The OCFP was pleased to provide feedback to the Ministry of Health on Proposed Regulations for Home and Community Care

Scope of Services, Service Maximums (slides 9 – 11)

We are pleased to see the list of services has been expanded to include those that were previously absent, however we would like to note a few gaps and concerns below:

• Availability of personal support: There is concern that the combining of home care and community care may inadvertently “dilute” the funding targeted to increasing personal care. Is there a way to protect funding specifically for personal assistance? According to the CIHI report, publicly funded home care does not cover all costs associated with caring for someone at home; some families experience significant out-of-pocket expenses. This poses a major financial barrier for many Canadian patients and their families, and a key reason for premature admission to long-term care. The report also stated that those living in rural and remote communities faced higher travel costs for medical appointments and limited availability of home care services and supports. 

• While we welcome the addition of physiotherapy, it would be useful to clarify whether the added physiotherapy services would also include occupational therapy (including home assessments) as this service is often what is needed (more than physiotherapy). Of note, we outline additional concerns with the physiotherapy services below. 

• Many of the mentioned services fall under the purview of primary care and public health. As we have mentioned in our last submission, to ensure continuity of care (and avoid potential duplication of services), it is important to connect with, coordinate with, and loop back the patient’s most responsible provider (MRP) – their family physician (FP) or nurse practitioner (NP) – so that the patient receives wrap-around comprehensive non-fragmented care. Because the patient’s MRP knows them best, they are best positioned to provide the insight that can help in determining the full spectrum of care needed, including home and community care. 

• We note that newcomers to Ontario who need end-of-life care as part of their home and community care, and who were insured by another province or territory, would be able to waive OHIP coverage. Could the ability to waive OHIP coverage be extended to other circumstances? For example, family physicians often see frail/elderly patients who need home and community care (but not end-of-life) who have be recently moved to Ontario to be reunited with family. It would be helpful to consider including them. 

•                  Finally, we would like to note that expanding scope of services is only one factor in ensuring that no patient in Ontario who requires home care is left behind. Equally important to expanding scope of services, is re-examining Ontarians’ eligibility to receive these services – see our comments below in Question 2. 

2. Client/Patient Eligibility Criteria (slides 12 - 13)

Do you have feedback on any aspects of the proposed approach set out on slide 11?

• We agree with the need to support those in transition to long-term care, as long as it does not divert resources from other sectors such as primary care. With respect to this transition group, it would be helpful to explain why it includes only behavioural issues, and not physical and cognitive issues. Some of our family physician members emphasize the importance of including physical and cognitive issues as part of in-home supports. 

Do you have feedback on whether client/patient eligibility criteria should be defined provincially in regulations, or left to be determined more locally (and if they should be defined provincially, what they should be)? 

• We believe that Indigenous communities are best positioned to lead this piece. We defer to our colleagues in the Indigenous Primary Health Care Council and Indigenous leaders and community members to define this piece of the legislation.

• We support the need for cultural safety and inclusion of Traditional Healers. 

Re: Slide 12:

• The bullet referring to "end of life care (not only palliation)" is unclear. Some of our family physician members have expressed that many of their patients are living with end-stage disease but would not necessarily be considered end-of-life or meet the criteria for palliative care. Further clarity here would be helpful to ensure that the eligibility criteria are inclusive.

• We welcome the addition of psychology services. Will those services include both assessment and management? If focusing on management, it would be helpful to include geriatric-psychology (for pharmacological management for behavioural concerns).

• Regarding the language around "person has a long-term mental health disability," who determines if the patient has a disability? Could patients who are somewhat functional but meet the criteria of the Disability Tax Credit request in-home psychology? Some of our members have noted that this could be potentially used too broadly since psychology services in the community are cost-prohibitive for many – as such, we suggest that implementation details define specific criteria. 

