Healthcare Quarterly

Healthcare Quarterly 11(4) September 2008 : 77-78.doi:10.12927/hcq.2008.20075
Longwoods Review

One Eye Down and the Other Looking Ahead: Moving On in Home Support and Community Care

Shirlee Sharkey and Nancy Lefebre


The research paper "Employers, Home Support Workers and Elderly Clients Reveal Key Issues in Delivery and Receipt of Home Support" provides an excellent summary of challenges affecting home care today. As proponents of knowledge exchange and evidence-based decision-making, it is encouraging to see home care being evaluated. From recruitment and retention to scheduling to responsiveness to client needs, the findings of the Nexus Home Care Project are both consistent with and relevant to our experience at Saint Elizabeth Health Care, the largest provider of home and community-based healthcare in Ontario.
The themes identified in the study are regrettably not new - our sector has been dealing with them for years now, and most people would agree there are no simple solutions. We believe this fact should inform but not dissuade us in how we move forward.

In their discussion and conclusion, the authors state that "at the end of the day, the delivery and receipt of service are all about the quality of human interaction." It is from this point we would like to begin. Through all our years in home care, we have learned that the beginning point from which you look at things is critical. In other words, "what you see depends mainly on what you look for" (Sir John Lubbock).

While home care is one of the fastest-growing segments of the Canadian healthcare system, our efforts to collectively understand and unleash the potential of this dynamic and evolving sector are often limited by our definition and perspective. The creeping medicalization of home care through the reduction of home support services is but one example of this.

There seems to be both a temptation and a tendency in home care to apply the same provider/location-based lens that is common in other areas of the system. Yet, as far as healthcare settings go, the home is anything but typical. In comparison to public healthcare facilities such as hospitals, clinics and long-term care, home environments are multifaceted and diverse, with many variables that are difficult to control. As providers, we are "guests in the home," which creates a different relationship and the need for an approach to care that begins with the clients' and families' wishes and desires.

Indeed, the need to balance the private sphere of peoples' homes with the public work of healthcare impacts everything we do as a home care organization, from safety to quality to staff education and support. We believe this tension represents an incredible challenge and opportunity for home care: not only to involve clients and families in decision-making but to start the entire conversation from their vantage point- looking specifically at their needs, values and expectations, location and points of access.

Self-managed care models seek to provide individuals with greater freedom and control in planning and directing their own care and making their own choices (Spalding et al. 2006). While such models are offered in most jurisdictions across Canada, we still encounter a discomfort at all levels with giving clients and families "too much control," especially on large-scale issues such as how, when and where they experience our public healthcare system.

Home Support: High Five from Saint Elizabeth Health Care
The following are key ingredients for enabling amazing care and amazing talent within home and community support services:
  1. Inter-professional practice that facilitates role optimization through integration and collaboration so that all healthcare talent is practising at its full capacity
  2. Preceptorship programs that assist personal and home support workers in understanding and establishing therapeutic relationships
  3. Continuous learning and support - essential to survive and thrive in a fast-paced, ever-changing environment
  4. The right tools and technology to enable seamless communication and collaboration among a virtual workforce (e.g., equipping support workers with BlackBerries to tackle scheduling issues)
  5. Your terms, your territory … home care can be this good, when it's all about people

Based on past patterns, it is clear that small incremental changes have not been particularly effective at addressing or alleviating the core challenges facing our sector. Therefore, we argue the need for an approach with two prongs - one that focuses on interventions to address the real and growing issues of today and one that focuses on new approaches to realize the solutions of tomorrow. Another way to describe this is to keep one eye down and the other looking ahead.

Truly moving on in home support and community care will require us to define and embrace new planning, delivery and evaluation models that are based on a profound and shared understanding of the following factors:

  • Our social responsibility and response to an aging population
  • Consumer values and behaviour - who we are and how we live
  • The unique features and emerging opportunities of the home environment
  • The need for customization - how, when and why
  • The key barriers and levers for change
According to economic theory, if you change one critical component, there is a domino effect on future outcomes. The authors hit the nail on the head in noting that the delivery and receipt of home support are all about human interaction. We believe there needs to be a great deal more exploration and emphasis in this area from a research and planning point of view. Collectively as Canadians we bring a great deal of wisdom, experience and creativity to this challenge.

With a new process and starting point, people themselves will lead us to a whole different approach to healthcare - one that is designed to enable and realize the full potential of talent, of clients and families and of health and care at home.

About the Author(s)

Shirlee Sharkey, BScN, BA, MHSc, CHE, is president and chief executive officer of Saint Elizabeth Health Care, Markham, Ontario.

Nancy Lefebre, RN, MScN, FCCHSE, is senior vice-president and chief clinical executive of Saint Elizabeth Health Care.

Together, they have more than 40 years of experience in home and community care, ranging from front-line nursing practice to executive leadership positions. You can contact Ms. Sharkey at 905-940-9655, ext. 6383, or by e-mail at


Lubbock, J. "John Lubbock Quotes". Quotations. 2006. ThinkExist. Retrieved July 30, 2008 < _depends_mainly_on_what_we_look_for/219231.html >.

Spalding, K., J.R. Watkins and A.P. Williams. 2006. Self Managed Care Programs in Canada: A Report to Health Canada. Ottawa: Home and Continuing Care Unit of the Health Care Policy Directorate, Health Canada. Retrieved July 29, 2008. < hpb-dgps/pdf/pubs/2006-self-auto/2006-self-auto-eng.pdf >.


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