Methods: Based on 65 in-depth, semi-structured interviews conducted between 1999 and 2001, a qualitative case study of the Hamilton Community Care Access Centre was undertaken to understand how clients, caregivers, case managers and home care workers perceive the effects of the competitive bidding process, and the changes that arise from the awarding of new contracts, on their experiences with continuity of care. The analysis of interview transcript data focuses on how the contracting process affects organizations, relationships and individuals, and client care from the perspective of interviewees who reflected on their own and others' experiences. The study captures the experiences of clients, providers and managers following the first competitive contract processes completed in 1998 and 1999.

Findings: Dedicated staff time at the management level and several weeks of dedicated case manager time were required to manage and implement the competitive contracting model. The bidding process created instability in the homecare workforce and aggravated human resources challenges in this sector. There were also negative effects on the long-term trusting relationships between case managers and providers, and between providers and clients. Home care workers reported poorer job performance and satisfaction, and the morale of service providers declined. There were a number of actual and perceived effects on client care including lack of continuous monitoring, difficulty with specialized care provision, and potential 'dumping' of clients with complex service needs when newly contracted providers could not meet their contractual commitments.

Conclusions: This study describes many of the problems associated with the competitive contracting model. The findings suggest that it is not clear whether the benefits associated with the process will outweigh these difficulties. They also suggest there is a need to improve measurement of quality of care in order to ensure that agencies have workers with adequate skills to meet the needs of clients. Furthermore, procedures that ensure continuity of care and the accountability of the provider agencies need to be developed. Such findings are particularly relevant considering that managed competition in Ontario is currently under review.

Reference: Abelson, J, Tedford Gold, S, Woodward, C, O'Connor, D, Hutchison, B. "Managing under managed community care: the experiences of clients, providers and managers in Ontario's competitive home care sector."Health Policy, 2004, 68: 359-372.

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