The Nexus Home Care Project examines the experiences of employers, home support workers and elderly clients and their family members in the delivery and receipt of home support services. The primary purpose of this research is to identify salient issues in the delivery and receipt of home support services to elderly individuals from the perspective of employers, home support workers and clients. The data for this study, funded by the Canadian Institutes of Health Research, are derived from in-depth interviews with home support employers (n = 11), home support workers (n = 32) and elderly clients (n = 14) in British Columbia. Employers emphasized recruitment and retention and the increasing complexity of client needs, and raised questions regarding the appropriateness of home support as a part of the healthcare continuum. Home support workers stressed scheduling and time demands, the tension in providing intimate ongoing care at an emotional distance and the balance between tasks outlined in the care plan and the needs and wants of elderly clients. Elderly clients indicated an ongoing need to prepare for and manage services and expressed a need for companionship. Findings are discussed as they inform and extend our understanding of the key tensions in home support. Strategies for addressing these tensions are also identified.

Home care - the delivery of health and social services to individuals living in the community - stands at the forefront of current debates on healthcare in Canada. Home care costs have doubled over the past decade, from $1.6 to $3.4 billion (Canadian Institutes for Health Information 2007). In this same time period, the number of home care recipients has increased by 24% (Statistics Canada 2006). This study examines the key issues in the delivery and receipt of home support services to elderly individuals from the perspective of employers, home support workers and clients.

Undeniably, home care is the most rapidly expanding sector of Canada's healthcare system (Canadian Institutes for Health Information 2007; Coyte and McKeever 2001). It is estimated that one million people in Canada use home care services annually (Shapiro 2002). An 80% increase in home care expenditures is expected by 2026 (Coyte and McKeever 2001). Health human resource projections suggest that Canada will need to double the number of home care workers (currently estimated at approximately 32,000) to meet demands by the end of the decade (Hollander 2001). Each province has its own home care program, with no national standards in place (Shapiro 2002). Under provincial jurisdictions, the nature of service provision is determined more by where one lives in Canada than by need (Martin-Matthews and Phillips 2003).

Home care involves a wide variety of workers with different levels of training and qualifications. They include nurses, care managers, social workers, physiotherapists, occupational therapists and home support workers. Most home care workers are employed in home support and are often "unregulated" workers who provide non-professional services in the form of personal assistance with daily activities, such as bathing, dressing, grooming and light household tasks. They are variously known across Canada as home support workers, personal support workers, community health workers, community healthcare aides, home helpers and homemakers (Mahmood and Martin-Matthews 2008; Martin-Matthews 2007). In 2001, an estimated 32,000 home support workers provided 70-80% of the home care needs for Canadian home care recipients. This included both personal care (bathing, toileting, grooming etc.) and work related to instrumental needs (e.g., food preparation, cleaning, laundry etc.) (Home Care Sector Study Corporation 2003).

Overall population aging combined with a strong desire to "age in place" creates an increased likelihood that many seniors will use home support services. Elderly people, particularly those aged 85 years and older, are the highest users of home care (Kirby 2002). Home care can also arguably provide a cost-effective health service alternative. For example, in a study of the cost-effectiveness of long-term home care in Canada, it was found to be significantly less costly to government than care in a long-term care facility (Hollander 2001). Similarly, Chappell et al. (2004) found that even when a broader societal perspective incorporating out-of-pocket expenses and the care time of informal caregivers are factored into the analysis, home care is still more cost-effective than long-term or hospital-based care.

Despite the desire to age in place and the demonstrated cost-effectiveness of home care, in British Columbia, and throughout much of Canada, there have been substantial reductions in the provision of home support services, coinciding with a shift from a provincial system of care to regionalization (Konkin et al. 2004). In British Columbia, in 2001, a new healthcare delivery structure was established consisting of 16 health service delivery areas with five health authorities to govern, plan and coordinate services regionally (BC Ministry of Health Services 2001). At the same time, the criteria for allocation of home support services changed. For many individuals, this meant a streamlining or reduction of services.

