Socio-spatial patterns of home care use in Ontario, Canada: A case study

Health & Place 17 (2011) 195–206

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Socio-spatial patterns of home care use in Ontario, Canada: A case study Peter Kitchen a,n, Allison Williams a, Raymond W. Pong b, Donna Wilson c a b c

School of Geography & Earth Sciences, McMaster University, 1280 Main Street West, Hamilton, Ontario, Canada L8S 4K1 Centre for Rural and Northern Health Research, Laurentian University, Canada Faculty of Nursing, University of Alberta, Canada

a r t i c l e in f o

abstract

Article history: Received 1 February 2010 Received in revised form 7 July 2010 Accepted 29 September 2010 Available online 13 November 2010

Home care is the fastest growing segment of Canada’s health care system. Since the mid-1990s, the management and delivery of home care has changed dramatically in the province of Ontario. The objective of this paper is to examine the socio-spatial characteristics of home care use (both formal and informal) in Ontario among residents aged 20 and over. Data are drawn from two cycles of the Canadian Community Health Survey (CCHS Cycle 3.1 2005 and Cycle 4.1 2007) and are analyzed at a number of geographical scales and across the urban to rural continuum. The study found that rural residents were more likely than their urban counterparts to receive government-funded home care, particularly nursing care services. However, rural residents were less likely to receive nursing care that was self-financed through for-profit agencies and were more reliant on informal care provided by a family member. The study also revealed that women and seniors were far more dependent on services that they paid for as compared to informal services. People with lower incomes and poorer health status, as well as rural residents, were also more likely to use informal services. The paper postulates that the introduction of managed competition in Ontario’s home care sector may be effective in more populated parts of the province, including large cities, but at the same time may have left a void in access to for-profit formal services in rural and remote regions. & 2010 Elsevier Ltd. All rights reserved.

Keywords: Home care Health disparities Urban–rural continuum Formal and informal care

1. Introduction Over the past several decades, Canada’s health care system has undergone considerable change. With an aging population and rising health care costs, provincial governments have implemented policies aimed at improving the efficiency and quality of care while attempting to keep costs under control (Baranek et al., 2004; CHCA, 2009). It is recognized that in many situations, care in the home is a desirable alternative to hospitalization or admittance to a longterm care facility. Most people prefer to receive care at home when recovering from an injury, receiving treatment for a chronic condition or when dying. Home care is now the fastest growing sector of health care in Canada. This growth has been attributed to a number of factors including an aging population, the search for cost-effective alternatives to institutional care, advancements in technology and treatment, shortage of acute and long-terms beds, an increased demand for home care by patients and their families and changing attitudes towards institutional care (Cˆote´ and Fox, 2007; Kotecha and Birtwhistle, 2009). At the same time, a growing body of research is showing significant differences in health status and utilization of health

n

Corresponding author. Tel.: + 1 905 525 9140 20112; fax: +1 905 546 0463. E-mail address: [email protected] (P. Kitchen).

1353-8292/$ - see front matter & 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.healthplace.2010.09.014

services between urban and rural Canadians (DesMeules, 2006; CIHI, 2008; Pong et al., 2010). Both the ‘‘Romanow Report’’ (Romanow Report, 2002) and the ‘‘Kirby Report’’ (Kirby and LeBreton, 2002) have drawn attention to the health of Canadians living in rural and remote areas and indicated that access to health services is an important challenge. In particular, access to medical specialists and hospitals with advanced acute-care services is more difficult due to a shortage of local services or greater distances from urban centres. Home care is defined by the Canadian Home Care Association (CHCA, 2008a, p. viii) as ‘‘an array of services for people of all ages, provided in the home and community setting, that encompass health promotion and teaching, curative intervention, end-of-life care, rehabilitation, support and maintenance, social adaptation and integration, and support for the informal (family) caregiver.’’ This paper seeks to contribute to the research on health disparities by comparing the use of home care in Ontario by residents aged 20 and over in urban and rural areas and among different regions of the province. The following three research questions are posed: (1) To what extent do rural residents rely on home care services compared to their urban counterparts? (2) What are the predominant social, health and geographic determinants of home care use and (3) How have policy changes affected the availability of home care services in rural and remote communities of Ontario?

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This study employs data from the Canadian Community Health Survey (CCHS) for 2005 and 2007. The CCHS is released on an annual basis by Statistics Canada and contains several questions on home care utilization that is funded and not funded by government as well as perceptions of unmet home care needs. Based on the CCHS survey questions, three types of home care are examined: (1) formal home care services that are at least partially paid for by government. (These services are typically provided through nonprofit agencies and involve nursing, therapy, counseling, personal care, housework and the preparation and delivery of meals.) (2) Formal home care that is paid for entirely by the user and which is typically provided by private, for-profit agencies and (3) informal home care provided by family members, friends or neighbours. In addition, the paper investigates patterns of home care use across the urban to rural continuum and among different regions of the province. Statistics Canada’s Metropolitan Influence Zones (MIZ) measure a person’s proximity to an urban area based on geographical location and the proportion of residents commuting to work in urban centres. The paper is divided into four sections. The first is a review of the literature on home care in Canada, focusing on key policy changes in Ontario and challenges associated with the delivery of home care in rural and remote areas. The second outlines the methods employed in the research and the third presents the results of the data analysis. The fourth section discusses policy issues related to variations in home care use in Ontario. Although this is a case study focusing on Ontario, it has implications for other regions of Canada and internationally since few studies have focused on the socio-spatial characteristics of home care use.

1.1. Setting the scene: growth and change in home care in Canada There is a large body of literature devoted to home care in Canada, the majority of which deals with the economic and policy issues associated with the people and organizations that deliver home care services. By comparison, less research has focused on the use of home care, particularly the socio-spatial characteristics of the people receiving these services. Clearly, there is an important link between the provision and use of home care services, which will be explored in this paper. Home care was not that common in Canada until the 1970s, but since then has grown rapidly with each province taking a different approach. There are no national standards for home care nor is there a pan-Canadian program; a situation that Seggewiss (2009) argues has led to a ‘‘patchwork of programs across the nation, with access and availability conditional on geographic region, if not chance’’. Home care is not an insured service under the Canada Health Act, which applies only to insured health services that cover hospital care (acute, rehabilitation and chronic) and medical services (CHCA, 2009). While the provinces and territories all provide home care services, there are significant variations in access, costs and wait times (Seggewiss, 2009). Over the past 30 years, home care has undergone dramatic change in Canada’s largest province of Ontario. A number of authors have documented the restructuring of Ontario’s health system in the 1980s and 1990s and its impact on home care (for example, see Baranek et al., 1999, 2004; Armstrong and Armstrong, 2003; Williams, 1996, 2006; England et al., 2008). Central to this restructuring was closing or merging of dozens of hospitals in the 1990s and the concurrent shift of care to the home coupled with the opening of some health services, including home care, to market forces. England et al. (2008) provide an excellent review of this period of change in Ontario (led by the Progressive Conservative government from 1995 to 2003) and its effect on the management and delivery of home care.

