A big winner in the massive overhaul of the health care system could be community care.

The focus is finally starting to shift to the often-overlooked and under-resourced sector that includes home care, long-term care and primary care.

Savings expected to be found through better integrating the health-care system appear to be earmarked for beefing up community care to cope with the aging population and patient demand to heal at home.

Even hospitals are talking about moving some of their own funding to the community in an attempt to ease the overcrowding, log-jamming acute care.

"To be successful we would like to see a proportional shift of the amount of health care dollars currently spent on in-patient care to be more home and community focused because that is where people really want to see care," said Cheryl Williams, executive vice-president clinical at Joseph Brant Hospital.

A Burlington family physician marvels at hearing such talk from hospitals, which have long had a reputation of being insatiable.

"That is a pretty remarkable statement for a hospital to say," said Dr. Harpal Singh, lead physician at the North Burlington Medical Centre Family Health Group.

"There is a limited amount of resources and your hospital is saying if we as a team can organize those services better and integrate better, than perhaps we can use the existing amount of funding to provide more care and better care for patients."

The most expensive place to provide care is in a hospital. Yet 5,100 Ontario patients ready to be discharged were stuck in acute care in February mostly because they were waiting for home care or long-term care.

The Progressive Conservatives say they are ending this bottleneck with their revamp of the health-care system that came into effect June 6 under the Connecting Care Act.

An investigation by The St. Catharines Standard and The Hamilton Spectator provides the most comprehensive coverage to date of the restructuring considered the biggest change since Medicare.

The plan announced in February puts a super agency named Ontario Health in charge of the entire health-care system — from hospitals to community care to organ donation to cancer care.

It will oversee dozens of regional groups called Ontario Health Teams made up primarily of health and social service organizations working together to integrate services locally and help area residents navigate the system.

For the first time, it will remove legal barriers that prevent different types of providers from working directly together.

It means hospitals will be able to co-ordinate directly with home care and long-term care without having to go through the Local Health Integration Network (LHIN) or before that the Community Care Access Centre (CCAC).

"It can start to grease the wheels for the whole system," said Rob MacIsaac, president and CEO of Hamilton Health Sciences.

"I think having that direct relationship with home care will allow us to have (a) more intimate understanding of each other's pain points.

"It should allow for less duplication and more efficiencies and effectiveness just because of the fact that we can deal directly with each other without an intermediary."

Home-care leaders are equally eager to get rid of the middleman.

"Hospitals cannot reach out to home care and the home-care provider cannot reach out to the hospital. That is a structural impediment," said Sue VanderBent, CEO of Hamilton-based Home Care Ontario.

"Those two areas — hospital and the home — need to have a more direct relationship just like the family doctor needs to have a more direct relationship."

VanderBent envisions increased dialysis at home, improved palliative care in the community, better use of technology and more flexibility regarding the maximum amount of home care provided.

"What we are excited about is the opportunity to break down silos that currently exist that make it difficult for people to stay at home with the proper amounts of care and that make it difficult for people to leave the hospital in a timely fashion," she said.

The hope is that working together will get patients out of the hospital and back home faster while a similar relationship with primary care will divert patients from coming to the emergency room in the first place.

"Having a third party is not always effective at all," said Anthony Dale, president of the Ontario Hospital Association.

"It can often be slow and it can often be unresponsive. Hospitals are 24-7 places and LHINs and the old CCACs are not."

So far, there is no clear plan on where the caseworkers arranging the home care and long-term care will go once the LHIN shuts down.

It's also unknown who will get to decide what organizations provide home care or what will be in the contracts.

"In her announcement, (Health Minister) Christine Elliott was quite silent about this question of home care," said Marvin Ryder, former Hamilton Health Sciences board chair.

"The LHINs had that role. They would make sure the contracts were let to deliver care in the homes. Now who is making that decision?"

The Premier's Council on Improving Health Care and Ending Hallway Medicine recommended in its June report that Ontario Health Teams take over all aspects of care co-ordination. But it's unclear if that will happen.

It's significant, considering there were more than 5.4 million home-care visits in this LHIN in the fiscal year that ended March 31, 2018. In total, almost 90,000 people received care in the community.

"We already have horrifying situations where people aren't getting anywhere near the frequency of attention they need, the depth of care they need nor even the expediency ... after they are discharged from hospital," said provincial NDP Leader Andrea Horwath, Hamilton Centre MPP. "I don't see how this model is going to fix that."

