Out of Place: Mediating Health and Social Care in Ontario’s Long-Term Care Sector

Abstract

The paper discusses two reforms in Ontario’s long-term care. The first is the commercialization of home care as a result of the implementation of a “managed competition” delivery model. The second is the Ministry of Health and Long-Term Care’s privileging of “health care” over “social care” through changes to which types of home care and home support services receive public funding. It addresses the effects of these reforms on the state–non-profit relationship, and the shifting balance between public funding of health and social care. At a program level, and with few exceptions, homemaking services have been cut from home care, and home support services are more medicalized. With these changes, growing numbers of people no longer eligible to receive publicly funded home care services look for other alternatives: they draw available resources from home support, they draw on family and friend networks, they hire privately and pay out of pocket, they leave home and enter an institution, or they do without.

Introduction

Using a political economy of health framework (Coburn, 2001), this paper reflects on changes to Ontario’s publicly funded home care and home support services and the growing space between what services are available and the ability of families and friends to support care needs unmet by changes to these services. The changes are the result of two reforms. Commercialization of home care as a result of the implementation of a “managed competition” delivery model is the first reform discussed. The second is the Ministry of Health’s privileging of narrowly defined “health care” above “social care” through mandating which types of home care and home support services meet eligibility requirements for public funding.

Commercialization of Ontario’s home care delivery system, and the privatization of social care, shifted the state–non-profit relationship in the long-term care sector. The government’s adoption of market contracting imperatives and the privileging of health care set the context within which the constellation and nature of non-profit providers has changed. Nonprofit home care providers who contract successfully operate increasingly like their for-profit counterparts; and home support organizations, formerly grassroots and independent, are more formalized, less grass-roots, and less locally specific. The ways non-profit organizations mediate between state funding and community needs has consequences for individuals and their reliance on family and friends for care.

Before addressing the implications of these reforms, it is important to outline the policy context for these changes. In the early period of state-funded home support and home care (1958–1990), programs developed independently. Collectively referred to as the long-term care sector, the funding, administration, and regulation came from different ministries and was regulated by different legislation and programs, resulting in a complicated array of services, providers, and payment options for those needing care. Up until 1990, the health and social care divide was represented institutionally in the division between the Ministry of Health (MOH) and the Ministry of Community and Social Service (MCSS). In a real sense, consolidation pitted the social services MCSS against the medical MOH culture. In the past, MCSS had taken the lead in order to ensure that long-term care was not overly “medicalized” by MOH as a significant number of social care services were funded by MCSS (Baranek, 2000, pp. 92–93). MCSS-funded home support services included volunteer meals on wheels, transportation, visiting, homemaking and maintenance, adult day programs, and congregate dining. Services developed under a decentralized state administrative structure, a federal-provincial 50/50 cost-share from the Canada Assistance Plan, with a heavy reliance on local, grassroots, non-profit organizations and municipally run Elderly Persons Centres for service delivery.

MOH-funded home care services included professional nursing and rehabilitation therapies, and paraprofessional personal support work. Services developed within a decentralized financing structure, but with highly centralized administration, relying on state employees for delivery of some services, but primarily on non-profits and increasingly on for-profits for the majority of service delivery. Compared with home support, home care’s funding stream was more complicated. The latter began under a 50/50 cost share with the Medical Care Act, but it was switched to a combination of cash and tax point transfers with Established Programs Financing in 1978.

The funding streams for social care–oriented home support and health-oriented home care were merged by Mike Harris’s Ontario Conservative government in the aftermath of the Canada Health and Social Transfer (CHST) created by the 1995 federal budget. The CHST effectively granted provinces much greater latitude to make decisions about program fund allocation. Subsequently, following the recommendations of the Romanow Report, funding for health in Ontario was once again split off from social care through the return of separate transfers, but substantial changes to the long-term care sector have reduced the state’s role in funding support for social care, with drastic consequences for older women, who need the services the most and who may be socially isolated.

Since its inception in the 1950s, Ontario’s long-term care was fragmented and lacked coordination. Care recipients’ demands for integrated, co-ordinated access to home support and home care, in conjunction with policy makers’ recognition that demographic change was leading to a sharp increase in the number of seniors, prompted the start of a decade-long reform (Van Horne, 1986). Five different models were proposed between 1986 and 1996 by three ideologically opposed governments (Table 1).

Table 1.

Long-term care reform models 1986–1996

Governing Party	Report Title	Home Care Access Model	Date of Report
Liberal	New Agenda	One-stop shopping	1986
	Strategies for Change	Service access organizations	1990
New Democrats	Redirection of Long-term Care and Support Services in Ontario	Service coordination agencies	1991
	Partnerships in Long-term Care (4 reports)	Multi-service agencies	1993
Progressive Conservative	Alternatives to the MSA	Community Care Access Centres and managed competition	1996

Mike Harris’s Progressive Conservatives implemented the final reform – the managed competition model. Of all the models proposed, it is the most market-oriented. Prior to its implementation (1996/1997), home care services were delivered primarily by non-profit organizations. The for-profit sector held limited home care contracts prior to managed competition; generally, it was no more than 20 to 30 per cent of contracted hours and/or visits. Managed competition tied the award of home care contracts to a competitive “request for proposal” (RFP). Individual Community Care Access Centres (CCACs) situated regionally across the province manage home care contracting and refer individuals to home support services (e.g., adult day care).