While these shifts have had significant consequences, such as a 24% drop in individuals receiving home supports between 2000-2001 and 2004-2005 and a 12% drop in hours (Cohen et al. 2006), there have been few attempts to discern the key issues and concerns of home care employers, workers and clients and their families. In order to better understand the key issues in the delivery and receipt of home support services, the primary objective of Nexus Home Care Project is to examine the role of home support workers employed through home care agencies in the continuum of care to community-dwelling elderly persons receiving either post-acute or chronic care. Building on the approach and findings of a panel study conducted in Ontario (Martin-Matthews and Wakefield 1992), the Nexus Home Care Project examines the working relationships between home support workers and their elderly clients, family members of clients and employer agencies, focusing on three intersecting sets of issues:

1. The public and the private (the mechanisms by which home support workers negotiate the private sphere of clients' homes and families versus the public world of health service)
   
2. The professional and non-professional (the issues facing home support workers in relation to perceptions of professional and non-professional roles and relationships with employers and co-workers, as well as with elderly clients and their unpaid caregivers)
   
3. The paid and the unpaid (the negotiation of the affective versus contractual nature of the "care" relationship with elderly clients and the prevalence of the use of unpaid time to meet client needs)

The Nexus Home Care Project is a multi-phased, multi-site program of research. In the pilot phase of our research, the focus of this paper, we had three key objectives: (1) to explore the issues identified by managers and owners (employers) of home care agencies in British Columbia, (2) to determine the issues in delivery of service from the perspective of home support workers providing care to community- dwelling elderly clients and (3) to determine the salient issues for community-dwelling elderly clients currently in receipt of home support services.

Methods

Data Collection

The data for our study were generated through in-depth semi-structured interviews over an eight-month time period from November 2005 to August 2006 with home care employers, home support workers and clients. Interviews were conducted in person and, in a few cases (depending on the preference and needs of the respondent), over the telephone. Interviews were approximately one to one and a half hours long. They were taped and transcribed verbatim. The recruitment process for employers, home support workers and elderly clients varied slightly.

Recruitment of Employers

Home care employers were recruited using information available in the public domain (telephone directories under home care and through websites and pamphlets). To maximize variation in the sample, we contacted a wide variety of agencies with differences in geographical location, size, length of time in operation and distinction of being public, private or not for profit. We also contacted directors of home and community care in the five regional health authorities in British Columbia. Letters were mailed to individual agencies, and then follow-up calls were placed to determine those that were willing to participate in the study. Additional key informants were identified through names and contact information provided through this process (the snowball method of recruitment) and were selected for their perceived relevance to the project.

Recruitment of Home Support Workers

Five agencies from metropolitan Vancouver and Vancouver Island were purposively selected to enable access to home support workers for the purpose of the study. A letter was mailed to the managers or supervisors of the selected agencies asking for their assistance in recruiting home support workers. Four of the five agencies were willing to help the project recruit their employees. Notices were placed in employee mailboxes or in pay stubs and posted in the common area at each agency office. Home support workers interested in participating in the study then phoned the project manager to schedule an interview. Community health workers in Vancouver were interviewed in a meeting room at the University of British Columbia, at their home, at the library in downtown Vancouver or at a community centre close to their home. Community health workers from Vancouver Island were interviewed in a hotel conference room in Victoria.

Recruitment of Elderly Clients

Two agencies from Vancouver, one private and one not for profit, were purposively selected to access home support clients. The first agency mailed out letters to 50 elderly clients; the second agency mailed letters to five elderly clients. An advertisement was also placed in Vancouver's newspaper The Province. Posters were placed in several community centres and buildings frequented by seniors.

Sample

The study sample consisted of 11 home support employers, 32 home support workers and 14 elderly clients. The characteristics of these three study groups are presented in Tables 1-3.