Perhaps the most important change was the creation in 1996–98 of 43 Community Care Access Centres (CCACs), which replaced 38 home care programs and 36 placement coordination services in the province. By 2007, the 43 CCACs had been reduced to 14, which were coterminous with the geographic boundaries of the province’s 14 Local Health Integration Networks (LHINs). The mandate of CCACs is to provide a single point of access to manage and coordinate long-term care and home care services in their regions. They do not provide any services themselves but employ case managers to arrange access to contracted services. CCACs use competitive bidding for contracts from local nonprofit and privatefor-profit agencies to provide nursing, homemaking, personal support, and other services (England et al., 2008). Prior to the creation of the CCACs, home care was delivered by nonprofit agencies such as the Victorian Order of Nurses and Meals on Wheels. The introduction of managed competition in Ontario’s home care sector is a contentious issue and has been the focus of much research during the last decade. For instance, Abelson et al. (2004) assessed the quality of home care services under this policy environment in the Hamilton, Ontario CCAC; Aronson et al. (2004) examined the employment conditions of support workers employed by for-profit, non-unionized agencies; Zeytinoglu et al. (2009) studied casualized employment and turnover intention among home care workers in the province and Woodward et al. (2004) considered the attributes that contribute to continuity of home care under the competitive bidding model. In a pair of studies, Randall and Williams (2006, 2009) assessed the impact of Ontario’s managed competition reform on rehabilitation home care services from the perspective of professional providers. In a study relevant to the objectives of this paper, Cloutier-Fisher and Skinner (2006) considered the effect of managed competition on voluntary sector providers of long-term care to elderly populations in small rural areas of Ontario. Based on a series of keyinformant interviews with service providers from the voluntary sector, the authors contend that managed competition has contributed ‘‘to a loss of service and a reduction in service availability and access for people living in rural areas’’ (Cloutier-Fisher and Skinner, 2006, p. 107). On a more positive note, in a study of home care nursing services delivered under managed competition in 11 CCACs in Ontario, Doran et al. (2007) found that contract characteristics (longer and shorter contracts; nonprofit and forprofit) were largely not related to the consistency of principal nurse visits or client outcomes. The research also revealed that clients cared for by for-profit agencies reported slightly higher satisfaction with care and better mental health outcomes than clients cared for by not-for-profit agencies. It should be pointed out that the authors did not directly consider regional geographic variations or urban– rural residency although they did select CCACs from each region of the province. As stated, less attention has been paid to the socio-spatial aspects of home care use in Canada. This is surprising in light of the immense geography of the country and the fact that residents living in rural and remote regions often experience very different health outcomes. A number of researchers have addressed issues of home care in rural and remote areas. Authors such as Angus et al. (2005), Chapell et al. (2008), Sims-Gould and Martin Matthews (2008) and Forbes and Edge (2009) have recently contributed to a better understanding of the challenges associated with caregiving and patient needs in the rural setting. It is important to situate rural home care within the context of the unique circumstances in which many rural residents live. As Kulig (2010) points out, life expectancy for both men and women is lower in rural Canada while the incidence of respiratory disease is higher as are overall mortality rates, especially those related to circulatory diseases, injuries and suicide. At the same time, access to primary care,

P. Kitchen et al. / Health & Place 17 (2011) 195–206

medical specialists and acute care hospitals is often far more difficult in rural areas as is accessing home care services. This should be cause for concern as accessibility is one of the five principles of the Canada Health Act. However, it appears that to date, unequal accessibility due to geographic impediments has not received the same amount of policy attention. The Canadian Home Care Association (CHCA, 2006, 2008b) describes a number of challenges that rural home care programs face. Chief among these is a lack of health human resources (e.g., doctors, nurses, home support workers) as well as a limited number of informal/family caregivers in rural and remote communities. These challenges are compounded by a net out-migration of young people, fewer support systems and local resources, limited means of transportation, and the need to travel long distances and many hours to see very few clients (CHCA, 2008b, p. 6). Furthermore, Forbes and Edge (2009, p. 121) describe how the absence of intermediary services (e.g. Meals on Wheels, caregiver respite programs, supportive housing), specialty services, and long-term care beds in rural and remote communities often result in premature admission to acute care and long-term care facilities, ‘‘which may be at a distance and result in the splitting up of family units and increased costs to the health care system’’. An under-explored area of research is the effect of managed competition on the quality and availability of home care services in rural and remote regions. Several organizations including the Canadian Home Care Association (CHCA, 2008b), the Canadian Healthcare Association (CHCA, 2009) and the Health Council of Canada (2008) have pointed to the potential problem of for-profit agencies choosing not to compete for home care contracts in situations where they are less able to make a profit, particularly in remote areas with small or dispersed populations and a shortage of health care professionals. In these situations, a gap in home care provision may exist, one in which family members and under-resourced nonprofit agencies will attempt to fill.

1.2. Characteristics of home care use in Canada Only a handful of studies have employed survey data to examine the social and geographic characteristics of home care use in Canada. Using cross-sectional data from the first three cycles of the National Population Health Survey (NPHS 1994/95, 1996/97, 1998/99), Forbes et al. (2003) investigated individual determinants of use of publicly funded home care by Canadian 18 years or older. In a follow-up study, Forbes and Janzen (2004) drew data from two cross-sectional cycles of the NPHS (1996/97 and 1998/99) to investigate the characteristics associated with the use of publicly funded home care services among rural and urban Canadians aged 18 or over. The study examined 13 independent variables including age, gender, education, income, perceived health, activity restriction, and chronic condition. Rural was defined as ‘‘the population living outside places of 1,000 people or more, or a population living outside places with densities of 400 or more people per square kilometer based on the previous census’’ (Forbes and Janzen, 2004, p. 229). The study found that rural residents are increasingly less likely to receive personal care assistance and rural home care users appear to have more resources (e.g. higher levels of education) that likely influence their ability to access and receive home care services. In another study, Mitchell et al. (2006) used longitudinal data from the Manitoba Study of Health and Aging (MSHA) to examine rural-urban differences in home care service use over time. At baseline (1991/92), data on 885 communitydwelling, cognitively intact adults aged 65 or over not receiving home care were collected. Place of residence was categorized as urban/small town zone or predominantly rural area in Manitoba.

