How to care for Canada’s aging population in light of rising institutional care costs, persistent shortages of health human resources and the unsustainability of the current health care paradigm is a key public policy issue that is only going to become more pressing over the next decade. With the first of the baby-boom generation having turned 65 in 2011, deciding how to adapt the health care system and adjust the policies that govern it to meet the changing needs of the population are timely issues for Canadian policy-makers.

Canada is experiencing a demographic shift, with both the number and proportion of Canadians reaching age 65 set to increase over the next two decades. In response, concerns have been raised about the financial sustainability of Canada’s publicly funded health care system. While the escalation in health care costs is not in dispute, population aging contributes relatively modestly to rising public-sector health care spending. In their paper ”œAn Evidence-Based Policy Prescription for an Aging Population” (partly based on a 2011 IRPP study by Neena Chappell), Neena Chappell and Marcus Hollander suggest that it is not shifting demographics but factors such as increased medical interventions, the use of costly new technologies and increases in overall service utilization that will be the main cost drivers of the health care system over the next 10 years.

Persistent and costly problems such as the increasing number of elderly ”œbed blockers” stuck in alternative level of care (ALC) beds and the increasing frequency of seniors  seeking care for chronic conditions through emergency rooms (ERs) make it essential for policy-makers to consider how the health care system should be adapted over the next decade to ensure that appropriate care can be provided to those in need.

The existing health care system is focused on one-time, episodic conditions by providing short-term interventions in a hospital setting or by a physician. However, this type of system is not adequate to meet the complex needs of seniors, nor is it cost effective for this population. Instead, gerontological research suggests that a comprehensive continuing care system would be most appropriate for an ag- ing population because seniors tend to require many types of care, at varying times, from different providers, in a va- riety of settings along the health care continuum. To ensure that the needs of seniors over the next decade will be met by the right programs and services at the right time, we will need to un- dergo a paradigm shift from a system that prioritizes episodic, short-term in- terventions to one that supports long- term, comprehensive care.

With 93 percent of seniors in Can- ada living in private households, home and community care are the most in- demand types of LTC, especially for elderly women. Home care utilization rates among women are more than 20 percent higher than those for men, stemming from the fact that women tend to both marry older men and live longer than men. Women are also more likely than men to have their care needs unmet. In addition, women have historically been responsible for the care work in private households. This trend persists in today’s home and con- tinuing care sector, with women mak- ing up the majority of paid and unpaid care providers. Care work continues to be devalued in Canada through a lack of respect and recognition, poor working conditions and inadequate remuneration, making home and com- munity care a gendered issue.

Home care is typically provid- ed to persons who require medical care, as well as personal care and/or homemaking help. Conversely, com- munity care refers to the provision of social care services to persons who do not need support for specific medical issues. While differences in baskets of services, funding, eligibility require- ments and delivery mechanisms may be the norm across Canada, it is clear that these types of care involve more than simply moving services that used to be provided in hospitals and doctors’ offices into people’s homes.

Home and community care exists at the interface between health and social care. The inextricable link be- tween these types of care, when pro- vided in the context of a private home, continues to present a challenge for policy-makers because of the tendency to dichotomize care into siloes " ”œhealth care” versus ”œsocial care.” This way of thinking has long been institu- tionalized in Canadian policy-making, with health and social care typically being the jurisdiction of different gov- ernment ministries, offered by differ- ent care providers, funded by different sources and governed by different legis- lation. For example, while transporta- tion is not traditionally considered a ”œhealth” care service and is not under the jurisdiction of health ministries, legislation or providers, for a senior liv- ing alone the inability to access trans- portation can lead to poor nutrition, poor medication management, a fail- ure to attend medical visits, premature functional decline and preventable ill- ness, all of which can result in hospital- ization or institutionalization.

International and Canadian re- search has shown that investing in home and community care helps maintain the health, well-being and autonomy of seniors and their carers and also moderates demand for sen- iors’ care in more costly areas of the health care system (e.g., ER, ALC or residential LTC). Yet the home and community care sector in Canada remains very much in need of additional strategic investment from gov- ernments " in increased funding and policy and program development.

A key lesson from Paul Williams and Janet Lum’s balance of care re- search in their article ”œChicken Little? Why the Healthcare Sky Does Not Have to Fall,” is that the presence of home and community care services at the local level is a necessary but insufficient condition for aging at home. Mechanisms for ac- cessing, coordinating and man- aging multiple services and providers are equally import- ant, particularly for seniors. To address this, some jurisdictions have introduced integrated care programs into the home and community care sector. In this context, integrated care can be under- stood as the process of connecting and aligning health and social care services and assisting the teamwork of paid and unpaid care providers into a coordinated continuum of care for seniors to maintain their health and autonomy while living in their home. While much of the high-profile work on integrated care to date has oc- curred at the systems level and has revolved around improving the acute care system and better integrating care subsystems along the continuum of care, many jurisdictions, both in Canada and abroad, have been experi- menting with pilot projects intended to better integrate care for seniors at the individual level. A preliminary as- sessment of integrated care programs in Ontario and Alberta has indicated that, when introduced in the home and community care sector, these pro- grams may have the potential to ad- dress some of the universal challenges of delivering health and social care to seniors in a coordinated way.

