Forecasting Staffing Needs for Ontario's Long-Term Care Sector.

This paper presents a forecasting model for personal support workers (PSWs) and nurses (registered nurses [RNs] and registered practical nurses [RPNs]) for Ontario's long-term care (LTC) sector. In the base-case scenario, the model projects a shortfall in the supply of full-time equivalent (FTE) workers required to meet the expected demand for care for all workers by 2035, which would require an estimated increase of 11,632 FTE PSWs, 6,031 FTE RNs and 10,178 FTE RPNs entering the market by 2035. The results of this paper may have important implications for health human resources policy planning in Ontario's LTC sector.

The Introduction of New Non-Drug Health Technologies into Canadian Healthcare Institutions: Opportunities and Challenges.

INTRODUCTION: A recent pan-Canadian survey of 48 health organizations concluded that structures, processes, factors and information used to support funding decisions on new non-drug health technologies (NDTs) vary within and across jurisdictions in Canada. METHODS: A self-administered survey was used to determine demographic and financial characteristics of organizations, followed by in-depth interviews with senior leadership of consenting organizations to understand the processes for making funding decisions on NDTs. RESULTS: Seventy-three and 48 organizations completed self-administered surveys and telephone interviews, respectively (with 45 participating in both ways). Fifty-five different processes were identified, the majority of which addressed capital equipment. Most involved multidisciplinary committees (with medical and non-medical representation), but the types of information used to inform deliberations varied. Across all processes, decision-making criteria included local considerations such as alignment with organizational priorities. CONCLUSIONS: NDT decision-making processes vary in complexity, depending on characteristics of the healthcare organization and context.

Ontario's Retirement Homes and Long-Term Care Homes: A Comparison of Care Services and Funding Regimes.

ABSTRACTGrowing demand for beds in government-subsidized long-term care (LTC) homes in Ontario is causing long waitlists, which must be absorbed by other residential alternatives, including unsubsidized retirement homes. This study compares Ontario's LTC homes and retirement homes for care services provided, funding regimes, and implications of differential funding for seniors. Descriptive data for both types of homes were collected from public and proprietary sources regarding service offerings, availability, costs, and funding. Overlaps exist in the services of both LTC and retirement homes, particularly at higher levels of care. Although both sectors charge residents for accommodation, most care costs in LTC homes are publicly funded, whereas residents in retirement homes generally cover these expenses personally. Given waitlists in Ontario's LTC homes, many seniors must find residential care elsewhere, including in retirement homes. Several policy alternatives exist that may serve to improve equity of access to seniors' residential care.

Organizational responses to accountability requirements: Do we get what we expect?

BACKGROUND: In health care, accountability is being championed as a promising approach to meeting the dual imperatives of improving care quality while managing constrained budgets. PURPOSES: Few studies focus on public sector organizations' responsiveness to government imperatives for accountability. We applied and adapted a theory of organizational responsiveness to community care agencies operating in Ontario, Canada, asking the question: What is the array of realized organizational responses to government-imposed accountability requirements among community agencies that receive public funds to provide home and community care? METHODOLOGY/APPROACH: A sequential complementary mixed methods approach was used. It gathered data through a survey of 114 home and community care organizations in Ontario and interviews with 20 key informants representing 13 home and community care agencies and four government agencies. It generated findings using a parallel mixed analysis technique. FINDINGS: In addition to responses predicted by the theory, we found that organizations engage in active, as well as passive, forms of compliance; we refer to this response as internal modification in which internal policies, practices, and/or procedures are changed to meet accountability requirements. We also found that environmental factors, such as the presence of an association representing organizational interests, can influence bargaining tactics. PRACTICE IMPLICATIONS: Our study helps us to better understand the range of likely responses to accountability requirements and is a first step toward encouraging the development of accountability frameworks that favor positive outcomes for organizations and those holding them to account. Tailoring agreements to organizational environments, aligning perceived compliance with behaviors that encourage improved performance, and allowing for flexibility in accountability arrangements are suggested strategies to support beneficial outcomes.

The Canada Health Act for the Twenty-First Century?.