Methods

This paper is based on the author’s doctoral work. The fieldwork was conducted between 2002 and 2003. The design is an embedded case study (Yin, 1994) of the state–non-profit relationship in Ontario’s home care and home support services, with a more detailed subunit analysis of organizations operating within the geographic boundaries of the former¹ Waterloo Region – Wellington-Dufferin (WWD) District Health Council (DHC). Three DHCs across the province had produced planning documents that detailed the issues facing home support services (i.e., Toronto, Southeastern Ontario, and Waterloo Region –Wellington-Dufferin) since 1995/1996. The WWD DHC was selected because it already had an established working relationship with local non-profits (Waterloo Region District Health Council, 1996; Waterloo Region Working Group on Community-Based Long Term Care Services, 1995), and had recently produced a report highlighting the volunteer-ism challenges facing home support non-profits (Waterloo Region – Wellington-Dufferin District Health Council, 2001).

The focus of the research is the changing nature of the non-profit–state relationship in long-term care. To understand the dynamics between the non-profit home support system and the evolving home care system, the author conducted qualitative and quantitative data analysis of six different data sources to triangulate findings and ensure converging lines of inquiry. Content analysis was conducted with QSR NUD*IST Nvivo software of transcribed key informant interviews (N = 48). The author conducted interviews with

• Waterloo Region CCAC and Wellington-Dufferin CCAC

• All 11 non-profit and all 6 for-profit organizations in WWD, of which 10 were providing home support and eight were providing home care services at the time of the interview

• Other non-profits located in Toronto

• Representatives of government agencies, including the Ministry of Health and Long-Term Care, the CCACs, and the DHC

• Provincial level associations representing non-profits.

All of the organizations approached agreed to participate. A list of interviewees’ affiliations is located in Appendix 1. Financial and statistical analysis was done with the following data sources: Ministry of Health and Long-Term Care’s (MOHLTC) Community Support Services Administrative Database (CSSAD) for the years 1995–2001, annual service plans and annual reports of 10 home support organizations located in WWD 1980–2001, and secondary published data for the financing of home care. Finally, a complex time series chronology (Mahoney, 2000) was compiled using provincial and regional policy and planning documents.

Implications of the Reforms

This section discusses two reforms and the consequences for individuals in need of care, and the families and friends that provide unpaid caring. The first reform is the commercialization of home care, through MOHLTC implementation of a “managed competition” delivery model. The second is the MOHLTC privileging of “health care” over “social care” through limiting which types of home care and home support services meet eligibility criteria to receive public funding.

Commercialization

With the implementation of managed competition, the duration of contracts was shortened, and providers were awarded contracts on the grounds of price and quality of proposal. Four years after its implementation, as a result of many lost contracts, non-profit organizations retained only 40 per cent of nursing hours and less than 60 per cent of nursing visits (Ontario Association for Community Care Access Centres, 2001). Several analyses emphasize the negative implications of managed competition (Baranek, 2000; Baranek, Deber, & Williams, 1999; Browne, 2000; Jenson & Phillips, 2000; Williams, Barnsley, Leggat, Deber, & Baranek, 1999). A recent government review of the sector reaffirms its continued use of the managed competition model (Caplan, 2005).

Managed competition commercialized the sector, as non-profits from across the province ceased operating as a result of the loss of home care contracts. Multiple interviews revealed that those non-profits that have persisted now operate more “like a business”. With the loss of contracts, unionized nurses who lose their jobs leave the home care sector because wages and guaranteed hours at other for-profit and newer non-profits in the area are not comparable to what they had, and wages are more competitive in the hospital and long-term care institutions.

Analysis of the Community Support Services Administrative Database (CSSAD) reveals that public funding of the sector has grown: provincial funding for homemaking/personal support services grew by more than 45 per cent between 1995/1996 and 2000/2001, compared with more than 80 per cent in WR and less than 10 per cent in WD for the same period. Limiting public funding by not funding the sector to the level of demand forces contracting organizations to make difficult choices. For home care nursing services, Ontario’s total provincial funding increased by nearly 30 per cent, while in WR it grew by more than 88 per cent and more than 21 per cent in WD. In WR, total CCAC expenditure more than doubled, growing by 53.1 per cent between 1997/1998 and 2000/2001 (Daly, 2003a). Despite the funding growth, since managed competition was implemented, the sector is far more commercialized. The Ontario Association of Community Care Access Centres (Ontario Association for Community Care Access Centres, 2001) reported that by 2000 nonprofits retained only 40 per cent of hours and 60 per cent of visits compared with 60 per cent and 80 per cent respectively in 1995.

