Method: This study attempted to answer the following research question: "What are the factors that determine if a long-term care client will be cared for at home or in a LTC facility?" The researchers turned to community care coordinators from several provinces to answer this question. 89 community care coordinators were recruited from urban and rural settings in five Canadian provinces to participate in focus groups. Community care coordinators, or case managers, are responsible for assessing a client for home care or facility placement; they also manage and monitor home care services. Community care coordinators were chosen for this study because they are in the unique position of knowing the available resources and the characteristics of the client and the client's support system at the time care decisions were made. The coordinators were mainly nurses (74%) and most had 6 or more years of experience working in the home care sector (81%). Focus group discussions were audio taped, transcribed and analyzed using quantitative (statistical) and qualitative tools.

Findings: Consistent with previous studies, the authors found that the decisional process for determining the appropriate setting for LTC is multi-factorial. The researchers identified 6 over-arching categories of factors that case managers consider in choosing between home care and facility placement for clients. These included organizational, system, client, informal provider, formal provider and care coordinator factors. Since home care is not covered under the Canada Health Act, each province has different regulations pertaining to eligibility, access, and funding for home care services that determine the choices that are available. Interestingly, these regulations are interpreted differently across regions within provinces. System factors such as housing, transportation, access to day programs, and availability of LTC facilities influence where, how much, and by whom care will be provided. "The health status and socio-economic status of the client are client factors that case managers must also consider." Furthermore, "access to appropriate facility care also determines the location of care." Shortage of care providers, particularly nurses and home support workers, adds to the incidence of long-term care admissions.

Conclusions: Based on their findings, the authors identify several key areas for reform. Many individuals would prefer to stay in their homes but are unable to consider this option because they cannot afford the medical supplies, equipment and/or housing renovations necessary. The authors urge "national, provincial, and territorial agreement with regard to client/family funding related to home care." Furthermore, "integrated health services (primary, tertiary, long-term, and palliative) should be fostered within each region to avoid early admission to facilities and reduce pressures across the health delivery system."

Reference: Alcock D, Angus D, Diem E, Gallagher E, Medves J: Home care or long-term care facility: Factors that influence the decision. Home Health Care Services Quarterly 2002; 21(2): 35-48.

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