In the current political climate of fiscal constraint and public sector down-sizing, ALC reductions have been the primary focus of policy-makers who are looking to apply cost-saving measures to the health care system. However, when policy-makers treat home care as a money-saving substitute for hospital or residential LTC, they tend to ignore its potential to achieve cost savings by moderating the demand for more cost- ly services in the first place. Although it is legitimate to use home care to relieve ALC or ER pressures, given that these are two of the least cost-effective places for seniors to get caught in the system, when publicly funded home care ser- vices are disproportionately allocated to people discharged from hospitals, it reduces the support available to those with chronic conditions who need pre- ventative care in order to avoid institu- tionalization or acute care admission. While the ALC reduction and acute care substitution functions of home care are important, using home and community care for the purposes of LTC substitution and preventing insti- tutionalization are also worthy endeav- ours that are often undervalued in gov- ernment policy and funding decisions.

The Seniors Managing Independent Living Easily (SMILE) program, operated out of the South East Local Health Inte- gration Network in Ontario and admin- istered by the Victorian Order of Nurses, seems to be a good example of an inte- grated care program that aims to priori- tize health promotion, disease preven- tion and LTC substitution. The SMILE program began in 2008 with the mis- sion of empowering seniors by giving them access to home support services thatwereindividualizedtotheirspecific needs. With funding from the Ontario government’s Aging at Home Strategy, enrolled seniors are permitted to choose the health and social care services they feel they need in order to age in their homes in safety, health and comfort. There is a long list of seniors waiting to access SMILE; however, those who are able to join the program enjoy benefits such as a return of the responsibility for financing lower-level needs from the individual back to the state, and access to preventative monitoring by staff in order to anticipate future risks and care needs and to respond accordingly.

Another challenge encountered in home care delivery is the ability to coordinate the many professionals, paraprofessionals and other carers who provide a broad array of services to seniors. The formal home care sys- tem represents about 20 percent of the services provided in the home care sec- tor and can include medical care, help with activities of daily living (e.g., per- sonal hygiene, dressing or feeding) and help with instrumental activities of daily living (e.g., house or yard work, medication or financial management, grocery shopping or transportation). The informal system includes support given by spouses, family members, friends and volunteers, and represents over 80 percent of the home help pro- vided to seniors. A common character- istic of many integrated care programs is the use of an innovative approach to collaborative partnerships, often in the form of interprofessional teams, to aid with the organization of and com- munication between the many carers providing support and services to sen- iors living at home.

The Interprofessional Model of Practice for Aging and Complex Treat- ment (IMPACT) clinic was an integrat- ed care program introduced by a team based at Sunnybrook Hospital in To- ronto in 2007. Although the original pilot project has concluded, the IM- PACT model offers a starting point for thinking about how a multidisciplinary approach to teamwork could be used to provide care to elderly persons with complex needs. The main IMPACT intervention was a two- to three-hour appointment where a team of pro- fessional carers, in conjunction with the care recipient and a family carer, worked together in real time to assess and analyze the care recipient’s medic- al, functional and psychosocial needs. This program attempted to streamline the assessment process by enabling the care recipient to see several practitioners at once; facilitating communication between carers by providing a forum for collaboration; and empowering care recipients and family carers through in- clusion on the care team.

There is room for refinement of the IMPACT model, particularly in that, al- though it is essential for a home care team to have participation, support and validation from physicians, it is perhaps not necessary for the physician to be responsible for the leadership and management of the team. Likewise, the IMPACT team was dominated by regulated professionals. In contrast, the unregulated care providers, who un- dertake the majority of the social care work, spend the majority of time with the care recipient in their home and often develop some of the closest rela- tionships with the care recipient, were not represented.

How to offer care that revolves around the care recipient remains a sig- nificant challenge when delivering care to seniors who live at home. In general, the health care system in Canada does not offer person-centred care. Instead, it requires patients to navigate the sys- tem and work around structural, pro- vider and resource-based barriers in or- der obtain the care services they need. Person-centred care is focused on the individual needs of recipients, allowing them free and easy access to the care services they need, when they need them, without encountering the afore- mentioned barriers. Moving health care delivery away from the status quo and toward more person-centred care is a goal of many policy bodies, such as the World Health Organisation and the Organization for Economic Co-opera- tion and Development. Integrated care programs could be a promising avenue for facilitating care services for seniors living in their homes by offering them an easily accessible basket of services that meets their individual health and social care needs.