A brief history of changes to non-profit service delivery in the two regions illustrates how the landscape changed after the introduction of managed competition. Prior to its introduction, 80 per cent of home care services delivery was through two nonprofits: the Victorian Order of Nurses (VON) held contracts to provide nursing and the Red Cross did homemaking/personal support. By January 2003, the VON announced that they would close their operations after serving the regions for over 90 years. The decision followed the loss of a nursing contract in February 2002, and the subsequent loss of personal support/homemaking in WD and nursing in WR. In February 2002, the WD CCAC dropped the VON in the pre-qualification round of bidding for a new 2-year contract as a result of their branch deficit. With an annual budget of $10.5 million, it ended the fiscal year in March 2001 with a deficit of $806,000 – up from a year 2000 deficit of $546,000 (Kelly, 2002). The initial loss of contract in WD was blamed on the insecure financial position of the branch. New contracts were awarded to Saint Elizabeth Health Care – a non–profit – and Care Partners – a for-profit (Wellington-Dufferin CCAC, 2002). The WD homemaking/personal support work contract was lost by the VON in 2003, and awarded to the Red Cross (non-profit), HLO (for-profit), and Paramed (for-profit). The nursing contract for Waterloo was lost in the 2003 request for proposal (RFP) round, and services for Paramed, Comcare, and Care Partners were expanded. In February 2003, the MOHLTC approved the transfer of all of the WD VON community support services (day away program, meals on wheels, security checks, friendly visiting, and transportation) to the VON Peel Region Branch (VON Canada, 2003). Issues related to the impact of pay equity on their full-time hourly paid nursing staff, and the debt acquired from merging two branches into one were cited as some of the reasons for the VON’s difficulties (interviews with executive director, community support organization; program consultant, Ministry of Health and Long-Term Care; and executive director, Community Care Access Centre).

The Canadian Red Cross continues to play a significant role in home care and home support. The first meals on wheels program in Ontario was opened in 1963 and operated out of the Brantford Red Cross. Since the mid-1990s, the organization has undergone dramatic change. The organization experienced difficulty recovering from the tainted-blood crisis and the RFP process. In 1998/1999 they reported that they had submitted 24 RFPs across the province, with a success rate of 60 per cent (Canadian Red Cross, 1998/1999). According to Canadian Red Cross Annual Reports, the following year they reported success in 17 of 21 proposals submitted. The success was also underscored by stunning defeats. For instance, the Red Cross lost a contract with Durham Access to Care, reversing a 43-year-long relationship with that community (Soo, 2001). In 2000/2001 the organization “streamlined” its administrative and management structure to lower service delivery costs (interview with Red Cross senior staff). It continues to provide homemaking, meals on wheels, and transportation provincially. In WR, the local branch provides homemaking on contract with both CCACs. In WD, it provided CCAC homemaking, and meals on wheels on contract with the VON (paid through a MOHLTC contract). In WR and WD, the revenue from the CCAC supplies 90 per cent of Red Cross revenue. Private pay clients, insurance, charitable homemaking with United Way funding, and federal funding for the Veteran’s Affairs program make up the remaining 10 per cent (Struthers, 2004).

A newcomer to the region, though not new to the sector, Saint Elizabeth Health Care (SEHC) began providing non-profit nursing services in Toronto in 1908. The organization briefly held a contract for personal support work in Waterloo in 1998/1999 and 1999/2000, but lost in a subsequent round of contracting (analysis of CCAC Annual Reports). They were able to secure a nursing contract in 2001 following the failure of the WWD VON to qualify in a financial prequel submission to the Wellington-Dufferin CCAC nursing RFP, which, as of 2006, they have retained. In 1997/1998, SEHC held nursing contracts with 12 CCACs, and no Personal Support Work (PSW) contracts. By 2001, they held nursing contracts with 19 CCACs, and PSW contracts with 9 CCACs (analysis of CCAC Annual Reports from across the province). The Ontario March of Dimes also now holds a contract to provide personal support services in WD.

A simple analysis of the landscape of providers in WR and WD shows the shift in private for-profit providers (Table 2). There are three main for-profit companies providing nursing and personal support services in the region.

Table 2.