As the participants in the Canada Health Act, Version 2.0 conference made clear, there is a strong case to be made that this key piece of legislation no longer captures some key challenges to managing health care in Canada. Particular issues include 'portability' across provincial/territorial boundaries, and the definition of insured services. However, the CHA is not a barrier to reform; it acts as a floor, rather than a ceiling. Health reform may thus require a combination of new legislation to set conditions for which new services should be insured, and developing mechanisms to identify priorities, ensure appropriateness, and improve efficiency, which are unlikely to be addressed through overarching legislation. The CHA should thus be maintained, recognizing that it is necessary, but not sufficient.

Funding Long-Term Care in Canada: Who Is Responsible for What?

As Adams and Vanin (2016) have noted, different ways of funding long-term care (LTC) have different implications. Because health is not just healthcare, and LTC is not homogeneous, determining the appropriate public-private mix is complex. We suggest that how issues are framed helps influence policy choices, including who should pay for what, and how things should be financed. In addition, the distribution of expenditures for some services can be highly skewed, affecting the extent to which average cost data are useful in extrapolating their costs. We note that health expenditures fall into multiple categories, each presenting different policy issues. For example, framing LTC as health, as basic costs associated with living or as forced savings (like pensions) affects which funding approaches might be used, and the extent to which changes in the population distribution will affect cost structures. Underlying these discussions are questions of solidarity, and how much we believe that we are our brother's - or grandmother's - keeper.

Paying for Primary Care: The Factors Associated with Physician Self-selection into Payment Models.

To determine the factors associated with primary care physician self-selection into different payment models, we used a panel of eight waves of administrative data for all primary care physicians who practiced in Ontario between 2003/2004 and 2010/2011. We used a mixed effects logistic regression model to estimate physicians' choice of three alternative payment models: fee for service, enhanced fee for service, and blended capitation. We found that primary care physicians self-selected into payment models based on existing practice characteristics. Physicians with more complex patient populations were less likely to switch into capitation-based payment models where higher levels of effort were not financially rewarded. These findings suggested that investigations aimed at assessing the impact of different primary care reimbursement models on outcomes, including costs and access, should first account for potential selection effects.

Paying for primary care: a cross-sectional analysis of cost and morbidity distributions across primary care payment models in Ontario Canada.

Policy-makers desire an optimal balance of financial incentives to improve productivity and encourage improved quality in primary care, while also avoiding issues of risk-selection inherent to capitation-based payment. In this paper we analyze risk-selection in capitation-based payment by using administrative data for patients (n = 11,600,911) who were rostered (i.e., signed an enrollment form, or received a majority of care) with a primary care physician (n = 8621) in Ontario, Canada in 2010/11. We analyze this data using a relative distribution approach and compare distributions of patient costs and morbidity across primary care payment models. Our results suggest a relationship between being in a capitation-based payment scheme and having low cost patients (and presumably healthy patients) compared to fee-for-service physicians. However, we do not have evidence that physicians in capitation-based models are reducing the care they provide to sick and high cost patients. These findings suggest there is a relationship between payment type and risk-selection, particularly for low-cost and healthy patients.

Thinking about accountability.

Accountability is a key component of healthcare reforms, in Canada and internationally, but there is increasing recognition that one size does not fit all. A more nuanced understanding begins with clarifying what is meant by accountability, including specifying for what, by whom, to whom and how. These papers arise from a Partnership for Health System Improvement (PHSI), funded by the Canadian Institutes of Health Research (CIHR), on approaches to accountability that examined accountability across multiple healthcare subsectors in Ontario. The partnership features collaboration among an interdisciplinary team, working with senior policy makers, to clarify what is known about best practices to achieve accountability under various circumstances. This paper presents our conceptual framework. It examines potential approaches (policy instruments) and postulates that their outcomes may vary by subsector depending upon (a) the policy goals being pursued, (b) governance/ownership structures and relationships and (c) the types of goods and services being delivered, and their production characteristics (e.g., contestability, measurability and complexity).

Acute care hospitals' accountability to provincial funders.