197

The authors found that urban residents were more likely to receive home care than those in small town-zones or predominantly rural areas. In research focusing on Ontario, Hall and Coyte (2001) acquired household data from the 1994/95 NPHS and linked it to the Ontario Home Care Administrative System database to evaluate the relevant predictors of home care utilization. The sample employed in the analysis was 3830 individuals aged 25 and over, with164 (4.3%) receiving home care one year following the survey. The authors found that the use of formal home care is uncommon in Ontario with only 4.3% of sample respondents receiving this service. Furthermore, just 14% of older individuals (65 and over) from the sample received home care one year after the survey. In the early 2000s, the Canadian Community Health Survey (CCHS) began to replace the NPHS as Statistics Canada’s primary health survey. The CCHS is now conducted on an annual basis, with each data release containing information provided by Canadians who self report. Carrie re (2006) used data from the 2003 CCHS to investigate the use of formal and informal home care among older persons in Canada. In this study, formal home care encompassed government-subsidized health care or homemaker services, and care purchased from private agencies or provided by volunteers. Informal home care is help provided by family, friends or neighbours (Carrie re, 2006). The study found that most seniors relied on formal care and that women were more like to receive home care regardless of the source – formal, informal or mixed. It also revealed that large proportions of seniors who required assistance with activities of daily living did not receive any form of home care. Wilkins (2006) employed data from the 1994/95 NPHS and 2003 CCHS to examine changes in the use of government subsidized home care in Canada and found that the average age of recipients fell from 65 to 62 over this 8-year period. Also, the number of household residents who needed help with personal activities of daily living or with moving about in their homes increased substantially between 1994/95 and 2003. Wilkins (2006) contends that despite government-subsidized home care services reaching greater numbers of people in 2003, a smaller share of individuals with these basic needs received care. Each of these studies has made an important contribution to the literature. As indicated, a growing body of research points to the existence of regional health disparities and differences in access to health services in Canada. Combined with an aging population, significant changes in provincial home care policies and the fact that home care is the fastest growing sector of the health system, there is a pressing need to better understand the socio-spatial factors associated with the use of home care services in Canada.

2. Methods The authors applied for and were granted permission to use Statistics Canada’s CCHS master files, specifically to gain access to variables denoting the urban or rural residence of respondents. The CCHS includes a module where respondents are asked questions about the home care services that they have received during the 12 months prior to the survey. Table 1 shows the three questions from the CCHS that are analyzed in this research. Two levels of geography were examined. The first is the Local Health Integration Network (LHIN). Ontario has 14 LHINS, which are not-for-profit agencies that were created by the Government of Ontario in 2006 with a mandate to plan, integrate and fund health care services in its region including hospitals, Community Care Access Centres (CCACs), community support services, long-term care, community health centres, and home care. There is one CCAC

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Table 1 Canadian Community Health Survey (CCHS) questions. Variable name Concept Question

If ‘Yes’, type of care received

Variable name Concept Question

If ‘Yes’ type of care received

Variable name Concept Question

If ‘Yes’, reason for unmet needs

HMCE_09 Received home care services - cost covered by government. Have you received any home care services in the past 12 months, with the cost being entirely or partially covered by government? (‘Yes’, ‘No’, ‘N/A’) (1) Nursing care (e.g. dressing changes, preparing medications, VON visits) (2) Health services (e.g. physiotherapy, occupational or speech therapy, nutrition counseling) (3) Personal care (e.g. bathing, foot care) (4) Housework (e.g. cleaning, laundry) (5) Meals (preparation or delivery) HMCE_11 Received home care services - cost not covered by government Have you received any [other] home care services in the past 12 months, with the cost not covered by government (for example: care provided by a private agency or by a spouse or friends)? (‘Yes’, ‘No’, ‘N/A’) (1) Nurse from private agency (2) Homemaker or other support services from private agency (3) From neighbour or friend (4) From family member or spouse HMCE_14 Self-perceived unmet home care needs. During the past 12 months, was there ever a time when you felt that you needed home care services but you didn’t receive them? (‘Yes’, ‘No’, ‘N/A’) (1) Not available in area (2) Cost

within each LHIN and they cover the same geographic area although they are separate administrative entities. The second level of geography is the Public Health Unit (PHU) of which there are 36 across Ontario. Each PHU is an official health agency established by a group of urban and rural municipalities to administer, among others, health promotion and disease prevention programs. Although PHUs have no direct role in the provision of home care services, they are included in this research to demonstrate a more detailed geographic variability of home care use. The geographic boundaries of PHU are nested within the LHINs. There are various definitions of ‘‘rural’’ in Canada and other countries and ‘‘rural’’ can mean different types of communities (Du Plesssis et al., 2002; Bollman and Clemenson, 2008). For instance, rural can refer to a community within relatively close driving distance to a major metropolitan area, such as Toronto, or it can refer to remote areas, many hundreds of kilometers from the nearest city. There have been developments over time in differentiating rural from remote and rural from urban. Wilson et al. (2009) outlined various definitions of rural as related to distance from a city, travel time and population density. The CCHS master file contains two measures of rurality. The first is a variable (GEODUR2) that divides the residence of each respondent into two categories—urban or rural with rural defined as a place that has a population less than 1000. The second is a variable (GEODSTAT) that employs metropolitan area (CMA) and census agglomeration (CA) influence zones (MIZ). CMAs and CAs contain large urban areas, together with neighbouring census subdivisions (municipalities) that have a high degree of social and economic integration with the urban core. A Metropolitan Influence Zone (MIZ) refers to the population living outside the