"We are definitely operating well over capacity," says Rob MacIsaac, the CEO of Hamilton Health Sciences. | Courtesy of Hamilton Health Sciences

Bidding for care

A flashpoint in home care has long been the bidding system that sees agencies awarded contracts for home care.

It has forced some nonprofit longtime providers such as VHA Health and Home Support Services in Hamilton to shut down while others have struggled to compete. St. Joseph's Home Care slashed wages in 2012 to win contracts.

"Now 90 per cent of the home-care delivery is done by private companies whereas before it was the opposite," said Horwath.

"I'm worried the home care sector is going to continue to be dominated by private interests and our home-care dollars are going to continue to be padding the pockets of for-profit companies while our loved ones don't get the hours of care that they need."

The contracts result in a patchwork of providers, making it difficult for patients to get consistent, reliable and efficient care, said the Registered Nurses' Association of Ontario.

"Home-care people end up with three or four agencies: One because they do only weekends, another because they do only nights, the other because they don't do PSWs, the fourth because they only do PSWs," said CEO Doris Grinspun. "That is insane."

Care co-ordinators work under such inflexible rules that there is little room to tailor the care to the circumstances, she said.

It's left the home-care system "heavily bureaucratized," said the Ontario Hospital Association.

"You have an assessment tool that is being used in a very universal way for every single home-care patient," said Dale.

"You have contracts that ... haven't been modernized in 10 to 13 years so they're very antiquated."

One-size-fits-all in home care is the opposite of the what the Premier's Council concluded patients want.

"Ontarians want more flexible home care services that respond to their individual needs and easier access to mental health and addictions services and supports in community settings," stated the June report.

Something as simple as assigning home-care staff to one part of the city isn't possible in the current system because so many different providers hold the contracts.

"It's inefficient," said Dale.

"They often are driving all over different parts of communities. If we could just step back and think about how to deliver the care in a more effective way, you could get those health care workers to see more patients in a shorter or equal amount of time."

Even one supportive housing building could have home-care providers from half a dozen different agencies visiting each day.

"I watch how many agencies enter into some of our buildings to deliver service to a population and I think, 'What if we contracted with one organization to deliver those services,' " said Paul Johnson, general manager of the health and safe communities department for the City of Hamilton.

"That provides an ability to deliver more service to a system that desperately needs it."

The race to the bottom to win contracts has made it hard to recruit and retain staff with home-care nurses paid far less than those in hospitals. The work can also be unstable if agencies lose the contract.

"Home care is a threadbare service in terms of staffing," said Michael Hurley president of the Ontario Council of Hospital Unions (OCHU), the hospital division in Ontario of the Canadian Union of Public Employees (CUPE).

"In home care, the resources that have been provided have not in any way kept up with the demand," he said. "This is a service run right off its feet trying to keep up."

He doesn't predict the restructuring will improve community care at all.

"This restructuring will accelerate the privatization of home care," said Hurley.

"That will lead to downward pressure on wages, that will lead to higher turnover and quality problems ... It's going to misdirect resources away from care toward the profits for these companies."

"To be successful we would like to see a proportional shift of the amount of health care dollars currently spent on in-patient care to be more home and community focused because that is where people really want to see care," said Cheryl Williams, executive vice-president clinical at Joseph Brant Hospital. | Handout photo

Family doctors take the lead

The biggest gains could be in primary care, which is expected to take on a more central role in the new Ontario Health Teams that will oversee and co-ordinate care.

The Burlington team application is led by a family physician and primary care is the foundation of the proposal.

"The focus should be on the patient and the family," said Singh, co-chair of the proposed Burlington Ontario Health Team with Williams.

"Where the patient and family really access care is through their family doctor and services allied with primary care."

It's about establishing primary care as the foundation to help patients and families navigate the health care system.

"If primary care will not be the anchoring pillar of the health system, this province will not have a high functioning health system," said Grinspun.

There has been talk of moving the care co-ordinators currently at the LHIN to family health teams, community health centres, Indigenous health centres and other types of family physician and nurse practitioner clinics.

"They need to be located in primary care," said Grinspun.

"All those interprofessional teams should have in their midst these care co-ordinators who have tremendous expertise and can help the teams co-ordinate care for patients and be proactive."

