This commentary by Victorian Order of Nurses Canada, written in response to "Getting What We Pay For? The Value-for-Money Challenge," by McGrail, Zierler and Ip, answers four key questions about Canada's home and community care sector: (1) What are our objectives? (2) Where do we achieve good value now? (3) Where and why are we failing? and (4) What will help us do better? We conclude that although the home and community care sector offers great promise in meeting the evolving health and social needs of Canadians, it is not living up to its potential. We propose the development of a national, integrated approach to home and community care to help Canadians remain healthy and independent in their homes. This would represent a wise financial investment for governments and would contribute to the long-term health of Canadians.

Despite the infusion of billions of dollars and other resources, the Canadian healthcare system continues to face significant challenges. Its numerous blemishes notwithstanding, most Canadians remain committed to our universal healthcare system. But how long can we expect Canadians to accept what is offered unquestioningly? Consumer expectations are rising. Canadians want timely, integrated, comprehensive care. Many want to play an active role in their health and well-being and to be a valued member of the healthcare team. And they want to remain independent and active in their homes and communities for as long as possible.

Access to care and services is partially dependent on who you are, where you live and what you can afford. This is especially true for home and community care. For the most part, home and community care is fragmented, inadequate and inaccessible to many. The bulk of healthcare funding continues to be spent on hospitals, drugs and physicians, with too little being devoted to care and supports in communities. This pattern continues despite mounting evidence supporting the value of integrated, targeted and managed home and community care (Williams et al. 2009) and the preference of Canadians to live, heal, age and die in their homes. The primary question posed in the paper by McGrail, Zierler and Ip is therefore a very good one: are Canadians really getting value for money for healthcare?

Following the authors' lead, we have chosen to ask ourselves four questions in relation to home and community care. In this commentary, we offer our own perspective on what Canadians want from their healthcare system. We explore where we are getting good value now, challenges with our current approach and, of course, the opportunities for moving forward.

Question 1: What Are Our Objectives for the Healthcare System?

Mary's day starts like any other. As she rolls over in bed, she sees Joe beginning to stir. She wonders, "Will this be a good day or bad day?" Since Joe was diagnosed with Alzheimer's disease eight years ago, every morning has begun like this one for Mary. This disease has stripped not only Joe, but Mary as well, of the life they once knew. Like many Canadians, Mary assumed that the healthcare system would be there when she needed it, providing appropriate care and supports to help her and her family. She didn't anticipate the amount of responsibility she would need to assume for Joe's care – keeping him healthy, safe and socially engaged soon became a full-time job.

Today, it is generally understood that health includes mental, social and emotional well-being, as well as simply "the absence of disease." Although in theory healthcare leaders and decision-makers have adopted this broader approach, in practice we continue to invest much more heavily in "fixing" physical ailments than addressing the other, equally important aspects of health. As a result, our health system is narrowly defined and our investments are not creating the kind of system that Canadians want and need.

We can all agree that our healthcare system should help all Canadians to live the healthiest lives possible. What is more contentious is how to achieve this objective. How do we ensure we have a system that responds to all Canadians? How do we maximize the health and quality of life of Canadians, rather than focusing on treating their illnesses?

People require different supports at different times in their lives. Particularly in home and community care, one size does not fit all. A 15-year-old boy who breaks his leg playing basketball may require a cast, radiographs, physiotherapy and short-term home care. Mary and Joe require something quite different: ongoing access to clinical, personal and home supports. They need adult day programs, help with housekeeping and bathing, in-home respite care and possibly financial support and transportation to help them lead a "healthy" life. Yet, in many areas of the country, access to such supports is limited or simply unavailable.

If the objective of our healthcare system is to allow all Canadians to lead the healthiest, lives possible, then, from our perspective, many Canadians are being let down. Canada's commitment to the home care sector ranks poorly internationally (Organisation for Economic Cooperation and Development 2005). If governments in Canada are serious about helping Canadians "age at home," significant new investment in the home and community care sector is required.