Distribution of publicly funded contracts to provide nursing and homemaking/personal support work in Waterloo Region (WR) and Wellington Dufferin (WD) 1995–2006

	Nursing								Personal Support Work
	1995		2001		2003		2006		1995		2001		2003		2006
Non-profit	WR	WD	WR	WD	WR	WD	WR	WD	WR	WD	WR	WD	WR	WD	WR	WD
Canadian Red Cross Community Health Services
Victorian Order of Nurses
Saint Elizabeth Health Care
Ontario March of Dimes
For-profit	WR	WD	WR	WD	WR	WD	WR	WD	WR	WD	WR	WD	WR	WD	WR	WD
Bayshore Home Health
Care Partners
Comcare Health Services
ET Now
HLO
Paramed Home Health Care

Source: key informant interviews, CCAC annual reports and websites

First, Care Partners (formerly McKeeba) started providing nursing services after winning in the first round of the Wellington Dufferin nursing RFP. The company had provided visiting nursing to the Home Care Program (HCP) in Owen Sound since 1984, but had not moved outside of that area. As of 2003, they held contracts for nursing in eight CCACs, including both WD and WR. The second is Paramed, whose parent company is Extendicare, a major multinational long-term care service provider. The Waterloo Region Paramed business unit started in 1986 providing private homemaking and nursing. Finally, Comcare is a national company with 28 branches. In 1986, both Paramed and Comcare began to provide homemaking for the pilot Integrated Homemaker Program (IHP) when the Red Cross was unable to meet the service demand. Between 1989 and 1990, Paramed began to offer shift nursing for the HCP. VON still held the visiting nursing contract. Both companies were able to expand their business by providing vacation relief for therapy, shift nursing, and homemaking. Once the RFPs were issued, Paramed and Comcare won contracts. Currently, Paramed provides homemaking, occupational therapy, shift nursing in schools, and visiting nursing for medically fragile children, general, and palliative cases. In Ontario, Comcare holds contracts with at least 35 of the 43 CCACs (2003). They provide nursing, PSW, and the range of therapies. As of publication, three additional companies hold contracts for these services: ET NOW, Bayshore Home Health, and HLO.

Health Care Privileged over Social Care

Beginning in 1990, the government consolidated the administration and funding for long-term care in the Ministry of Health and Long-Term Care, which enabled it to make funding and regulatory changes that reflected its overall goals for the sector. First, the government created a joint MCSS/MOH Integrated Homemaker Program. Second, it consolidated MCSS and MOH responsibility for long-term care into a single centralized administrative structure with local area offices. Third, it switched the lead ministry from MCSS to MOH. Fourth, it reallocated responsibility for long-term care from the municipality to the province. Finally, it created a single ministerial point of access for home and social care services (Ministry of Community and Social Services, Ministry of Health, & Ministry of Citizenship, 1991a, 1993a, 1993b; Williams, 1996). Consolidation in one ministry did not result in a wholesale withdrawal of the state from the sector. In fact, it intensified the province’s grip on this policy sector, facilitating multiple regulatory and funding changes. As a result, there has been a change in the quantity and type of supports available to vulnerable adults and people with disabilities, reflecting a cultural shift away from a social care to a health care philosophy (Daly, 2003a).

Since ministerial consolidation, long-term care policy is increasingly focused on health care, obscuring social care, and creating social exclusion with serious implications for the large numbers of service users, and paid and unpaid care providers (Aronson & Neysmith, 2001; Daly, 2003b). Pervasive issues for users of home care and home support services – who are elderly and/or have disabilities – arise out of tensions between exclusion that results from being confined to one’s home, and inclusion or participation in the community. According to Aronson and Neysmith, the tension is perpetuated by policy language that adopts health care institutional terminology.

Basic elements of an individual’s social self – cooking, grooming, visiting, and maintaining a home – are compromised by service cutbacks, redefinitions, and changes (interviews with executive director, home support agency; and executive director, Community Care Access Centre). This is a serious issue for the elderly or those living with a disability. For instance, publicly funded home care programs, with the exception of Veteran’s Affairs (Struthers, 2004), no longer provide homemaking services (analysis of Community Support Services Administrative Database). Instead, public funds are focused on limited personal support, rehabilitation, and nursing care. Home support services lack access to consistent human and financial resources, and available state resources are increasingly tied to the provision of discreet services as opposed to support geared to individuals’ needs.

Hospital restructuring has resulted in decreases to lengths of stay and an increasing number of day procedures performed, which combined have increased demand for CCAC and home support. Policy decision-making, of which the final report of the Commission on the Future of Health Care in Canada (Romanow, 2002) is a prime example, position home care as an extension of hospital care. The result is less budget room to properly fund home support for chronic care users so that they may remain outside of institutional settings. An environment of time constraints, increased workloads, and reduced hours of care despite clients’ assessed need, all contribute to an environment where workers prioritize health over social care. For instance, a dressing change, or a bath –especially when it is the only one provided that week – are prioritized over a chat and a cup of tea, or a clean bathroom and fresh laundry, for that matter. In this way, health is narrowly confined to the body. The upkeep of the home space of frail elderly and people with disabilities is downloaded to private individual and family responsibility, as though a clean washroom does not contribute to health, and a clean living room where one can have guests to alleviate isolation does not contribute to one’s social needs.