Ontario's acute care hospitals are subject to a number of tools, including legislation and performance measurement for fiscal accountability and accountability for quality. Examination of accountability documents used in Ontario at the government, regional and acute care hospital levels reveals three trends: (a) the number of performance measures being used in the acute care hospital sector has increased significantly; (b) the focus of the health system has expanded from accountability for funding and service volumes to include accountability for quality and patient safety; and (c) the accountability requirements are misaligned at the different levels. These trends may affect the success of the accountability approach currently being used.

Hospitals' internal accountability.

This study aimed to enhance understanding of the dimensions of accountability captured and not captured in acute care hospitals in Ontario, Canada. Based on an Ontario-wide survey and follow-up interviews with three acute care hospitals in the Greater Toronto Area, we found that the two dominant dimensions of hospital accountability being reported are financial and quality performance. These two dimensions drove both internal and external reporting. Hospitals' internal reports typically included performance measures that were required or mandated in external reports. Although respondents saw reporting as a valuable mechanism for hospitals and the health system to monitor and track progress against desired outcomes, multiple challenges with current reporting requirements were communicated, including the following: 58% of survey respondents indicated that performance-reporting resources were insufficient; manual data capture and performance reporting were prevalent, with the majority of hospitals lacking sophisticated tools or technology to effectively capture, analyze and report performance data; hospitals tended to focus on those processes and outcomes with high measurability; and 53% of respondents indicated that valuable cross-system accountability, performance measures or both were not captured by current reporting requirements.

Home and community care sector accountability.

This paper focuses on accountability for the home and community care (HCC) sector in Ontario. The many different service delivery approaches, funding methods and types of organizations delivering HCC services make this sector highly heterogeneous. Findings from a document analysis and environmental scan suggest that organizations delivering HCC services face multiple accountability requirements from a wide array of stakeholders. Government stakeholders tend to rely on regulatory and expenditure instruments to hold organizations to account for service delivery. Semi-structured key informant interview respondents reported that the expenditure-based accountability tools being used carried a number of unintended consequences, both positive and negative. These include an increased organizational focus on quality, shifting care time away from clients (particularly problematic for small agencies), dissuading innovation, and reliance on performance indicators that do not adequately support the delivery of high-quality care.

Accountability through regulation in Ontario's Medical Laboratory Sector.

Although the use of performance indicators for the analytical (and highly measurable) phase of the medical laboratory process has had a long and successful history, it is now recognized that the value of a laboratory test is embedded in a system of care. This case study, using both documents and interview data, examines the approaches to accountability in the Ontario Medical Laboratory Sector, noting both the challenges and benefits. This sector relies heavily on the regulation instrument, including a requirement that all medical laboratories licensed by the provincial government must follow the guidelines set out by the Quality Management Program - Laboratory Services. We found the greatest challenges exist in the pre-analytical phase (where a large portion of total laboratory errors occur), particularly the interface between the laboratory and other providers.

Hopes and realities of public health accountability policies.

Holding local boards of health accountable presents challenges related to governance and funding arrangements. These challenges result in (a) multiple accountability pressures, (b) population health outcomes whose change is measureable only over long time periods and (c) board of health activity that is often not the key immediate direct contributor to achieving desired outcomes. We examined how well these challenges are addressed in Ontario, Canada at early stages of implementation of a new accountability policy. Findings reveal that senior and middle management are open to being held accountable to the Ministry of Health and Long-Term Care (MOHLTC), but are more oriented to local boards of health and local/regional councils. These managers perceive the MOHLTC system as compliance oriented, and find internal accountability systems most helpful for performance improvement. Like health-care system accountability metrics, performance indicators are largely focused on structures and processes owing to the challenges of attributing population health outcomes to public health unit (PHU) activities. MOHLTC is in the process of responding to these challenges.

Accountability and primary healthcare.