Question 2: Where Do We Achieve Good Value Now?

At first, Mary felt up to the task of managing her own work and taking care of Joe's evolving needs. But as his symptoms worsened, she was forced to quit her job to care for him full-time. As the stress of caring for Joe increased, a sense of helplessness overcame Mary. Unsure of what to do, she turned to local community organizations (such as Victorian Order of Nurses [VON]), her church and friends and family for help. Joe has now joined an Alzheimer day program, where he participates in social and recreational activities tailored specifically for people with this disease. This gives both Joe and Mary a chance to recharge their batteries – at least for a few hours a week.

Three areas where we achieve good value related to home and community care are the provision of long-term home and personal supports, the contributions of unpaid family and friend caregivers and the work carried out by volunteers – with the last two areas of value falling outside of the formal healthcare system.

1. Evidence shows that helping people with daily tasks, such as housekeeping, is a cost-effective way to help people remain independent in their homes, thereby reducing reliance on institutional care. A study conducted by Marcus Hollander (2001), a leading Canadian researcher in this area, found that providing long-term home supports can prevent or reduce the rate of admissions to hospitals and residential care. Results showed that after three years, people whose home support services were cut ended up costing the healthcare system more than those who retained their services. The higher costs were related to a greater need for acute care and residential care after services were terminated. Therefore, providing home and personal supports to people with ongoing care needs provides Canadians good value for money.
2. Family and friend caregivers deliver the vast majority of care for people with ongoing needs living at home – more than 80%. Almost a quarter of Canadians report having cared for a family member or friend with a serious health problem (Pollara 2007). The support provided by caregivers ranges from a few hours a week to around-the-clock care. Caregivers play a vital role in the health and well-being of hundreds of thousands of Canadians – many of whom are seniors. Unpaid caregiving helps contain the costs of healthcare and other social services. In terms of elder care, it is estimated that caregivers provide roughly $25 billion of unpaid care annually to the healthcare system (Hollander et al. 2009). All the care and support provided by caregivers is done with relatively little support and recognition from the formal healthcare system.
3. Volunteers also deliver a tremendous benefit to the system and demonstrate incredible value (Petch and Shamian 2008). They provide support to home care staff, clients and their caregivers. In partnership with community organizations, they deliver a number of services and supports to people in their homes and strengthen the capacity of the formal home and community care sector. Programs such as Meals on Wheels and volunteer visiting are often available only because of a dedicated volunteer base.

Clearly, the healthcare system benefits from the work of caregivers and volunteers. However, relying too heavily on unpaid providers to support people in their homes and communities is an unsustainable strategy, unless policies are implemented that better distribute the responsibility of care (Shamian 2007).

Question 3: Where and Why Are We Failing?

Although a good start, the supports available to Joe and Mary do not fully meet their needs. For example, chores that Joe used to do – like mowing the lawn or paying the bills – have been assumed by Mary. Mary is now responsible for running the entire household, caring for her husband, organizing her husband's healthcare – the list goes on and on. Lately, Mary has very little time for herself. As a result, her health is starting to fail and she is increasingly feeling overwhelmed. Sensing the stress, Joe's case worker offers Mary the option of placing Joe in a long-term care facility, but neither Mary nor Joe wants that. They just need a little more help at home with day-to-day activities. Unfortunately, the additional help they need is not available.

Mary can't understand why government will pay for Joe to live in a long-term care home but not for more services to help him remain at home with his family, where he wants to be. Other countries, such as Germany, have flexible long-term care systems that allow their citizens to choose where they would like to age. However, for Mary and Joe, their options are limited.

