ill persons, including the increased participation of women in the workforce and the shift in nursing from private home duty to hospitals. Although some health and social support for home care has developed recently, this support clearly does not match that for hospital care. These findings indicate that location of death is an important focal point for studying and planning improvements in end-of-life care.

Addressing myths about end-of-life care: research into the use of acute care hospitals over the last five years of life.

Despite very little confirming evidence, one of the most pervasive beliefs about dying is that terminally ill people receive a great deal of health care in the last few days, weeks, or months of life. A secondary analysis of 1992/93 through 1996/97 Alberta inpatient hospital abstracts data was undertaken to explore and describe hospital use over the five years before death by all Albertans who died in acute care hospital beds during the 1996/97 year (n = 7,429). There were four key findings: (1) hospital use varied, but was most often low, (2) the last hospital stay was infrequently resource intensive, (3) age, gender, and illness did not distinguish use, and (4) most ultra-high users were rural residents, with the majority of care episodes taking place in small, rural hospitals.

Care-giving and care-seeking behaviours of parents who take their children to an emergency department for non-urgent care.

OBJECTIVE: This study explored the care-giving and care-seeking behaviours of parents who took their children to the emergency department (ED) of a large urban hospital in Western Canada for non-urgent care. METHOD: Data were collected from a convenience sample of 114 parents during a two-week period in January 1992, using a self-administered 53-item questionnaire. The data were analyzed using nonparametric statistics (Chi-square) and thematic content analysis. RESULTS: Eighty-two percent of parents were unsure of or overestimated the seriousness of their child's illness or injury. Prior to attending the ED, 40% of parents administered comfort measures and 45% gave medications. Only 17% of parents used at-home reading materials, while 31% sought lay advice. Fifty-eight percent of parents did not try to contact their family physician or the ED by telephone before coming to the ED. Forty-eight percent of parents who phoned their family physician were unable to obtain advice, and those who did were almost always referred to the ED. Eighty-eight percent of those who phoned the ED were instructed to bring the child to the ED. INTERPRETATION: The results suggest the need for more acceptable, accessible community primary care services.