This paper examines the accountability structures within primary healthcare (PHC) in Ontario; in particular, who is accountable for what and to whom, and the policy tools being used. Ontario has implemented a series of incremental reforms, using expenditure policy instruments, enforced through contractual agreements to provide a defined set of publicly financed services that are privately delivered, most often by family physicians. The findings indicate that reporting, funding, evaluation and governance accountability requirements vary across service provider models. Accountability to the funder and patients is most common. Agreements, incentives and compensation tools have been used but may be insufficient to ensure parties are being held responsible for their activities related to stated goals. Clear definitions of various governance structures, a cohesive approach to monitoring critical performance indicators and associated improvement strategies are important elements in operationalizing accountability and determining whether goals are being met.

Accountability in the City of Toronto's 10 long-term care homes.

Long-term care (LTC) residential homes provide a supportive environment for residents requiring nursing care and assistance with daily living activities. The LTC sector is highly regulated. We examine the approaches taken to ensure the delivery of quality and safe care in 10 LTC homes owned and operated by the City of Toronto, Ontario, focusing on mandatory accountability agreements with the Local Health Integration Networks (LHINs). Results are based on document review and seven interviews with LTC managers responsible for the management and operation of the 10 LTC homes. One issue identified was the challenges associated with implementing new legislative and regulatory requirements to multiple bodies with differing requirements, particularly when boundaries do not coincide (e.g., the City of Toronto's Long-Term Care Homes and Services Division must establish 10 different accountability agreements with the five LHINs that span into the City of Toronto's geographic area).

Ensuring accountability through health professional regulatory bodies: the case of conflict of interest.

How do self-regulated health professions' regulatory bodies address financial conflict of interest (coi) and ensure accountability to the public? using document analysis, we examined how four ontario regulatory colleges (physicians, nurses, physiotherapists, audiologists/speech-language pathologists) defined coi and the education, guidance and enforcement they provided for coi-related issues. These colleges are upholding the mandates to define, identify and address financial coi by providing regulations or standards and guidelines to their membership; they differed in the amount of educational materials provided to their registrants and in the possible coi scenarios they presented. Although there were few disciplinary hearings pertaining to financial coi, findings for the hearings that did occur were documented and posted on the college public registers (the listing of all registered college members along with all relevant practice information), informing the public of any limitations or restrictions placed on a member as a result of the hearing.

Information and communication technology (ICT) and eHealth policy in Latin America and the Caribbean: a review of national policies and assessment of socioeconomic context.

OBJECTIVE: To examine the availability of national information and communication technology (ICT) or eHealth policies produced by countries in Latin America and the Caribbean (LAC), and to determine the influence of a country's socioeconomic context on the existence of these policies. METHODS: Documents describing a national ICT or eHealth policy in any of the 33 countries belonging to the LAC region as listed by the United Nations were identified from three data sources: academic databases; the Google search engine; and government agencies and representatives. The relationship between the existence of a policy and national socioeconomic indicators was also investigated. RESULTS: There has been some progress in the establishment of ICT and eHealth policies in the LAC region. The most useful methods for identifying the policies were 1) use of the Google search engine and 2) contact with Pan American Health Organization (PAHO) country representatives. The countries that have developed a national ICT policy seem to be more likely to have a national eHealth policy in place. There was no statistical significant association between the existence of a policy and a country's socioeconomic context. CONCLUSIONS: Governments need to make stronger efforts to raise awareness about existing and planned ICT and eHealth policies, not only to facilitate ease of use and communication with their stakeholders, but also to promote collaborative international efforts. In addition, a better understanding of the effect of economic variables on the role that ICTs play in health sector reform efforts will help shape the vision of what can be achieved.

Information and communication technology (ICT) and eHealth policy in Latin America and the Caribbean: a review of national policies and assessment of socioeconomic context / Política en materia de eSalud y tecnologías de la información y la comunicación en América Latina y el Caribe: análisis de las políticas nacionales y evaluación del contexto socioeconómico