Home support organizations also prioritize health care in response to the state’s decision to fund a discreet package of health-oriented services that are most easily measured. In addition, demand for support services has increased. As a consequence of CCAC expenditure controls imposed in 2003, the levels of service to individuals have dropped; they are not getting as much service as specified by their assessed need. Non-profits note they are facing higher demand for their services as a result of more CCAC referrals, particularly for individuals on CCAC waiting lists and as a result of existing clients with greater health needs and a higher level of acuity. But, as CCACs continue to be financially constrained from providing a level of service to meet individuals’ assessed needs, a growing number of clients whose needs are too great for non-profits to meet are not being served by the CCACs (interviews with executive director, home support agency; and executive director, Community Care Access Centre). According to those interviewed, the service gap is between preventive home support services and the health care needs of those on CCAC waiting lists. The preventive function of home supports keeps clients from needing higher acuity services (Hollander & Tessaro, 2001). Many interviewees expressed concern for this “growing gap” in service—people not served by CCAC and too ill for home supports. This concern seems justified, given the subsequent implementation of waiting lists and priority codes for homemaking and personal support services by CCACs.

The nature of services has changed, as illustrated by the example of organizations that prioritize transportation to medical visits above trips to loved ones’ gravesites or to the hairdresser. Two trends contribute to this shift favouring the tie to medical care. First, the ability of organizations to access stable funding is hindered by increased demands without commensurate increases in funding, so when they are forced to choose, they choose to support health care. Second, downloading and cost-cutting in other parts of the system increase the intensity of acute care needs among individuals requesting home support. As a result, more resources are needed to assess and determine their eligibility, which draws attention and resources.

In the case of transportation, although ministry funding entitles organizations to provide transportation to events other than medical appointments, in some cases funding levels have not kept pace with the costs of providing support in this area, and organizations have since medicalized the focus of their transportation program. One interviewee representing a non-profit summed up her organization’s experience making choices about how to provide support as follows:

The people we have couldn’t get on [public transportation]. They can’t even get in and out of the van … the only people we’re serving right now are those who need an escort. And, … if they need an escort, they probably need an escort to get in and out of a hairdressing place, too, but we’ve had to limit it to medical appointments and … urgent … court or legal things … I’d like to be able to … take people to more than just doctor’s appointments. Like I’d like to be able to take them to the hairdresser’s or to the … funeral home, or to the … nursing homes, cemeteries, or wherever they wanted to go. (Interview with executive director, home support agency)

One person interviewed from a municipal organization noted that transportation to social events was still given equivalent priority in their organization.

Now I’ve always made it clear in my budget that whether the ministry recognizes this or not, prevention is something that we will always try and keep on our table. We have a philosophy in this organization that to have a ride to the hairdresser is as important as having a ride to the cardiologist. And we try and live that … certainly if we have one driver, that driver would have to go to the cardiologist, we have no choice. But we do try to keep these other things on the table as far as we can. (Interview with executive director, home support agency)

The point is simply that the focus of the available support changed in some organizations in relation to the costs of the service and the ability to attract willing volunteers. While overall funding has increased (Browne, 2003; Coyte, Hall, & Croxford, 1999), more demand and higher program costs deflate the benefits of the increases. Furthermore, the voluntary nature of the service requires staff administration to recruit, retain, and train volunteers. If the funding mechanism deprives the organization of the resources necessary to grow, it becomes unable to meet its mandate. The example of transportation is important, since in dollar terms provincial transportation funding has doubled but the number of organizations providing the service has declined by 12 per cent (analysis of CSSAD). The result is more money available to fewer organizations. Nevertheless, organizations in WR and WD still note that they provide transportation services only with some measure of difficulty. Consequently, it is important to understand shifts in the focus of the service. For instance, are organizations able to provide the type and level of service that they would like to and feel is required in their community? And do they have the staff and volunteer resources and capacity to provide and expand the service to meet existing and future demand?

In addition, the number of volunteers willing to provide an escorted trip to a doctor’s office is limited by the uncertain amount of time that people will be required to wait to see the doctor. This restricts the number of available volunteers. In other instances, particularly in rural areas where public transportation is non-existent, drivers, who routinely use their own vehicles, are unable to escort anyone who is not mobile enough to get in and out of the vehicle without assistance.

Even the most socially oriented supports, such as friendly visiting, have changed substantively with pressures to address health care needs. For instance, provincial funding has increased for friendly visiting services in WR and WD. The inclusion of shopping and banking in the definition of friendly visiting broadens its focus from a social call to a service. This broad definition for friendly visiting gives organizations flexibility to manage the program but it also has the potential to make this service a transaction rather than social support. Two quotations illustrate the point. First, one interviewee representing an organization that provides friendly visiting noted that it is at times viewed by other organizations, particularly the CCAC, as a residual service. This was particularly the case when financial pressures in other parts of the home care system reduced the amount of professional and paraprofessional service available to people.