commuting zones of larger urban centres (CMAs and CAs). Statistics Canada classifies four zones.1 This study examined the total population aged 20 and over receiving home care services in Ontario. Data from CCHS Cycle 3.1 (2005, n¼36,629) and Cycle 4.1 (2007, n¼19,631) were analyzed. The two cycles were pooled to create a single data set (n¼ 56,260), representing the total population aged 20 and over in Ontario and including people who received home care (n ¼1687) and people who did not (n ¼54,573). Pooling was necessary as the total number of people receiving government-funded home care in Ontario is relatively small (about 3%) and a larger sample size is required to compare residents living in certain geographic areas, particularly in the Moderate and Weak/No MIZ, where the number of respondents is insufficient in a single CCHS cycle for most statistical analyses. Also, home care policy was fairly stable in Ontario between 2005 and 2007, with most of the major changes occurring in the late 1990s and early 2000s. For these reasons, the authors felt that combining the two CCHS cycles was justified. However, the pooling of data presented a challenge with respect to the weight variable attached to each individual in the survey. The weight variable represents an estimate of the total population. In a recent article, Thomas and Wannell (2009) proposed several methods for adjusting weights when combining cycles of the CCHS. The authors recommended that weights be scaled by a constant factor, ai ¼1/k. If two cycles are combined, this means a ¼0.5. Following this approach, the master weight for each individual in the two Cycles (3.1 and 4.1) was divided by 2 creating a new adjusted weight. The authors also felt that it was important to examine the adult population aged 20 or over for two reasons. First, it created a larger sample size thus permitting a more detailed statistical analysis. Second, it is evident that home care is an important health service for many people and not just for seniors. Table 2 shows that in 2005/07, nearly 124,000 people in Ontario aged 20–64 received government-funded home care (44% of the total) and another 129,000 received non-government-funded home care (50% of the total). The data analysis involved four steps: (1) descriptive statistics, (2) mapping, (3) contingency tables and (4) logistic regression. In the first step, simple descriptive statistics were produced showing the basic socio-economic and geographic characteristics of home care use (both government and non-government funded) in Ontario. In the second step, mapping software (ESRI ArcGIS) was employed to create a choropleth map showing the geographic distribution of government-funded home care use in the province’s 14 LHIN regions and 36 Public Health Unit regions. The third step in the data analysis was the use of contingency tables to measure the strength of the relationship between home care use and geography. Specifically, the use of government and non-government funded home care by type (i.e. nursing, meal preparation, homemaking, etc.), was examined across four metropolitan influence zones (CMA/CA, strong MIZ, moderate MIZ, weak/no MIZ). The fourth step involved logistic regression analyses of the CCHS data. A series of models were devised where the dependent variable represents people who have received home care and the independent variables denote a number of socio-demographic (gender, age, marital status, income, education), health (self-rated health status) and geographic (urban–rural, MIZ) characteristics. Regression

1 Strong MIZ: At least 30% of the municipality’s resident employed labour force commute to work in anyCMA or CA; Moderate MIZ: At least 5%, but less than 30% of the municipality’s resident employed labour forcecommute to work in any CMA or CA; Weak MIZ: more than 0%, but less than 5% of the municipality’s resident employed labour forcecommute to work in any CMA or CA; No MIZ: Fewer than 40 or none of the municipality’s resident employed labour force commute to work in any CMA or CA.

P. Kitchen et al. / Health & Place 17 (2011) 195–206

Table 2 Population aged 20 and over receiving home care services in Ontario, 2005/2007. Government-funded home care services Total

Percenta

Total

% Health unit pop. aged 20 and over

Percenta

Total receiving 281,938 Sex Male 108,429 Female 173,509

3.0

260,169

2.7

38.5 61.5

84,603 175,566

32.5 67.5

Age 20–34 35–49 50–64 65 and over

30,098 47,060 46,642 158,138

10.7 16.5 16.5 56.1

29,384 51,043 48,680 131,062

11.3 19.6 18.7 50.4

Location Urban Rural

231,437 50,501

82.1 17.9

229,956 30,213

88.4 11.6

a

Table 3 Received home care services in Ontario, 2005/2007: Aged 20 and over by public health unit.

Non-government funded home care services Total

199

Percent of total population aged 20 and over in Ontario.

coefficients are employed to estimate odds ratios for each of the independent variables in the model. The objective is to identify the significant factors influencing the use of home care in Ontario, be they socio-economic, health or geographic. 2.1. Social and geographic characteristics of home care use in Ontario 2.1.1. Overall use Table 2 provides a summary of home care use in Ontario. In 2005/07, approximately 282,000 people aged 20 and over received government-funded home care services, representing 3% of the total population in this age group. The majority of users were women (61.5%) and seniors aged 65 or over (56.1%). The share of government-funded home care services provided to urban and rural residents essentially reflects the urban–rural population distribution in Ontario: 82% urban and 18% rural. Table 2 also shows that slightly fewer people, about 260,000 (2.7%), received non-government funded services with a substantially higher proportion of women receiving this type of home care (67.5%). In addition, seniors (50.4%) and rural residents (11.6%) were less likely to receive non-government funded home care than government-funded services. In 2005/07, 57,532 people in Ontario received both types of home care, representing 0.6% of the population aged 20 and over, and 10% of total home care users. Two-thirds (66%) of these dual users of home care were seniors. 2.1.2. Geography The analysis of the CCHS data revealed a fairly even distribution of home care provision across Ontario’s14 LHIN regions. However, a more variable pattern of utilization emerged among the province’s 36 Public Health Unit (PHU) regions. Table 3 shows that PHUs with large rural catchment areas had the largest proportions of governmentfunded home care users. These include Eastern Ontario and Leeds in the eastern part of the province, Muskoka–Parry Sound and Haliburton in the north central part, and Chatham-Kent in southwestern Ontario. The lowest use was apparent in the more heavily populated urban regions of the Greater Toronto Area (Durham, York, Peel), Hamilton and Niagara and in south central Ontario (Waterloo and Brant). Fig. 1 shows the use of government-funded home care in Ontario’s LHINs and PHUs. The map reflects the data in Table 3, which clearly shows the highest rates of use (4–7%), were in the rural areas of central and eastern Ontario, and in the southwestern portion of the province. The lowest rates of use (1–3.9%) were in the regions of Ottawa and Kingston in eastern Ontario, the Greater Toronto Area, and in Windsor-Essex in the southernmost tip of the province.

Government-funded home care services Highest use Eastern Ontario Muskoka-Parry Sound Leeds, Grenville & Lanark District Haliburton, Kawartha, Pine Ridge District Chatham-Kent

9841 6366 7837 7800 4292

6.7 6.7 6.0 6.0 5.4

9092 13,976 6561 16,531 982

2.1 1.9 1.8 1.8 1.0

Non-government funded home care services Highest use Peterborough County-City 7177 Niagara Regional Area 21,600 Renfrew County & District 4510 Muskoka-Parry Sound 5972 Lambton 5965

7.1 6.6 6.3 6.3 6.2

Lowest use Durham Regional City of Hamilton The District of Algoma Huron County Brant County