Hamilton has already proven the value of linking care co-ordinators with family practices. The LHIN placed one co-ordinator at McMaster Family Practice and Stonechurch Family Health Centre to help their nearly 50,000 combined patients navigate community services.

"We can access it quickly and we can also prioritize it," said Dr. David Price, head of family medicine at McMaster University.

"We know who is really going to need it."

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He gives the example of a family doctor choosing to make a house call so the home-care nurse can be freed up to go to a more urgent patient.

"We negotiate so the patients most in need can access the services," said Price.

"We have limited amounts but we can use it really wisely."

More focus on primary care could also play a key role in helping the health-care system cope with the aging and growing population.

"Imagine if you delay chronic illness by one year per person," said Grinspun.

"Imagine the good that will do for the person and for the budget.

"You can delay chronic illness by focusing on health promotion and disease prevention from social determinants of what is your living conditions to what do you eat and do you exercise."

The ball is in primary care's court to become the quarterback locally in the restructured health system.

"It's going to force us to think a little bit differently," said Price.

"It is going to take some leadership and some thoughtful dialogue among primary care if we are going to realize the potential here."

Thousands wait for long-term care

One of the biggest logjams in the system is the wait for long-term care beds, which ranges from 136 days to 798 days for nine out of 10 patients in Hamilton, depending on the home and type of bed.

In Niagara, the range is 50 days to 2,099 days.

The result is 3,132 people waiting in the community for a long-term care bed in the Hamilton Niagara Haldimand Brant LHIN, which includes Burlington. About one-third are in Hamilton.

"We are so short in our city when it comes to long-term care beds, it's a disgrace," said Horwath.

"I have very little confidence this government is going to open up the required investments to be able to have enough capacity to meet the needs of Ontarians."

The Progressive Conservatives have promised to build 15,000 long-term care beds over the next five years and renovate another 15,000 beds to modern standards.

"I hope sooner rather than later they start to approve those beds and get them there," said Marvin Ryder, former Hamilton Health Sciences board chair.

The government says it has allocated 7,200 of the beds and that 952 of them are coming to this LHIN. But there is no list of what long-term care homes are getting the beds.

"Specific details of all projects that have received an allocation to date are not available at this time," the Ministry of Health said in a statement in June.

The Canadian Union of Public Employees has expressed concern about the lack of transparency regarding the beds.

"We are thinking that there an element of secrecy about what homes are selected to create new beds," said spokesperson Stella Yeadon.

"Are the majority going to for-profit homes? Did municipalities apply and receive some? Also, are the beds going to mostly PC ridings?"

But the Registered Nurses' Association of Ontario says building tens of thousands of long-term care beds isn't the answer to the health care system's problems — or even what seniors want anyway.

"I don't think we have enough," said Grinspun.

"But if you beefed up primary care, home care and community services you'd have people much happier, healthier aging in place in their home or joint homes."

However, issues in long-term care run far deeper than simply finding the right number of beds as patients get older and sicker.

"The long-term care system is failing our loved ones," said Horwath.

"We have people who are not toiletted on time, they are in filthy incontinence diapers for hours and hours on end, people missing meals and people left 12 to 14 hours without seeing a single caregiver at all."

Long-term care providers need to be able to access more support, such as home care temporarily, particularly when a patient is sick or gets worse, said Price.

"How do you make sure you have the services so you don't end up having long-term care facilities bailing and saying, 'I've got to send the patient to hospital because we don't have the resources here or the facilities,' " he said.

"How do we work together so we keep those patients out of hospital."

Alternatives to long-term care are also needed but missing from the restructuring plan, said Horwath.

"We have an opportunity to avoid people having to go to long-term care prematurely if we put more supportive housing units in place but no one is talking about that," said Horwath.

"There should be some kind of transition opportunity."

At the end of the day the focus needs to be on the patient, Singh said.

The Premier's Council agrees recommending in June that patients be at the centre of their health care.

"If we keep coming back to who is the most important piece of this team it's really the patient," said Singh.

"We start from the patient's point of view and say what is the best way to move forward from the patient's perspective."

• • •

Millions of area residents turn to community care April 1, 2017 to March 31, 2018

5,406,924: Home care visits

10,628: Visits to schools

16,015: Visits to nursing care centres

4,732: People received hospice end-of-life care

3,538: Patients sent to long-term care

3,132: People waiting at home for a long-term care bed

Source: Hamilton Niagara Haldimand Local Health Integration Network

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