We had to really do a lot of weeding out when CCAC started referring people in droves. Because they did this past year when they had all their cutbacks. We had to really weed out the people who … thought that we would be able to provide what a homemaker had provided in the home. And what we found is that … in some cases having … a volunteer … now as opposed to 6 months ago when they had 15 hours worth of homemaking, makes sense because there isn’t as much traffic in the home …. And so the opportunity for a visitor is there …. In other cases … the homemakers were taking somebody to the grocery store … so when CCAC pulled back, clients were just mortified that they were going from 15 hours down to 1, and “Well what can your volunteer do for us?” “Well, our volunteer can only come for a social visit.” “Well that’s not what I need. I need my homemaker.” And so we had to really weed out those clients. (Interview with executive director, home support agency)

Second, another person from a home support organization, when interviewed, remarked that her organization had noticed more demands made of volunteers by seniors, particularly those wanting a social call, but for whom health-related needs, including activities of daily living, were not being met by their CCAC service allotments.

Where seniors want a visitor, but they cannot afford service … they’re making more demands on the volunteers. So for example, if they may have a disability where they’re not able to tie their shoes. Or maybe they can’t get their bra done up, you know, so the volunteer is coming, “Oh, honey can you please help with my bra? … change my shoes? Can you help me put my nylons on? … or to do some therapy exercises?” … They may ask them to take them out to do some grocery shopping. So they’re … asking and requesting … volunteers to do things that in the [past] it was “Well, let’s just have a cup of tea and a chat and go for a walk”, and that would really be the extent of it. But I think there’s definitely more pressure on volunteers. (Interview with executive director, home support agency)

While state funding for friendly visiting has continued to be strong (analysis of CSSAD), demonstrating the ministry’s support, its history as social care is threatened because of constraints elsewhere in the home care and health care system. For instance, home care clients used to be eligible for homemaking services. They now get none, but this does not mean that their needs have diminished. One interviewee noted that clients who request that volunteers provide transportation to medical appointments, help with grocery shopping, or conduct household chores affect what used to be a chat and a cup of tea. Friendly visiting, the social care program, is under threat because of the high levels of unmet need; in this type of environment there is pressure to transition into a transaction, where a volunteer does something more than a social call.

Evidence suggests that informal care is changing, as the nexus between formal and informal care changes (Wiles, 2002). In addition, the institutional arrangements, such as patterns of funding, and regulating and administering home care and home support services are altering the way non-family and friendly care is provided (Aronson, 2004; Daly, 2003a). According to the results of the General Social Survey, 39 per cent of women and 46 per cent of men received all of their care from informal sources in 2002, a figure that is unchanged since 1996. Of those receiving some form of care, the majority of men (52%) and women (47%) aged between 65 and 74 received their care informally (Cranswick, 2002). When it comes to provision of care within the home, little has changed. Mostly women, who are unpaid family, friends, and neighbours, provide the bulk of informal care (Armstrong & Kits, 2001; Grant et al., 2004; Morris, 2004). Consistent with findings in other studies (Armstrong & Armstrong, 2002; Aronson, 2004), Cranswick found that women’s reliance on the formal system is replaced or supplemented with care from formal sources after age 75. Family care seems to be taken for granted, even though the demands of care change the nature of the familial relationship (Neysmith, 2001).

A study of WR CCAC clients concluded that recipients of homemaking/personal support work tended to be “older, female, widowed, living alone, less able to get out of the home, more disabled, more cognitively impaired, longer-term clients and at higher risk of institutionalization compared with non-recipients” (Hirdes, Dalby, & Poss, 2001). The vulnerability of the clients receiving personal support poses potential consequences for decisions to restrict access to these services.

In WR and WD, economic viability resulted from organizations’ capacity to realign to health care goals. The institutional shift to the Ministry of Health and federal level transfers that “capped” federal social transfers to Ontario and then amalgamated them with health transfers have shifted the institutional milieu under which non-profits in this sector operate. A health care focus changes not only the type of staff, but also their ability to respond flexibly to individuals’ and caregivers’ needs as well as the types of supports. In WD and WR, when an organization’s main focus was social care for the well elderly, they did not remain viable. Organizations that have established some measure of balance between social and health care still note that there is tension when trying to provide social care in a health-care model.

You’ve got all that funding for OHIP, the doctors, and then [a] huge amount of money going to the hospital system, and most of it for acute care …. Long-term care community services aren’t the only part that’s really had to fight for space …. Community mental health is … another whole area that’s now getting a lot more attention ….but has had to fight to try and get the attention … To be fair to the [government] … hospitals show up and say it’s a crisis because they don’t have $150 million. Well … community supports agencies show up and say if we could have another million we’d do a lot … which one is (going to) get a 3-hour meeting? … it’s not fair, it’s not reasonable. (Interview with program consultant, Ministry of Health and Long-Term Care)

In dealing with clients with greater health care needs, organizations report they are too stretched financially to provide many of the social care services that are still required, but are no longer a part of the approved services funded by the ministry. Moreover it is difficult to advocate for softer preventive services when clients are not even receiving enough health care.