1.6 1.5 1.3 1.3 0.8

Lowest use Durham Regional York Regional Waterloo Peel Regional Brant County

6824 5972 1121 556 1537

2.1.3. Home care use across the urban to rural continuum A series of contingency tables were created to measure the extent of home care use across four geographic areas (MIZ) representing the urban to rural continuum. The results are presented in Figs. 2–8. Fig. 2 reveals that the use of government and non-government funded home care services was fairly even in the four zones with the Moderate MIZ having a slightly higher proportion of users of each type of service. Figs. 3 and 4 illustrate the use of five types of government-funded home care services. First, the use of nursing care (dressing changes, preparing medications, etc.), was evenly distributed in three zones (CMA/CA, Strong MIZ, Weak/No MIZ) but substantially higher in the Moderate MIZ. Second, the use of personal care (e.g. bathing, foot care) was less in the Weak/No MIZ. Third, possibly reflecting levels of availability, the use of health services (e.g. physiotherapy, nutrition counseling) dropped from urban to rural and was the lowest in the Moderate MIZ and Weak/No MIZ. Fourth, there was no difference in the four MIZ among people receiving housework support (e.g. cleaning, laundry) as a type of government-funded home care. Finally, as illustrated in Fig. 4, people residing in the Weak/No MIZ were much more likely to receive meals (42%) than their rural or urban counterparts. Figs. 5 and 6 display the use of four types of non-government funded home care, which was further subdivided into two categories: (1) self-financed formal care, involving a nurse or homemaker and (2) informal services, involving care from a neighbour/friend or family member. Fig. 5 demonstrates that when paying out-of-pocket, the use of a nurse or homemaker dropped across the urban to rural continuum (from 7.5% in CMA/CAs to 2.5% in the Weak/No MIZ for a nurse and from 14.7% in CMA/CAs to 10% in the Weak/No MIZ for a homemaker). Fig. 6 shows a small difference in respondents receiving home care from a relative or friend (19.5% in CMA/CAs and 17.5% the Weak/No MIZ). However, Fig. 6 reveals a greater

200

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Fig. 1. Received government home care services: Ontario, 2005/07 (precent of population aged 20 and over). Provincial total: 3.0%.

Percentage

5 4

4.5

3 2.8

2

3.8

3.7

3.2

3.2

2.8

3.1

1 0 Non-Government Funded Services

Government Funded Services CMA/CA

Moderate MIZ

Strong MIZ

Weak or no MIZ

70 60 50 40 30 20 10 0

55.4

63.0 54.0

56.0

20.8

14.0

Nurse

20.2

16.2

12.0

Personal care CMA/CA

Strong MIZ

Moderate MIZ

16.8

10.1

Health services Weak or no MIZ

Fig. 3. Population aged 20 and over receiving government-funded home care services: Ontario, 2005/07 by place of residence.

50 Percentage

Percentage

Fig. 2. Population aged 20 and over receiving home care services: Ontario, 2005/07 by place of residence.

40

42.0 32.3

33.0

32.7

32.7

30

23.1

27.0

23.2

20 10 0 House work CMA/CA

Strong MIZ

Meals Moderate MIZ

Weak or no MIZ

Fig. 4. Population aged 20 and over receiving government funded home care services: Ontario, 2005/07 by place of residence.

12.2

P. Kitchen et al. / Health & Place 17 (2011) 195–206

14.7

16 Percentage

201

10.4

12

9.6

10.0

7.5

8

4.2

4

2.5

2.4

0 Nurse CMA/CA

Homemaker Strong MIZ

Moderate MIZ

Weak or no MIZ

Percentage

Fig. 5. Population aged 20 and over receiving non-government funded home care services: Ontario, 2005/07 by place of residence.

80 70 60 50 40 30 20 10 0

62.0

24.0

19.5

20.5

72.3

68.3

17.5

Neighbour/friend CMA/CA

69.8

Family member

Strong MIZ

Moderate MIZ

Weak or no MIZ

Percentage

Fig. 6. Population aged 20 and over receiving non-government funded home care services: Ontario, 2005/07 by place of residence.

100 90 80 70 60 50 40 30 20 10 0

73.2

21.4

15.6

11.9

80.4

85.0

81.0

12.1

Informal

Self-Financed Formal Care CMA/CA Moderate MIZ

Strong MIZ Weak or no MIZ

Fig. 7. Population aged 20 and over receiving non-government funded home care services: Ontario, 2005/07 by place of residence.

Percentage

25

21.6

20

24.4

22.3 16.7

15.6

12.8

15

19.6 16.7

10 5

2.0

1.8

2.0

1.9

0 Unmet needs

Care not rec'd: Not available in area CMA/CA

Strong MIZ

Moderate MIZ

Care not rec'd: Cost

Weak or no MIZ

Fig. 8. Self-perceived unmet home care needs and reason why care not received population aged 20 and over: Ontario, 2005/07 by place of residence.

reliance on care from family members between urban and rural areas (62% in CMA/CAs and 68.3% in the Weak/No MIZ). Fig. 7 is a summary of the data presented in Figs. 5 and 6 and shows a clear drop across the urban to rural continuum in the use of home care services that were self-financed and an increased reliance on informal care. These trends may reflect the inability of rural residents to pay for some home care services and/or the lack of availability of for-profit home care services in rural and remote areas.

Fig. 8 shows that perception of unmet home care needs was identical across the urban to rural continuum with about 2% of respondents in each of the four zones reporting unmet needs. However, when asked about the reasons for these unmet needs, important differences were evident between urban and rural residents. Far more rural residents reported that home care services were not available in their area, particularly residents of Moderate MIZ. (This CCHS question, however, does not distinguish the type of unmet home care service). Interestingly, the cost of

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Table 4 Sample characteristics for independent variables: population aged 20 and over in Ontario (all respondents, n¼46,862) a. Variable Gender Male Female Age 20–34 35–49 50–64 65 and over Marital status Single Married/common Law Separated/divorced Widowed Household income Under $20,000 $20,000–$49,999 $50,000–$79,999 $80,000 and over Education Less than High School High School College/Trades Cert. University Self-rated health Excellent/very good Good Fair/poor Rural residence Urban Rural Place of residence CMA/CA Strongly Infl. MIZ Moderately Infl. MIZ Weakly/Not Infl. MIZ

a

21,321 (45.5%) 25,541 (54.5%) 10,381 13,100 12,454 10,927

(22.2%) (27.9%) (26.6%) (23.3%)

8686 27,906 5444 4824

(18.5%) (59.5%) (11.6%) (10.3%)

5967 14,862 11,692 14,341

(12.7%) (31.7%) (24.9%) (30.6%)

5904 8622 18,041 14,492

(12.6%) (18.5%) (38.5%) (30.5%)

26,928 (57.5%) 13,210 (28.2%) 6724 (14.3%) 37,319 (79.6%) 9543 (20.4%) 36,638 3882 3814 2528

(78.2%) (8.3%) (8.1%) (5.4%)

Missing cases (n ¼9938) were dropped for the regression analyses.

home care was cited as a factor for unmet needs far more frequently among urban residents than those living in more rural and remote areas of Ontario.