Re: Slide 13

• As mentioned above, we support the addition of physiotherapy services, however, the criteria seem too restrictive overall. We are concerned that the criteria are missing key groups of frail patients who would benefit from in-home physiotherapy, and occupational therapy, as discussed above. Our family physician members see many frail/elderly patients, many of whom are younger than 65 years old and/or have decline in function, and for whom physiotherapy and occupational therapy could significantly support them in living at home but are otherwise unable to access these services. We suggest expanding the eligibility and consider adding "frailty with recurrent falls or significant risk for falls".

• Furthermore, we are concerned about patients with degenerative/neuromuscular disorders; while they would not consistently meet the criterion "service is expected to result in progress..." physiotherapy is still important and necessary to maintain some strength despite expected disease progression.

• Respiratory Therapy (RT) services criteria also seems restrictive. It would be useful to add "late-stage respiratory disease (not necessarily O2 dependent) who would benefit from in-home RT support to manage their disease." CHF/COPD patients who do not require O2 would still benefit from brief RT support that is otherwise difficult to access (alternatively, this could be included in physiotherapy services for chest physiotherapy, etc.).

• We perceive the eligibility criteria for diagnostic and laboratory services to be slightly liberal. We are not confident that all persons with any one of the described needs require in-home lab/diagnostics (if that is what this service is). We suggest clarifying the rationale behind these criteria.

• As mentioned earlier, many of these services fall under public health and primary care. As such, to avoid duplication of services and to ensure continuity of care, connection with the patient’s MRP – the FP/NP – will be integral. Furthermore, transitioning to home and community care is an especially precarious period where most significant patient care issues occur due to lack of integration/coordination. As such, we continue to stress the importance of integrating home and community care sector with primary care and of ensuring coordination and timely communication the patient’s MRP. The patient’s MRP and their primary care team should be able to easily access information about the availability, wait times, eligibility, and types/range of home care services provided in their community. 

Re: Slide 14:

• Under “Future State,” we welcome and support the inclusion of "more integration with primary care.” This is key and a plan should be outlined clearly. We elaborate on this further below. 

Re: Slide 15:

• Regarding the statement "OHT monitors the quality and value of services provided" – how will quality be monitored? This will be an important piece to ensure consistent, quality care within the community. Furthermore, an equity lens should be incorporated for complex and chronic conditions. 

Final overall comment on eligibility:

• Most of the home and community care coordination services provided through the former Community Care Access Centres were episodic – about 60% followed from a hospitalization. This continues to be the case today. Prioritization currently seems to be on short-term home care that is focused on post discharge from hospital or palliative and wound care, and less on other vulnerable patients needing home care such as the frail elderly or those with complex chronic conditions including mental health and addictions. While downstream is articulated, home care should also be available upstream. The lack of available home care for these patients risks deteriorating their conditions further which, in turn, may lead to preventable emergency department use and/or hospitalization. This critical gap in care will only continue to grow given the increase in number of people living with multiple comorbidities, and who are living longer – this population requires ongoing support to manage their health in their homes and to avoid unnecessary and expensive hospital care. Thus, in examining the availability and eligibility of home care services, the Ministry should ensure that patients who have been historically denied services be ultimately connected to home and community services. 

3. Care Coordination (slides 17 – 20)

Do you have feedback on the proposed requirements for care coordination functions on slide 17? 

Several of the proposed care coordination functions are a step in the right direction, however, having a care plan is only one step in providing quality patient care. We see care coordinators as something more than just brokers of care services. They often assist patients in their navigation of the current system and together with physicians, are often tireless advocates for their patients’ needs. Effectively advancing care of patients in their homes and communities involves going beyond administrative tasks to having a dedicated team of interprofessional healthcare providers who are working seamlessly together towards improving the patient’s outcomes. As such, we continue to propose the following recommendations regarding care coordination: 

• First, the functions of care coordination must be less about the administrative role and more about what they aim to achieve: providing wrap-around care and system navigation support for the patient’s entire journey through the health and social systems. Care coordination functions within OHTs should encompass both coordination of care (“improving transitions”) as well as system navigation for patients (“better connections”). This will help support continuity and follow up of patients’ holistic and complex needs, including but not limited to: physiotherapy, rehabilitation, mental health and addictions, home care, community supports (i.e., Meals on Wheels) and other needs related to the social determinants of health (e.g., income and housing supports). 