A lot of what you’re doing is a social service. It really is. It is not … wounds dressings, any of those kinds of things, that … people often associate with health care …. A lot of people originally in the field have a lot of social service background. I can see why they did switch us over to health, because they wanted to have a more integrated service delivery model. And with the best of intentions they’ve started out with that, but I don’t think they’ve achieved anywhere near what they set out to do, and why they moved us over and how things got blended. I don’t think it was a success at all. (Interview with executive director, home support agency)

Interviewees identified the complexities inherent in trying to provide both home health and social care. One problem is that non-profits typically remunerate at a low level, making it difficult to attract new people who already have management or clinical training and experience. Being financially stretched, organizations are unable to compensate well, thus affecting their ability to attract skilled staff. Low pay levels are not a new issue for this sector. The novel aspect is the amount of education and skill level that is now required of staff. Reflecting the shift to service clients with multiple and more complex health care needs, organizations have begun to try to attract more professional baccalaureate and community-college trained individuals, with backgrounds in non-profit management, gerontology, and personal support work. According to interviewees, when combined with a low pay level, these additional requirements make it very difficult for organizations to fill vacancies.

On the downside is the money, and it’s really got to be dealt with. It’s really in a … critical position. And they’re aware of it too, the board knows it. Where we’re [going to] get it, I don’t know. If you go to a fundraiser and people find out that it’s for salaries, there’s not a chance that you’re [going to] raise a nickel. For some weird perception, people think that we do this because we want to volunteer. (Interview with executive director, home support agency)

This problem has a direct impact on organizational viability and will become an increasingly prevalent issue as the current group of executive directors, most of whom started the organizations, is ready for retirement.

Organizational culture does affect service priorities. At a provincial level, the absorption of home-based social care for the elderly and people with disabilities into the Ministry of Health further privileges health care over social care. Interviewees uniformly indicated that the “basket of services” to which they are restricted is rigidly defined and has redirected the focus of home support organizations away from prevention programs in favour of health care for people who are likely already ill or increasingly frail. A former government minister echoed this concern:

Long-term care was moved from MCSS to Health … which was a bad thing to do. [But] it was done for good reasons. I actually said to the premier at the time that I didn’t think that he should do that … because I knew and recognized from my years of previous activity at community level that the one thing that we wanted to avoid in terms of the design for a long-term care model was a medicalized model and a health institutional model, that it really need to … spread to the broader community, social supports for seniors and that has the biggest impact on their health status. So that was a challenging thing for the people within that division and a clash of cultures of the Ministry of Health and the long-term care sector. (Interview with former provincial politician)

A former area office manager reflected that the shift out of MCSS to MOH was less than smooth, and incorporating community support into the health model did not work so well.

When long-term care came over … the Ministry of Health corporately really didn’t deal – didn’t adopt them very well … they’re part of us but … you know, it’s not on our radar at all quite frankly. Then … the ministry reorganized and went to regional offices. They just got tucked in there, like Mental Health did. (Interview with executive director, provincial association)

Despite the medicalized culture in the Ministry of Health, several things have remained the same under both ministries as a result of larger changes in government. For instance, the drive for accountability and efficiency is occurring across government, irrespective of the ministry:

That whole drive for efficiency and taking what is essentially a private sector model and superimposing it on the public sector has happened right across government, and if you go out to the ComSoc [MCSS] community agency, they’re dealing with the whole thing, the whole accountability framework around making services work for people, so it’s not just Health where that happened. But it is a very notable development in public policy. (Interview with former provincial politician)

Had long-term care remained under MCSS, it might have fared less well in the inter-ministerial battles for funding. In this war, health care has emerged as a clear winner. One interviewee noted,

You can’t just say ComSoc … would have done a better job. I mean if we did it under the Ministry of Health at the same time, it probably would have been the same thing because of the political and economic environment … I think if we were under ComSoc right now, we might be in a worse situation, given the political climate. (Interview with executive director, home support agency)

So while the cult of efficiency and government focus on accountability described by Stein (2001) is pervasive across government and would likely have affected organizations despite their ministerial affiliation, the philosophy and goals inherent in the logic of health as opposed to social care have multiple impacts on organizations. The types of supports they make available, their priorities, and their increasing focus on number-based accountability rather than broader social outcomes have all changed with the consolidation. As a result, the services provided, people hired, and composition of clients in need of support are all affected.