The Alberta-based Comprehen- sive Home Options for Integrated Care of the Elderly (CHOICE) pro- gram is an interesting example of an integrated care program that pro- motes person-centred care by offer- ing enrolled seniors a variety of home and day centre ser- vices that address their most common needs. In addition to support services offered in the home, the CHOICE program uses a one-stop health and recreational centre to provide seniors with easy access to a comprehensive package of services including a day health centre, recreational activities, health clinic, subacute care, transportation and emergency response. This program is operated through an interprofes- sional team that uses a combined approach of prevention, early inter- vention and frequent monitoring to match care services to each recipient based on their needs and navigates the system on their behalf in order to get these services delivered. Although CHOICE seems to be a promising model of how person-centred care can be provided to seniors, access to the program is quite limited and user co-payments are required to supple- ment provincial funding. The cost of participation in CHOICE neverthe- less remains less than the cost of sup- porting a senior in an institutional setting.

Although it is helpful to consider the lessons of initiatives that aim to integrate home and commun- ity care from the ground up, this ap- proach warrants additional research to determine if these types of programs would be able to address some of the other significant challenges within the home and community care sector that remain outstanding. In my view, the most pressing issue that remains inadequately addressed is the need for further attention to, and support of, unregulated and informal carers. In their 2002 book, Wasting Away: The Undermining of Canadian Health Care, Pat Armstrong and Hugh Arm- strong outline their guiding principle that the conditions of work are the conditions of care. This is especially applicable in the context of care pro- vision in private homes. In Canada, home and community care continues to be provided in gendered, classed and racialized environments. Much of the care provided in private homes is strenuous work done by women work- ing under isolated and sometimes dangerous conditions, yet this type of care work and the workers who do it remain undervalued. While it may be challenging to include unregulated workers (e.g., personal support work- ers [PSWs], home care aides or person- al companions hired privately by care recipients or their families) in care teams and programs given their lack of professional organization and the precarious nature of their em- ployment situations, it must be acknowledged that, of all the care workers in the formal system it is the unregulated carers who pro- vide both the largest quantity of care and the services that are the most im- mediately relevant to the daily health, autonomy and dignity of the care re- cipient.

Unregulated carers play an essen- tial role in the lives of home care re- cipients and should be supported by policy-makers and other care providers to participate in home and community care programs, policies and care teams in a more meaningful way. The Par- ticipatory Action Research for Mental Health Guidelines in Long-Term Care pilot study at Baycrest Hospital in To- ronto recently published the results of a promising pilot project, in which PSWs were invited to participate in interprofessional teams in long-term residential care settings. Policy-makers should consider implementing similar guidelines in home care programs in an effort to replicate this project’s positive staff-related outcomes.

Social care providers are expected to provide seniors with the high- quality care we as a society feel our elders deserve. Indeed, studies have shown that the majority of these carers are deeply committed to the role they play in the lives of the sen- iors they work with. Yet government support remains inadequate in num- erous areas of crucial importance to unregulated workers, including ensur- ing workplace safety; requiring higher staffing levels so carers have enough time to care for a senior to the best of their abilities; mandating ongoing training and professional develop- ment opportunities so carers are pre- pared to deal with the changing needs of the population they serve; and sup- porting increased job stability, secur- ity, fair remuneration and comparable benefits to carers doing similar work in other parts of the health continu- um. Governments should prioritize improvements to the conditions of work of unregulated carers in home and community care to enable these workers to provide correspondingly high-quality care.

A related challenge is the need for increased support for the informal carers providing elder care. Eighty percent of care to seniors living in their homes is provided by unpaid carers, and almost all home care re- cipients who have formal support also have informal support to help maintain their health and indepen- dence. Informal carers are typically a senior’s spouse or children and stud- ies show that these carers are overbur- dened. Almost one in five informal carers in Canada hase reported dis- tress in their role. While a few inte- grated care programs have included some support for informal carers by, for example, including them in the creation of care management plans or offering them opportunities for re- spite care, additional support services are needed. The federal government has made progress on this issue with the introduction of Compassionate Care Benefits through Employment Insurance. However, more support for the provincial initiatives is required.

There are many ways that the availability and flexibility of respite care could be increased. For example, the hours for publicly funded adult day programs could be extended to cover the entire work day, which would al- low informal carers the opportunity to keep, or return to, their formal employ- ment if they wish to. Also, easier access to information, training and greater social supports for carers would be ben- eficial. Governments should consider incorporating a service like the Care- ring Voice Network that uses phone and Web-based tools to encour- age learning and create virtual support between formal and informal carers into their exist- ing home and community care strategies.

Home and community care is a policy area that is fraught with chal- lenges, but it is critical to work toward resolving the issues if we are to meet the changing care needs of an aging population. Integrated care programs show promise as a method of overcom- ing some of the obstacles; however, more research is required to determine if these programs can be expanded to address some of the remaining gaps in service. In my view, more attention should be paid to integrated care pro- grams as a cost-effective method of de- livering accessible, coordinated, high- quality care to seniors, particularly by evaluating their contributions using a gender-based analysis in the context of private homes.