• Second, for optimal results and to strengthen integration where most care happens, embed care coordination in primary care. This leverages the fact that family physicians and nurse practitioners are the MRPs for their patients’ needs and problems, providing clinical evidence-based assessment and treatment recommendations. Furthermore, having care coordination in primary care has the potential to significantly reduce the duplication and improve clarity of roles that currently exists in our health system. Thus, we continue to urge the Ministry to embed care coordination in primary care. 

• Third, we need home and community care providers to connect with the patient’s MRP in a timely and ongoing way (particularly post discharge from hospital), which, in turn, supports continuity of care for patients. We note that the proposed care coordination functions include “working with parties in the circle of care”. This expectation does not go far enough in ensuring that patients are receiving comprehensive wrap-around care that maintains continuity with their MRP and their primary care teams. We ask that an additional and explicit expectation be put in place to ensure that care plans are shared, and seamless communication enabled, with the patient’s MRP. Of note, if care coordination were embedded in primary care, this added step would not be needed, as the care coordinators would be directly linked with the patient’s MRP and their primary care team. 

• Fourth, seamless digital communication between home care providers and primary care that can relay accurate information in a timely way is essential to high-quality care. Integrating data systems that enable care coordination, performance metrics, reporting, and research will significantly help to remove “red tape” or barriers that hinder communication, enabling MRPs to receive more timely information about their patient’s health. With care still often delivered in silos, patients must often repeat stories, as records are not appropriately shared across the system. Everything that is not tracked and communicated in a shared EMR that is relevant to the patient’s health and wellbeing can weaken the overall quality of care that the patient receives. It is imperative that there be one patient electronic record and that the care coordinator be supported in inputting their clinical and service delivery notes into that one record. 

• Finally, while “integration with primary care” is mentioned once in the deck, as it stands, it is not clear how this regulation concretely supports integration with primary care. It would be helpful to provide concrete examples (as was done in slides 14/15) on how patients can receive home and community care from the community, and not just as a result of hospital discharge. 

Additional comments:

• We support the inclusion of "actively seek to obtain assessment info..." in the first bullet and we believe this will be easier if home care is truly integrated with primary care. It will also be important to recognize that patients within Family Health Teams (FHTs) may already have some element of wrap-around care from multiple providers within their FHT. We want to recognize the importance of pre-existing relationships and avoid duplication; again, looping with the patient’s MRP is key. Of note, the majority of family doctors (70%+) and their patients are not part of funded team models.

• We support the requirement to ensure that French language care coordination and care services are actively offered. And similarly, we would support ensuring translation services for key assessments for patients who speak other languages. From the experience of some of our family physician members, some LHINs currently rely on family members for translation, which places an added burden on these family members. 

Feedback on the factors to be considered when planning care on slide 18?

• We recognize the inclusion of the point about "the availability of other family or other informal caregiver supports," but would like to note that often other family members are equally frail yet still seen as reliable caregiver supports. We continue to emphasize that integration with primary care would allow for improved communication and the family physician will have insight into the medical history/caregiving capabilities of other family members within the household. 

• The last point which refers to coordination with other providers is a missed opportunity to distinguish and clearly outline the valuable role of the patient’s MRP. The patient’s MRP is ultimately responsible for the patient's care, and thus it is important to ensure clear communication and collaboration between primary care and home care. 

• Regarding the written plan of care, it should be provided to the patient’s MRP and integrated into the family physician’s EMR. 

• It may be useful in this regulation, or as an accompaniment to the regulation, to emphasize the principle of efficiency to incentivize the development of concise summaries of care plans. Some of our family physician members describe care plans that are unhelpfully long and detailed. 

• It would be useful to include an example of how this would be sorted out if patients are being referred from the community. As mentioned earlier, the regulation seems to prioritize post-discharge patients as opposed to all patients requiring home and community care. 