Table 1. Characteristics of employers (n = 11)
Employer Type	n (%)
Health authority (employer)	1 (10.0)
Health authority (contracted agency)n	5 (45.0)
Private agency	5 (45.0)

Table 2. Characteristics of home support workers (n = 32)
Characteristics	n (%)
Gender Male Female	3 (9) 29 (91)
Marital status Married or common-law Separated or divorced Widowed Never married	16 (50) 8 (25) 1 (3) 7 (22)
	Mean (SD)
Age	48(10)
Years at current agency	7 (5)
Years as a home support worker	12 (9)

Table 3. Characteristics of elderly clients (n = 14)
Characteristics	n (%)
Gender Male Female	4 (29) 10 (71)
Marital status Married or common-law Separated or divorced Widowed Never married	4 (29) 1 (7) 9 (64) 0 (0)

Analysis

Face-to-face interviews were digitally recorded, transcribed and analyzed using the qualitative software database NVivo 7. The research team used a constant comparative method of analysis. Three members of the team independently analyzed the completed interviews and identified broad themes and concepts through repeat readings of the transcripts. These themes and concepts were coded in the software. After all the data were collected, uploaded and coded for major themes, the research team re-visited the transcripts. Four meetings over a one-month period took place in which team members independently read and then discussed four or five transcripts. Revisions were made to the coding structure and new sub-themes were identified, while others were confirmed and or renamed and rearranged (placed into different coding categories).

Results

Employers

Employers identified four key issues with respect to the delivery of home support services: recruitment and retention, the increasing complexity of client needs, an acknowledgment of the needs and desires of clients and the appropriateness of home support as a part of the healthcare continuum.

All the employers in our study discussed recruitment and retention. One employer of approximately 300 home support workers remarked that "recruitment and retention are our major issues." Similarly, two large employers of home support workers, called community health workers (CHWs) in British Columbia, stated:

"Worker shortages is our number one issue. We have one person solely dedicated to hiring. It is a long process and we are competing with facility jobs."

"The colleges are not meeting the demand for CHWs. CHWs are choosing to work in residential care facilities with regular rotations. CHWs are choosing to move to assisted living with regular rotations."

These comments also reflect the sentiments of a number of employers who indicated that the unpredictable hours make recruitment and retention difficult, with trained workers often preferring facility jobs. Echoing this, another employer acknowledged some of these issues related to recruitment and retention stating, "Recruitment and retention are difficult issues; the wages are low, the hours often unpredictable." Similarly, other employers stated, "Recruitment is an issue because of the scheduling," and, "CHWs work within windows of time."

While employers acknowledged that the unpredictability and relatively low remuneration for work are key factors influencing recruitment and retention, they also acknowledged that there are intrinsic benefits. An understanding these intrinsic benefits could contribute to recruitment and retention strategies: "What I really want to know is why some workers stay in the field. There are some that have been working in this job for 25 years - why? They are good people; they could get another job. To me, this is interesting."

Employers also indicated that increasing complexity of clients' needs was an issue in delivering home support services. One employer stated, "We need to come up with new ways to monitor people's needs. Clients have increasing acuity and are more medically complex than ever before." Similarly, other employers stated, "We are an emergency system where once we were not," and, "The community has become medicalized." It was also noted that hospital discharges to the community are becoming faster, and agencies sometimes only get an hour's notice: "Hospital discharges are requiring a quicker response."

Another issue for employers was the recognition of the tension between clients' needs and assigned tasks. Several employers noted the necessity of being flexible to client needs and preferences. One employer said, "We need to be flexible and provide a wide range of care. We need a system that can provide for true needs not just tasks. How can we create a different model?" Two other employers alluded to this tension and described strategies and solutions to ameliorate some of the tension. One stated, "Most clients prefer services in the morning. We are establishing guidelines to determine who should receive service in the morning and those who can get it in the middle of the day." The other noted, "The care that we provide is not client focused; continuity of care is an issue. The ideal would be if a client might have a pool of 10 or 15 workers that might come. Right now they see whomever."

The final issue raised by many of the employers, in particular those in the public system, was the question of the margins or limits of what constitutes healthcare. A number of employers questioned whether some tasks, such as light cleaning and meal preparation, should be included as healthcare. One employer stated, "Home support should not be a part of the health authority." Another echoed this comment with the following query, "Do cutbacks in the 'hospitality services' in fact cause problems for people? We need to ask, What is the role of the public system in hospitality/health maintenance versus the role of the individual? I don't think home support should be a part of the healthcare system."