2.1.4. Determinants of home care use A series of four logistic regression analyses was performed on the pooled 2005/07 CCHS data to assess the most significant determinants of home care use in Ontario. Each regression included three models where the independent variables were phased into the analysis. The sample characteristics of the eight independent variables are listed in Table 4. The data are reflective of the entire CCHS sample where there were higher proportions of female (55%); married (60%) and university educated (30%) respondents compared to the actual population. As shown in Table 4, only one health variable (self-rated health) was included in the analysis. Previous studies on home care (e.g. Hall and Coyte, 2001; Forbes et al., 2003) included additional variables such as the presence of a chronic condition and participation/activity limitation among respondents. The first round of analysis for this paper included these two variables. However, the results pointed to a high degree of inter-correlation between self-rated health and the presence of a chronic condition or participation/activity limitation. This finding suggests that a person who rates his or her health as fair or poor is likely to suffer from at least one chronic illness and to experience some activity limitation. For this reason, the decision was made to include self-rated health as the sole health-related variable in the data analysis.

Table 5 shows the results of the first regression analysis where respondents who received government-funded home care services were treated as the dependent variable, with the independent variables having significant odds ratios (po0.05 and 0.01) marked with asterisks. Model 1 consists of five socio-economic and one health variable. In Model 2, the urban–rural variable was added to the analysis to test the effect of place of residence on the use of government-funded home care. In Model 3, the urban–rural variable was replaced by the variable denoting the four geographic zones (MIZ) to determine the influence of distance from an urban centre on the likelihood of receiving home care services. The results indicate that older people were three times more likely (OR¼3.16) to receive government-funded home care than people aged 20–34. People in the lowest income households (under $20,000) were nearly twice as likely (OR¼1.93) to receive government-funded home care than those in the highest income households ($80,000+). People who rated their health as ‘Fair/Poor’ were 6 times more likely to receive government-funded home care than those who reported ‘Excellent/Very Good’ health. Rural residents (OR¼1.35) and those residing in the Moderate MIZ (OR¼1.31) were more likely to receive government-funded home care services than their urban counterparts. Tables 6 and 7 display the results of two regression analyses where the use of non-government funded home care was divided into two categories: self-financed formal care (Table 6) and informal services (Table 7). As shown in Table 1, the CCHS includes a single question on non-government funded home care and does not make a distinction between services which were paid for, such as a nurse or homemaker, or which were provided by a friend or family member. In an effort to reflect this important difference, the original CCHS variable was re-coded to create separate categories of non-government-funded home care. When comparing the results of the two analyses (independent variables with significant odds ratios) several important differences are apparent. First, women and seniors were far more reliant on home care services, which they paid for (Table 6) than on informal services (Table 7). Second, people living in households with lower incomes, particularly under $50,000, relied more on informal services. Third, there was a marked difference in health status, with people reporting ‘Fair/Poor’ health far more likely to be dependent on informal services (OR¼9.62). Fourth, geography was not a significant determinant of home care that was self-financed but rural residents were more likely to receive home care from informal caregivers (OR¼1.23). Table 8 sheds light on the factors influencing perception of unmet home care needs in Ontario. The CCHS question refers specifically to home care services not received when needed. The regression models suggest that this perception was strongest among women (OR¼2.24), those aged 35–49 (OR¼1.81), and residents of households with income less than $50,000 (OR¼2.02 and 1.67). In addition, respondents with a university education were more likely to report unmet needs than those with a high school diploma (OR¼0.57). Health was a factor in these perceptions, especially among respondents reporting ‘Fair/Poor’ health (OR¼9.98). Finally, place of residence and rurality did not influence perceptions of unmet home care needs.

3. Discussion The data analysis revealed several key findings with respect to home care provision in Ontario. In 2005/07, 3% of residents aged 20 or over received some form of government-funded home care, 2.7% received non-government funded services, and 0.6% received both types. Most home care recipients were women and seniors. Reflecting the province’s population distribution, the vast majority

P. Kitchen et al. / Health & Place 17 (2011) 195–206

203

Table 5 Odds ratios for receiving government-funded home care services: Ontario, age 20 and over, 2005/07. Variable

Model 1

Model 2

Model 2

Male Female Age 20–34 Age 35–49 Age 50–64 Age 65 and over Single Married/common Law Separated/divorced Widowed $80,000 and over Under $20,000 $20,000–$49,999 $50,000–$79,999 University Less than High School High School College/Trades Certif Self-rated health Excellent/very good Good Fair/poor Rural residence Urban Rural Place of residence CMA/CA Strongly influenced Moderately influenced Weakly/not influenced

Reference 1.28 (1.13-1.45)nn Reference 0.93 (0.75–1.16) 1.10 (0.88–1.37) 3.16 (2.55–3.91)nn Reference 1.34 (1.09–1.66)nn 1.12 (0.84–1.48) 2.08 (1.60–2.70)nn Reference 1.93 (1.57–2.38)nn 1.38 (1.17–1.63)nn 1.07 (0.90–1.28) Reference 0.90 (0.75–1.08) 0.87 (0.72–1.04) 1.34 (1.06–1.69)nn

Reference 1.29 (1.14–1.46)nn Reference 0.93 (0.74–1.15) 1.08 (0.87–1.35) 3.14 (2.53–3.89)nn Reference 1.32 (1.06–1.63)nn 1.12 (0.84–1.48) 2.07 (1.59–2.69)nn Reference 1.92 (1.56–2.37)nn 1.37 (1.15–1.61)nn 1.06 (0.89–1.27) Reference 0.90 (0.75–1.07) 0.87 (0.72–1.04) 1.33 (1.06–1.68)nn

Reference 1.28 (1.14–1.45)nn Reference 0.93 (0.75–1.16) 1.09 (0.87–1.36) 3.15 (2.54–3.91)nn Reference 1.33 (1.07–1.64)nn 1.12 (0.84–1.49) 2.07 (1.59–2.69)nn Reference 1.91 (1.55–2.35)nn 1.36 (1.15–1.61)nn 1.06 (0.89–1.27) Reference 0.90 (0.75–1.08) 0.87 (0.72–1.04) 1.34 (1.06–1.69)nn

Reference 1.80 (1.54–2.10)nn 6.16 (5.31–7.13)nn

Reference 1.81 (1.55–2.12)nn 6.23 (5.38–7.22)nn

Reference 1.81 (1.55–2.11)nn 6.18 (5.34–7.17)nn

Reference 1.35 (1.15–1.57)nn Reference 1.18 (0.92–1.51) 1.31 (1.02–1.67)nn 1.04 (0.74–1.48)

95% CI in brackets. nn

p o0.01.