Are there any rules or parameters in addition to what is set out on slide 19 that the ministry should consider regarding an HSP or OHT’s assignment of care coordination functions? 

• As noted earlier, there is no mention of ensuring that these services are connected to the patient’s MRP – whether in their workflow or digitally. Specifically, the section “If assigning care coordination functions to a contracted service provider..." should include a clear plan for timely communication and two-way collaboration with the MRP. We hear from some family physician members who receive little to no communication from contracted home care agencies who are supporting their sickest patients at home. According to a 2016 HQO report, among the provinces and countries surveyed, Ontario has one of the lowest reported percentages of family doctor communication with home care services. Family doctors also report challenges coordinating care with social services and other community providers. Where home and community care has been embedded in primary care, however, we have seen significant improvements. 

4. Bill of Rights, Locations of Service, Eligible Providers, Methods of Delivery (slides 21 -25)

Do you have any feedback on the proposed items on slides 21-25?

• Some of our members require clarity on who can be an HSP. It would be useful to explicitly outline somewhere (within or as accompaniment to the legislation) who would qualify as HSPs. Also, it would be helpful to explain the rationale behind the staged plan for care coordination to transfer to HSP, then OHTs.

• We also request clarification on how OHTs would fund home care services when we are still unclear about the legal/administrative form of organization of OHTs. OHTs are not yet an entity so we are unclear as to whom this funding would flow and to whom providers, such as family physicians, would make referrals for their patients. We also note that OHTs vary in terms of their development stage and their offerings. As well, not all family physicians are actively engaged with OHTs, so there needs to be consideration to ensure that the patients attached to them have the same access to services as those family physicians currently involved.

• While we are supportive of organizations receiving direct funding be not-for-profits, some of our family physician members are concerned that some private agencies will have their own restrictions on who/where they will see patients, which, in turn, may create some barriers for access.

• We support the digital delivery of home care, as long as issues regarding digital equity are considered.

5. Charges for Services (slide 26) 

6. Plans to Prevent Abuse, Complaints, Appeals, Patient Ombudsman (slides 27-30)

Do you have any feedback on the proposed items on slides 27-30?

7. Self-Directed Care, Residential Congregate Care, Other Related Amendments (slides 31 - 35)

Do you have any feedback on the proposed items on slides 31-35?

8. Other feedback 

To successfully integrate home care in Ontario Health Teams (OHTs), the Patient’s Medical Home (PMH) and the Patient’s Medical Neighbourhood (PMN) provide the framework to do this. The PMH/PMN vision is a system in which patients can easily access care throughout every stage of their life, which is seamlessly integrated with other services in the healthcare system, including home and community care. It is well documented that healthcare systems built on a strong primary care foundation, anchored in the PMH/PMN principles, improve patient experience, health outcomes and provider satisfaction, and lead to fewer unnecessary hospitalizations. i,ii

i Starfield B. Is primary care essential? Lancet. 1994;344 (8930):1129 – 33. Crossref, Medline , Google Scholar

ii Delnoij D, Van Merode G, Paulus A, Groenewegen P. Does general practitioner gatekeeping curb health care expenditure? J Health Serv Res Pol. 2000;5 (1): 22 – 6. Crossref, Medline, Google Scholar

iii BMJ 2017; 356 doi: https://doi.org/10.1136/bmj.j84 (Published 01 February 2017) 

Safe, effective, and efficient home care maintains continuity with the patient’s most responsible provider – often the family physician, who knows that person best because of a trusted relationship developed over a lifetime. This continuity of care is a key component of PMH/PMN principles and a pertinent variable in patients’ recovery and overall health. The evidence is clear: patients who were more closely followed by the same family physician were shown to have lower readmission rates and lower mortality. Maintaining continuity with the primary care provider has also been shown to improve patient satisfaction and reduce system costs. iii On the other hand, extensive data from Alberta’s evidence summary underscores the resulting erosion of continuity by not connecting with a patient’s family physician if they already have one.

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