Conclusions

The current role of non-profits in delivering home care and home supports has diminished significantly compared to the previous decade when they were primarily responsible for delivery of non-family supports. By contrast, the state’s role has expanded, not only in providing more funding to the sector, but in determining which organizations can perform what services, mandating the types and nature of services, and reducing the relationship with non-profits from partner to contractor status. One clear result of this shift in relationship is that public funding is directed only to the most medically oriented health care services – a shift that has marginalized social care services and eradicated funding to non-profits unable to conform to the new model. Quite simply, social care has been privatized and given over to family and friend networks. Although it is beyond the scope of this paper, such privatization raises several important questions. For instance, what are the implications of reducing social care services to marginalized, socially isolated, and excluded individuals lacking personal care networks? Does this have a different impact on people depending on where they live (for instance in rural or urban settings)? And how does the son with serious disabilities who outlives his parents, or the frail older woman without children who outlives her family and friends, cope?

In this sector, now commercialized and medicalized, non-profits are increasingly out of place. Nearly a decade since market-oriented policies were implemented, non-profits still providing home care services operate more as for-profit businesses. Working conditions in the sector have worsened as workload demands have increased. Those providing home supports find that their values of community responsiveness and social support have been replaced with concerns about accountability and lack of autonomy.

In such a system, it is the growing group of people not served or underserved by the reconfigured system that are forced to mediate between the state, for-profit companies, and non-profit organizations. Funding constraints, in the form of too little funding to meet growing demands, and changes to what is an allowable expenditure, alter the balance among service providers (non-profits and for-profits), and shift responsibility from the state to individuals, and their family and friend networks. For instance, growing numbers of people no longer eligible to receive publicly funded home care look for other alternatives. They draw available resources from home support, draw on family and friend networks, hire privately and pay out of pocket, leave home and enter an institution, or do without. At a program level, and with few exceptions, homemaking services have been cut from home care, and home support services are more medicalized. There is a growing gap between preventive home support and the health care required by individuals who are assessed as requiring care but are on waiting lists. The preventive function of home supports keeps people from needing higher acuity home care, so that the two programs need not overlap. Many interviewees expressed concern for a “growing gap” in service — people not served by CCAC and too ill for home supports (interviews with two executive directors of community support agencies; and a program consultant, Ministry of Health and Long-Term Care). This concern seems justified, given the implementation of waiting lists and priority codes for homemaking and personal support services noted above. Finally, the provision of fewer publicly funded home care and home support services translates into higher personal and familial costs. The result is a violation of established relationship boundaries and the conscription of unpaid work for coordinating, funding, and delivering home care and home support to family and friends.

Those left most vulnerable are the ones for whom preventive home care and home supports enabled them to remain in their own homes. Without these supports there is often little choice but to leave one’s home or become institutionalized. These are the “chronic home care users” (though this is the term most widely used, it holds pejorative connotations), who tend to be older, isolated, and female. It is these people as well for whom social care is most important, because it can alleviate isolation and loneliness.

Appendix 1: Key informant interview schedule

Affiliation	Date	Location
Government and government agencies	January 2002	Toronto
Provincial association	January 2001	Toronto
Government and government agencies	January 2002	Guelph
Government and government agencies	January 2002	Guelph
Government and government agencies	January 2002	Kingston
Government and government agencies	January 2002	Kingston
Government and government agencies	January 2002	Toronto
Home support non-profit	March 2002	Orangeville
Home support non-profit	March 2002	Kitchener
Home support non-profit	March 2002	Waterloo
Home support non-profit	April 2002	Cambridge
Home support non-profit	April 2002	Erin
Home support non-profit	April 2002	Cambridge
Home support non-profit	April 2002	Kitchener
Home support non-profit/professional non-profit	April 2002	Guelph
Other non-profit	April 2002	Cambridge
Home support non-profit	April 2002	Kitchener
Provincial association	April 2001	Toronto
Home support non-profit	April 2001	Toronto
Provincial association	April 2001	Toronto
Home support non-profit	May 2001	Toronto
Home support non-profit	May 2002	Waterloo
Government and government agencies	May 2002	Waterloo
Government and government agencies	May 2002	Mississauga
Government and government agencies	May 2002	Guelph
Provincial association	May 2002	Toronto
For-profit provider	May 2002	Waterloo
For-profit provider	May 2002	Waterloo
Home support non-profit	May 2001	Toronto
For-profit provider	June 2002	Guelph
For-profit provider	June 2002	Guelph
For-profit provider	June 2002	Mississauga
Home support non-profit	June 2002	Cambridge
Paraprofessional provider	June 2002	Kitchener
For-profit provider	June 2002	Cambridge
Other non-profit	August 2001	Toronto
Provincial association	August 2001	Toronto
Government and government agencies	September 2001	Toronto
Provincial association	September 2001	Toronto
Home support non-profit	September 2001	Toronto
Government and government agencies	October 2001	Toronto
Government and government agencies	October 2001	Toronto
Government and government agencies	October 2001	Toronto
Government and government agencies	November 2001	Toronto
Other non-profit	November 2001	Toronto
Professional non-profit	November 2001	Toronto
Government and government agencies	November 2001	Toronto
Government and government agencies	December 2000	Toronto