Table 6 Odds ratios for receiving self-financed formal home care: Ontario, age 20 and over, 2005/07. Variable

Model 1

Model 2

Model 3

Male Female Age 20–34 Age 35–49 Age 50–64 Age 65 and over Single Married/common Law Separated/divorced Widowed $80,000 and over Under $20,000 $20,000 to $49,999 $50,000 to $79,999 University Less than High School High School College/Trades Certif. Self-rated health Excellent/very good Good Fair/poor Rural residence Urban Rural Place of residence CMA/CA Strongly influenced Moderately influenced Weakly/not influenced

Reference 2.59 (1.92–3.49)nn Reference 1.55 (0.93–2.59) 1.66 (0.97–2.83) 5.07 (3.00–8.55)nn Reference 1.07 (0.65–1.75) 1.43 (0.78–2.61) 2.21 (1.25–3.89)nn Reference 1.15 (0.73–1.79) 1.01 (0.71–1.43) 0.84 (0.58–1.23) Reference 0.71 (0.48–1.06) 0.55 (0.34–0.87)n 1.03 (0.60–1.75)

Reference 2.60 (1.93–3.51)nn Reference 1.54 (0.92–2.58) 1.64 (0.96–2.80) 5.05 (2.99–8.53)nn Reference 1.05 (0.64–1.72) 1.43 (0.78–2.62) 2.19 (1.24–3.87)nn Reference 1.13 (0.72–1.78) 1.00 (0.71–1.42) 0.83 (0.57–1.22) Reference 0.70 (0.47–1.05) 0.54 (0.34–0.86)n 1.03 (0.60–1.75)

Reference 2.58 (1.91–3.48)nn Reference 1.55 (0.92–2.59) 1.67 (0.98–2.85) 5.09 (3.02–8.60) nn Reference 1.08 (0.66–1.76) 1.43 (0.78–2.61) 2.21 (1.25–3.90) nn Reference 1.17 (0.75–1.83) 1.03 (0.73–1.46) 0.85 (0.58–1.24) Reference 0.72 (0.48–1.07) 0.55 (0.35–0.87)n 1.03 (0.60–1.76)

Reference 1.62 (1.18–2.23)nn 3.66 (2.66–5.03)nn

Reference 1.63 (1.18–2.24)nn 3.70 (2.69–5.09)nn

Reference

95% CI in brackets. n

p o 0.05 p o0.01

nn

Reference 1.26 (0.89–1.78) Reference 1.14 (0.64–1.92) 0.61 (0.29–1.28) 0.46 (1.55–1.37)

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Table 7 Odds ratios for receiving informal home care: Ontario, age 20 and over, 2005/07 Variable

Model 1

Model 2

Model 3

Male Female Age 20–34 Age 35–49 Age 50–64 Age 65 and over Single Married/common Law Separated/divorced Widowed $80,000 and over Under $20,000 $20,000 to $49,999 $50,000 to $79,999 University Less than High School High School College/Trades Certif. Self-rated health Excellent/very good Good Fair/poor Rural residence Urban Rural Place of residence CMA/CA Strongly influenced Moderately influenced Weakly/not influenced

Reference 1.54 (1.34–1.77)nn Reference 0.90 (0.72–1.13) 0.83 (0.65–1.05) 1.73 (1.36–2.19) nn Reference 1.13 (0.90–1.41) 1.28 (0.96–1.71) 2.11 (1.58–2.82)nn Reference 1.70 (1.33–2.18)nn 1.86 (1.53–2.25)nn 1.44 (1.18–1.76)nn Reference 0.94 (0.76–1.15) 0.70 (0.57–0.88)nn 1.18 (0.91–1.53)

Reference 1.55 (1.35–1.79)nn Reference 0.90 (0.72–1.12) 0.82 (0.65–1.04) 1.72 (1.36–2.18)nn Reference 1.11 (0.89–1.39) 1.28 (0.96–1.71) 2.10 (1.58–2.81)nn Reference 1.70 (1.32–2.18)nn 1.85 (1.53–2.24)nn 1.44 (1.17–1.76)nn Reference 0.93 (0.76–1.13) 0.70 (0.56–0.87)nn 1.18 (0.90–1.53)

Reference 1.55 (1.35–1.78)nn Reference 0.90 (0.72–1.13) 0.83 (0.65–1.05) 1.73 (1.36–2.19)nn Reference 1.11 (0.89–1.39) 1.28 (0.96–1.71) 2.10 (1.57–2.80)nn Reference 1.68 (1.31–2.15)nn 1.83 (1.51–2.22)nn 1.43 (1.17–1.75)nn Reference 0.92 (0.75–1.13) 0.70 (0.56–0.87)nn 1.18 (0.91–1.53)

Reference 2.41 (2.01–2.90)nn 9.62 (8.07–11.45)nn

Reference 2.42 (2.02–2.91)nn 9.69 (8.13–11.54)nn

Reference 2.42 (2.01–2.91)nn 9.67 (8.12–11.51)nn

Reference 1.23 (1.02–1.47)n Reference 1.28 (0.98–1.68) 1.29 (0.97–1.71) 1.08 (0.73–1.60)

95% CI in brackets. n

p o 0.05 p o0.01,

nn

of home care users (more than 80%) lived in urban areas. However, rural residents were more likely than their urban counterparts to receive government-funded home care, particularly nursing care. With respect to non-government funded services, rural residents were less likely to receive nursing care and were more reliant on informal care provided by family members, relatives or friends. This may suggest that skilled nursing services not funded by government were less available to people living in rural areas or that rural residents were less able to afford nursing services that had to be purchased. In terms of the socio-demographic, health and geographic predictors of home care use, the data analysis revealed that the use of government-funded home care was more prevalent among women, seniors, the widowed, those with lower incomes and poorer health and people residing in rural areas of Ontario. Two types of non-government funded home care were examined (selffinanced formal services and informal services) and a similar set of predictors were uncovered: women and seniors were more dependent on services that they paid for while those with lower income and poorer health and people residing in rural areas were more likely to receive informal care. In total, about 6% of Ontario’s population aged 20 and over used some form of home care in 2005/07. However, utilization of home care services is expected to increase as the older population grows in size and as deinstitutionalization and community-based care are further promoted by the provincial government. Ontario’s ‘‘Aging at Home Strategy’’, announced in 2007, indicates the province’s intent to encourage Ontarians to age in place. Thus, it is opportune to examine patterns of home care utilization—who the home care users are, where are they located and what services they use. This study pays special attention to the geographic patterns of home care use—not only how rural and urban Ontarians differ in their use

of home care, but also differences in utilization by residents of different types of rural areas. Pong et al. (2010) have identified rural–urban differences in the way health services are used by Canadians. However, that study focuses mostly on the use of physician and hospital services that are covered by Canada’s medicare system. This article complements the Pong et al. (2010) study by revealing similar differences in home care use between rural and urban Ontarians and between Ontarians living in different regions. Insights gained from examining regional variations in health care utilization patterns can help guide policy-making and program planning. Another reason for paying attention to rural residents’ home care utilization patterns stems from the fact that rural Canadians tend to be older—those who are more likely to need home care. This study has shown that different regions of Ontario exhibited different patterns of home care utilization. For instance, the highest use of government-funded home care occurred in the eastern and northern parts of the province and the lowest rates of use appeared around the Greater Toronto Area. Thus, rather than adopting an one-size-fits-all home care policy or program, Ontario should encourage LHINs to adopt policies or design programs that best fit their regional needs or preferences. Similarly, residents in different types of rural areas use home care services differently. For instance, residents in Moderate and Weak/No MIZ were less likely to use nursing services that they have to purchase. Instead, they rely more on informal care. There is a need for the provincial ministry of health or LHINs, particularly those with large rural catchment areas, to examine the reasons behind such disparities and how home care-dependent residents living in the most vulnerable areas can be supported. Informal care is an area that has not received much public or government attention, possibly because it is often considered to be a family matter and not a public