Home Support Workers

From the perspective of home support workers, there were a number of key issues with respect to delivery of home support services to elderly clients. These included scheduling and time demands, the tension in providing intimate ongoing care at an emotional distance and the balance between tasks outlined in the care plan and the needs and wants of elderly clients.

Scheduling and time demands were among the biggest issues for home support workers. One 10-year veteran of home support stated, "Well, I guess that all of that is part of the problem with our job. It isn't that workers aren't getting hours, that there are huge gaps between. What other job are you expected to be available for 50 hours a week but only be guaranteed 20 or 15? Those who have a 15 to 20 posting are still expected to have 10-hour windows for every day and five days. You know ... that's a huge issue."

Another home support worker described the time crunch by stating, "I've only got 15 minutes here, and I've got to be in town by this time - the client doesn't care about that. She's not going anywhere; he's not going anywhere. Your time is their time. You come in and tell them how much time you've got to spend on them, that means that they're only that - they're only worth that much. 'My, she was in a hurry, weren't she?'"

Another key issue for workers was a tension between agency policies and guidelines and the personal nature of their work. Workers described the difficulty of being close at distance. One worker described this tension by stating, "We're not really supposed to be involving ourselves emotionally with the client. And I always kind of debate that because I think that to be a good healthcare worker, you do have to do that. I personally believe you have to be able to control your emotions and your own personal beliefs. But you do have to be involved in order to care; if you care, you'll be a better caregiver." Another expressed, "They say don't get personally involved with your clients. Well, I'm sorry but they're human beings, and if you're with people a year, two years, three years, four years, it's impossible not to get involved. I mean, you have to know your personal boundaries and keep your personal space, but, at the same time, you can't treat them like strangers when you see them three or four times a week, week in week out."

Key Points

Home care - the delivery of health and social services to individuals living in the community - stands at the forefront of current debates on healthcare in Canada. Home care costs have doubled over the past decade, from $1.6 to $3.4 billion. Despite the desire to age in place and the demonstrated cost-effectiveness of home care, in British Columbia and throughout much of Canada, there have been substantial reductions in the provision of home support services. There have been few attempts to discern the primary issues and concerns of home care employers, workers and clients and their families during this process of regionalization. Key concerns for home care employers included recruitment and retention, the increasing complexity of clients' needs, the tension between clients' needs and assigned tasks and the appropriateness of home support as a part of the healthcare continuum. Primary concerns for home support workers included scheduling and time demands, the tension in providing intimate ongoing care at an emotional distance and the balance between tasks outlined in the care plan and the needs and wants of elderly clients. For elderly clients, principle concerns included an ongoing need to prepare for and manage services and the need for companionship. Ultimately, the delivery and receipt of service are all about the quality of human interaction - whether one owns and operates an agency, works for a health authority, is a home support worker or is an elderly client.

Another issue for home support workers was the tension between client needs and assigned tasks. Many of the workers in our study indicated that there is often a disjuncture between what is assigned in the care plan and the needs and desires of their elderly clients. Several workers expressed this tension by stating,

"I explain to them, 'Look there are a lot of things that I can do for you, but this is one of the things that I'm not allowed to do. And if I were to hurt myself, I wouldn't be able to work. I wouldn't be able to pay my rent. So I really can't do that for you.' And if they're insistent, I just say, 'Well I'm sorry. Why don't you let me dial my office and you can speak with my supervisor.' Yeah, if you can't explain it to their satisfaction, then ... it's your responsibility to phone the office and have your supervisor explain to them."

"'Why can't you iron? I'm sure you can iron.' Well yes, I do know how to iron, but no, I'm not allowed to iron. That's really frustrating for them, you know, you can't get up on a stool to get something off the top shelf. Sometimes I'm not allowed to dust, those sorts of things. You know, that's hard for them to do. Clean behind the fridge. [laughs] It's like, 'No, sorry.' So, I'm quite limited in what I can, what I'm allowed to, do."

