This paper discusses notions pertaining to the home as a site of care in a climate of extensive cost cutting measures to community provided health care. It draws on data from a multi-disciplinary investigation of various dimensions of the home as a site of long-term care and examines processes through which the home is reconstructed as a care-giving space. It argues that with home care comes added need for caregivers to provide extra services (above and beyond those that would be required with hospital care) to ensure that care provided in the home respects and maintains the client's autonomy and independence. These extra services and perceived responsibilities are often not considered by policy makers when considering the uniqueness of transferring long-term care to the home environment. For, with the transfer of services from the hospital to the home comes additional responsibilities that may not be recognized in resource allocation decisions.

Background: In Canada, there have been extensive cost-cutting measures in community provided care. This has been felt "on the ground" in the form of reduced services, stricter limitations on what care is provided, and more tightly controlled access to service resources. The questions remain: How well are people being cared for in community sites such as the home? How is " home care" conceptualized and constituted? Is the possibility for caregivers to provide "caring" that goes beyond the immediate material care of the body, such as emotional nurturing and help with tasks ensuring one's autonomy in society, being comprised due to fiscal decisions? Currently we know little about the experiences of those receiving and those providing home care. This paper examines these relationships, focusing on issues such as how the blurring of "private" and "public" space is accommodated as the home is reconstructed as a space for care giving and care consumption.

Methods: This paper traces selected literature on bodies and homes that are pertinent to thinking through conceptual issues pertinent to analyzing the constitution of the home as a site for long-term care. The authors refer to case material from the "Hitting Home Project," a team research project conduced in Toronto, Ontario, which involved interviewing care recipients and caregivers. The analysis focuses on the unique factors associated with home care compared to hospital care, focusing on the complexities of seeing the home as a site of health care, the difficulties some home care recipients face with maintaining the "private-ness" of their home, and the difficulties some caregivers face as they attempt to provide "extra" services that are inherent with home care but not hospital care, with fewer and declining resources.

Findings: When the home becomes the care site for those whose health is compromised, it also becomes more public as it becomes the workspace for the caregiver. Entry of care services into the home challenges the "private-ness" of the home and the identities of those in the homes. This study found that the ability of the patient to have control over the home environment is a critical dimension of the constitution of home space as "caring space" that is safe for physically, mentally and socially vulnerable individuals. Oftentimes lacking private resources to hire help, home care recipients may rely on the "extras" that a caregiver provides to maintain a space that feels like a home instead of a care area where they are entrapped. The authors suggest that the uniqueness of home care is not presently recognized in health and social care policy.

Conclusions: Cost cutting measures on the part of the governments, which particularly hit home care services exacerbate the complexities inherent in the delivery of home care services. Ethical care in the home not only involves attention to the care recipients but also to the caregivers and the conditions under which they work. The capacity to accommodate the flexible care arrangements that are crucial to the ability of caregivers to provide client-centered, socially sensitive home care may be compromised when cost-cutting measures are implemented. That the home is not a typical space for the provision of health care (e.g., compared to hospitals, physician offices, nursing homes), and that conditions vary widely must be considered in formulating home care policies and resource allocation decisions. The study argues that the experiences and needs of caregivers must be considered in health and social care policy, and further argues that policies addressing home care must maintain a flexibility to enable caregivers to cater to the unique conditions they face.

Reference: Dyck I, Kontos P, Angus J, McKeever P. "The Home as a Site for Long-Term Care: Meanings and Management of Bodies and Spaces." Health and Place, 2005; 11: 173-185.

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