OBJECTIVE: To examine the availability of national information and communication technology (ICT) or eHealth policies produced by countries in Latin America and the Caribbean (LAC), and to determine the influence of a country's socioeconomic context on the existence of these policies. METHODS: Documents describing a national ICT or eHealth policy in any of the 33 countries belonging to the LAC region as listed by the United Nations were identified from three data sources: academic databases; the Google search engine; and government agencies and representatives. The relationship between the existence of a policy and national socioeconomic indicators was also investigated. RESULTS: There has been some progress in the establishment of ICT and eHealth policies in the LAC region. The most useful methods for identifying the policies were 1) use of the Google search engine and 2) contact with Pan American Health Organization (PAHO) country representatives. The countries that have developed a national ICT policy seem to be more likely to have a national eHealth policy in place. There was no statistical significant association between the existence of a policy and a country's socioeconomic context. CONCLUSIONS: Governments need to make stronger efforts to raise awareness about existing and planned ICT and eHealth policies, not only to facilitate ease of use and communication with their stakeholders, but also to promote collaborative international efforts. In addition, a better understanding of the effect of economic variables on the role that ICTs play in health sector reform efforts will help shape the vision of what can be achieved.

OBJETIVO: Analizar la disponibilidad de políticas nacionales en materia de tecnologías de la información y la comunicación (TIC) o eSalud formuladas por los países de América Latina y el Caribe, y determinar la influencia del contexto socioeconómico del país sobre la existencia de este tipo de políticas. MÉTODOS: Se seleccionaron documentos que describieran una política nacional de TIC o eSalud en cualquiera de los 33 países de América Latina y el Caribe según la clasificación de las Naciones Unidas, a partir de tres fuentes de datos: bases de datos académicas; el motor de búsqueda Google; y organismos y representaciones gubernamentales. También se investigó la relación entre la existencia de una política de este tipo y los indicadores socioeconómicos nacionales. RESULTADOS: Se ha producido algún progreso en el establecimiento de políticas de TIC y eSalud en América Latina y el Caribe. Los métodos más útiles para determinar las políticas fueron: 1) el uso del motor de búsqueda Google, y 2) el contacto con las representaciones de la Organización Panamericana de la Salud (OPS) en los países. Parece más probable que los países que han elaborado una política nacional de TIC hayan implantado también una política nacional de eSalud. No se observó ninguna asociación estadísticamente significativa entre la existencia de una política y el contexto socioeconómico de un país. CONCLUSIONES: Es preciso que los gobiernos intensifiquen las iniciativas para concientizar acerca de las políticas existentes y planificadas en materia de TIC y eSalud, no solo para facilitar su utilización y la comunicación con los interesados directos, sino también para promover iniciativas colaborativas a escala internacional. Por otra parte, una mejor comprensión del efecto de las variables económicas sobre la función que las TIC desempeñan en las iniciativas de reforma del sector de la salud ayudará a establecer la perspectiva de lo se puede llegar a lograr.

Barriers and facilitators to care for the terminally ill: a cross-country case comparison study of Canada, England, Germany, and the United States.

BACKGROUND: Why do many patients not die at their preferred location? AIM: Analyze system-level characteristics influencing the ability to implement best practices in delivering care for terminally ill adults (barriers and facilitators). DESIGN: Cross-country comparison study from a "most similar-most different" perspective, triangulating evidence from a scoping review of the literature, document analyses, and semi-structured key informant interviews. SETTING: Case study of Canada, England, Germany, and the United States. RESULTS: While similar with regard to leading causes of death, patient needs, and potential avenues to care, different models of service provision were employed in the four countries studied. Although hospice and palliative care services were generally offered with standard care along the disease continuum and in various settings, and featured common elements such as physical, psycho-social, and spiritual care, outcomes (access, utilization, etc.) varied across jurisdictions. Barriers to best practice service provision included legislative (including jurisdictional), regulatory (e.g. education and training), and financial issues as well as public knowledge and perception ("giving up hope") challenges. Advance care planning, dedicated and stable funding toward hospice and palliative care, including caregiver benefits, population aging, and standards of practice and guidelines to hospice and palliative care, were identified as facilitators. CONCLUSION: Successful implementation of effective and efficient best practice approaches to care for the terminally ill, such as shared care, requires concerted action to align these system-level characteristics; many factors were identified as being essential but not sufficient. Policy implementation needs to be tailored to the respective health-care system(s), monitored, and fine-tuned.