P. Kitchen et al. / Health & Place 17 (2011) 195–206

205

Table 8 Odds ratios for self-perceived unmet home care needs: Ontario, age 20 and over, 2005/07. Variable

Model 1

Model 2

Model 3

Male Female Age 20–34 Age 35–49 Age 50–64 Age 65 and over Single Married/common Law Separated/divorced Widowed $80,000 and over Under $20,000 $20,000 to $49,999 $50,000 to $79,999 University Less than High School High School College/Trades Certif Self-rated health Excellent/very good Good Fair/poor Rural residence Urban Rural Place of residence CMA/CA Strongly influenced Moderately influenced Weakly/not influenced

Reference 2.24 (1.93–2.61)nn Reference 1.81 (1.44–2.28)nn 1.41 (1.10–1.81)nn 1.35 (1.03–1.77)n Reference 0.74 (0.60–0.91)nn 1.10 (0.85–1.42) 1.61 (1.20–2.15)nn Reference 2.02 (1.59–2.56)nn 1.67 (1.38–2.03)nn 1.22 (0.99–1.49) Reference 0.84 (0.68–1.05) 0.57 (0.45–0.73)nn 1.09 (0.84–1.43)

Reference 2.25 (1.93–2.61)nn Reference 1.81 (1.44–2.27)nn 1.41 (1.10–1.80)nn 1.35 (1.02–1.77)n Reference 0.73 (0.59–0.90)nn 1.10 (0.85–1.42) 1.61 (1.20–2.15)nn Reference 2.02 (1.59–2.56)nn 1.67 (1.38–2.03)nn 1.22 (0.99–1.49) Reference 0.84 (0.68–1.05) 0.57 (0.45–0.73)nn 1.09 (0.84–1.42)

Reference 2.24 (1.92–2.60)nn Reference 1.81 (1.44–2.27)nn 1.42 (1.12–1.81)nn 1.35 (1.03–1.77)n Reference 0.74 (0.60–0.91) 1.10 (0.85–1.42) 1.61 (1.21–2.16) Reference 2.03 (1.60–2.58)nn 1.68 (1.39–2.04)nn 1.22 (0.99–1.50)n Reference 0.85 (0.68–1.06) 0.57 (0.45–0.73)nn 1.09 (0.84–1.42)

Reference 2.16 (1.79–2.61)nn 9.98 (8.37–11.89)nn

Reference 2.16 (1.79–2.61)nn 10.00 (8.3–11.9)nn

Reference 2.16 (1.79–2.61)nn 9.97 (8.36–11.8)nn

Reference 1.08 (0.89–1.31) Reference 0.96 (0.71–1.32) 0.89 (0.64–1.25) 0.74 (0.46–1.19)

95% CI in brackets. n

p o 0.05. p o0.01.

nn

policy issue. But, as this and other studies have shown, informal care and services provided by volunteers have a vital role to play in supporting those who need care but have chosen to stay at home, especially those who live in areas where formal services may be scarce, unavailable or not affordable (Pong, 2009; Williams, 2006). The paper described how Ontario went through a major reorganization of its home care sector starting in the mid-1990s with the creation of CCACs and the adoption of a mixed market approach to the delivery of services. Nonprofit agencies were forced to compete for home care contracts with private for-profit operators. While the merits of this policy shift can be debated, findings from this study suggest that managed competition works reasonably well for patients and their families if they reside in or close to urban areas. Overall, there is an acceptable range of professional services (e.g. nurses, homemakers, therapists) that are available—be they publicly funded or offered by the private sector. Also, because of their higher socio-economic status, it is likely that urban residents are better able to self-finance home care services compared to their rural counterparts. However, we can speculate that managed competition may not work as well in more remote areas as market conditions in less populated areas may be less congenial to private enterprises in home care services. This may result in increased pressure on families, friends and volunteers to provide informal care often in difficult conditions. The Ontario government should consider providing more funding for nonprofit home care agencies in rural areas with part of the funds used to attract and retain health care professionals. From a policy perspective, another aspect is equity in access to health care. This is an important issue in the Canadian health care system, particularly since accessibility is one of the five principles of the Canada Health Act, which undergirds the national Medicare system. Substantial regional disparities in utilization suggest

potential inequity in access to health care based on where people live and their socio-economic status. This study has found considerable urban–rural and intra-rural variations in use of different types of home care. Whether such regional variations constitute inequity and the causes of such variations deserve further investigation. From an international perspective, a parallel can be drawn between Canada and other nations. For instance, several countries in Western Europe reserve state funded health care services for lower-income people and have invested heavily in home care services. Countries such as Germany and the Netherlands have created a single funding stream for home care (WHO, 2008). In a recent paper, Szebehely (2009) compared resources for eldercare services in Canada and Sweden. Sweden is one the most generous countries in the world spending 2.74% of its GDP on eldercare services compared to 0.99% on average in the OECD and in Canada. Like Canada, there has been a growth in non-public eldercare services in Sweden, although private sector involvement is still comparatively small (Szebehely, 2009, p. 113). There are a number of avenues for further research on home care. One topic that warrants additional study is the effect of managed competition on the availability and quality of home care services in rural and remote regions. This could be achieved through a research program which combines quantitative and qualitative analysis. For example, survey data (e.g. CCHS) could be analyzed of users of multiple types of home care (nonprofit, private for-profit and informal) in a sample of Ontario’s northern and rural LHINs and by metropolitan influence zone (MIZ). This analysis would be complemented by a series of in-depth interviews with officials at the local CCASs to acquire a better understanding of the challenges of rural and remote home care delivery in a competitive market setting. Such a study would have important policy implications for Ontario and could be used as the basis for international

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P. Kitchen et al. / Health & Place 17 (2011) 195–206

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