Although the needs and the benefits are clear, Canadian governments have been slow to maximize the potential of home and community care. There are three fundamental flaws with our current approach to this sector:

1. Acute and post-acute medical needs are given priority over ongoing personal "non-medical" needs, such as housekeeping and meal preparation.
2. Home and community care and services are excessively rationed, leaving many ineligible for care and services. Clients who receive care often see their services discontinued before their needs have been adequately addressed.
3. Access to care and services across Canada is inequitable. There is no overarching national strategy to ensure all Canadians have access to comprehensive care and supports in the home.

Our limited approach to home and community care holds consequences for clients, their caregivers and the system as a whole:

• Clients: Inadequate access to care and supports in homes and communities means that people are left to fend for themselves or to rely on family and friend caregivers and community organizations. Some are left with no other option but to prematurely enter long-term care facilities or nursing homes, even though they may not require this level of care.
• Caregivers: By failing to comprehensively address Canadians' health needs, governments have simply transferred the costs and responsibilities of care outside the formal system onto the shoulders of individual Canadians. This added responsibility comes with too few resources and little recognition of their efforts.
• System: When Canadians do not receive the care they need to stay at home, they turn to institutions – frequently emergency rooms – for essential services. This misuse of the system can be more costly in the long run. For example, the growing number of pricey alternative-level-of-care beds is partially a result of the lack of capacity in the home and community care sector.

Question 4: What Will Help Us Do Better?

As time goes by, Joe's needs become more complex and the demands on Mary are more difficult to cope with. Mary feels she herself will wind up in hospital if something doesn't change. She resigns herself to placing her husband in a care facility. When Mary contacts Joe's case worker to start this process, she learns that her province has implemented a new home and community care strategy. Not only will the changes in the system ensure that Joe and Mary receive better support for their health and social needs, but it will be easier to navigate the system and access all the services they require. Because of this new funding, Joe now receives more care from others in his home, and Mary has been able to regain her own health and return to work part-time.

A robust and accessible home and community care system that is integral to our publicly funded healthcare system would help Canadians age at home and keep people well and out of emergency rooms, hospital beds and long-term care institutions. At VON Canada, we believe this can best be achieved through a national, integrated approach to home and community care. (VON Canada is the country's largest not-for-profit organization, delivering innovative, comprehensive home and community care to Canadians for more than 110 years and influencing the development of healthy public policy.)

VON Canada believes that the federal and provincial and territorial governments must work together to build a comprehensive, integrated and accessible home and community care system for all. As a starting point to help move this vital issue forward, VON Canada has identified the following three key areas that require immediate attention by governments and other concerned parties: (1) investigate, fund and develop integrated models of health and social care, (2) invest in technology for the home for use by providers, clients and their caregivers, and (3) recognize family and friend caregivers as part of the healthcare team and provide access to services, training and information to support them in their role. Taking decisive action in these areas will get Canada moving in the right direction. VON Canada outlines further recommendations in our 2008 Vision document Health Starts at Home.

While taking action across these three areas is necessary, VON Canada reminds governments of the importance of continual investment in all the social determinants of health. The formal healthcare system is only one of many determinants of health. Research indicates that only 25% of the population's health is a result of the "reparative work" of the healthcare system, while the other 75% is attributable to the social determinants of health (Standing Senate Committee on Social Affairs, Science and Technology 2002). All healthcare sectors have an obligation to advocate for governments to adopt a broad approach to health if we truly want to achieve health equity for all (World Health Organization 2008).

Conclusion

Although our story about Mary and Joe has a happy ending, for too many Canadians, this is not the case. People in their situation continue to get by with little or no support and, at times, are forced to seek institutional care far sooner than they want to, or is necessary. In the worst-case scenario, the system's lack of flexibility creates two patients instead of just one.

The number of Canadians who require home and community care is growing every day, and it is our collective responsibility to ensure that the proper supports and systems are in place to meet their needs. We have the demand (home care is the fastest-growing sector in health) and we have the means (Canada is one of the richest countries in the world); what we need is the leadership to take us to the next level. The health and quality of life of Canadians depend on it.

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