"I get frustrated with the system. I really do. I get really frustrated with the system. You see people who need the care who don't get it."

Elderly Clients

For elderly clients there were two key issues with respect to receipt of home support services: an ongoing need to prepare for and manage service and a desire and need for companionship.

Elderly clients are active agents in receipt of care, as expressed in their accounts of home support. The majority of clients described the need to manage service as being a key issue in the delivery and receipt of home support. Elderly clients describe this as ranging from uncertainty about who is coming to provide service (rotating workers) to having to provide ongoing orientation to new workers. One client stated, "We're not very happy with it right now because of the uncertainty of the help situation. ... We can't depend on the same girls all the time." Another noted, "Well she's new to the house - you got to take it. Let them come three times and then they can regularize themselves with the routine. But if you expect them to come in and be able to do everything the first day, then that won't work."

In addition, many clients identified the uncertainty of scheduling as being an issue. One client stated, "The whole business of adjusting my schedule to hers. She has to tell me when she's going to bring me my breakfast, so I sleep in till then. Some people tell me they're going to bring my breakfast at 7-7:30, so then I put the alarm on. So, you have to sort of roll with the punches."

For elderly clients, these key issues in home support were accentuated and in some ways contradicted by a desire and need for companionship. While elderly clients felt frustrated by the lack of certainty around workers and schedules, many elderly clients stressed the companionate aspects of home support as being essential to their well-being. For example, one client stated, "I like them. I look forward to them. I think they're great. But I think it's more just having someone in the house for those couple of hours, you know, 'cause I spend so much time by myself not being able to get out." A second client expressed, "Well they got me up. I would probably still be in bed. We always go for breakfast ... We've become friends."

Discussion and Conclusions

Using the perspectives of employers, home support workers and elderly clients, our study provides insight into the key issues in the delivery and receipt of home support services. The delivery of home support is a dynamic process. Employers, home support workers and elderly clients all identify issues that influence the delivery and receipt of service, including recruitment and retention of workers, scheduling and time demands, the tension between assigned tasks and clients' needs and desires and the conflict between frustration with service and the basic need for contact and companionship. Although there are some differences in the key issues identified by employers, workers and clients, there are several common threads.

First, employers, workers and elderly clients all experience frustration with the home support system from their particular vantage point. For example, while scheduling is a common issue for all three groups, the experience and impact vary for each. Employers emphasize the pragmatic aspect of creating schedules to service clients taking into account staffing ratios and so on. Home support workers stress the changing nature of their schedules and the impact on their work life and work-family balance. Elderly clients express frustration from not knowing when exactly workers will arrive and how long they will stay at a given visit. Seldom in our study did the different groups (employers, workers and clients) acknowledge that their concerns could also be issues for employers, workers or clients. It follows that solutions to address this issue must be targeted at multiple system levels with input from all stakeholders. A commitment to communication and shared understanding is a key component of this process.

Second, employers, workers and elderly clients are actively engaged in identifying issues and problem solving. In many of our interviews, employers, workers and clients identified responses and strategies to address their concerns. This demonstrates that while there are issues, there are also solutions. A possible strategy to make overall system improvements is to adopt an approach of "lead by example." That is, look at employers, workers and clients as holding the key to improvements. Hollander and Prince (2008) also demonstrate this idea in their work on continuing/community care. We argue that the key to an effective system of delivery is to first understand what is working within a system and then to examine the appropriateness or adaptability of individualized strategies.

Finally, it was clear throughout our study that relationships are the key thread within and among employers, workers and clients. Relationships are crucial in developing an understanding and appreciation of the system from multiple vantage points. They are also instrumental in making the system work. At the end of the day, the delivery and receipt of service are all about the quality of the human interaction - whether one owns and operates an agency, works for a health authority, is a home support worker or is an elderly client.

Next Steps

To further our understanding of the issues and dynamics in the delivery and receipt of service, the Nexus Home Care research is currently completing 150 interviews with home support workers, 75 with clients and 75 with family members as well as pilot studies with home support workers in Nova Scotia and Ontario.

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