Self-directed care will require a role for government

Now is the time to set the script and what those roles should be

By all indications, self-directed care is coming to Ontario, having already won numerous converts in other jurisdictions. Our government will be needed in key roles for both implementation and management, but now is the time to set the script and what those roles should be.

Unfortunately, the government is off to a rough start for self-directed care. Agencies that account for most of the publicly funded home-care services in the province recently launched a legal action against the Ontario government’s move to create Personal Support Services Ontario. PSSO would employ personal support workers directly in a new self-directed funding model, potentially competing with the private agencies.

For a bit of background, self-directed care is sometimes compared with a voucher system, where government funds the consumer for required care services and allows that person to make purchases from available care providers. This contrasts with aspects of our current funding model in Ontario where, for example, dollars go directly to long-term care homes, which then support those residents who gain admission.

A big driver is the trend toward autonomy and flexibility as important features of modern long-term care systems. Countries such as the Netherlands, Germany, England and Italy offer mixes of in-cash and in-kind benefits. It is estimated the Netherlands uses personal budgets, managed by the individual, to cover about 80 per cent of care requirements for older adults.

The Ontario government signalled its intent to push ahead with self-directed care in 2015 with Patients First: A Roadmap to Strengthen Home and Community Care, describing a model where “clients and caregivers are given funds to hire their own provider or purchase services from a provider of their choice.” In broad concept, self-directed care has won support here, not just from would-be consumers, but from provider associations such as HomeCare Ontario and policy thinktanks like the C.D. Howe Institute.

In fact, the benefits go beyond consumer choice. My own research suggests that self-directed funding could solve many inequities for seniors in gaining access to care. The current problem with funding “sites” of care, such as long-term care homes, is that it leaves out seniors — now about 30,000 in Ontario — who remain on the wait list and must access their care services at other sites. Some of these are publicly funded, but many, such as retirement homes, are not.

Self-directed funding turns this problem around. Seniors could use their vouchers to buy home-care wherever they desire and might eventually use them to purchase care services at whatever site suits them — their own homes, retirement homes, seniors’ apartments, supportive housing, or community care programs.

All of this brings us back to the roles for government in a world of self-directed funding. The first is deciding what to fund. Legally, both home-care and seniors residential care fall outside the definition of “medically necessary” services in our Canada Health Act, meaning that the provinces have broad discretion to decide what services to cover, for whom, and within what budget limits.

Second, wherever public dollars are being dispensed, it is a given that the government will take oversight responsibility for the assessment of those applying for funding. Properly applied, this means fitting the level of care funding to the acuity of the health condition and the treatment required.

Third, and perhaps most sensitive is the role that government will play in ensuring that care expenditure decisions are made responsibly by those receiving the funding. This is not just “big brother” in action. As a 60-year-old boomer myself, I embrace the culture of autonomy, but I also know that my ability to make smart choices could be different at 85 when I need the care.

Models from other countries point to three levels of oversight for vulnerable seniors, ranging from direct payments to the user, to financial intermediary models where expenditures are managed by a trusted party, to funding streams that go directly to an approved service provider.

Outside of the above roles, the government’s presence becomes controversial whenever it decides to compete head on with other providers of care services. The Canadian health-care system has a strong tradition of finding the right balance between funding care publicly while enabling service delivery through nonprofit and other private companies. Recent actions bring this balance into question for self-directed care.

The government has stated its intent to designate the PSSO as the exclusive provider of home-care workers to a select group of high-need care recipients across the province. In implementing PSSO, the government asserts it will be assuring home-care clients more choice in selecting caregivers and more control over their own care schedule. A concern of the health care agencies is that the government could soon move from a “pilot” phase to control significant market share in the home-care space, including both clients and the scarce pool of workers.

Consumer “choice” is indeed central to the concept of self-directed care. But real choice turns on a robust selection of caregivers and agencies vying (dare I say “competing”) for the favour of home-care clients on the basis of the service offered. There is a necessary role for government in planning and co-ordinating a clientbased model for self-directed care, but the prospect of it asserting preferred supplier status at the expense of existing homecare providers runs the risk of stifling rather than fostering greater choice for consumers of care.

The curtain has opened. Let’s avoid the temptation to upstage other actors.