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Canadian Home Care Policy and Practice in Rural and Remote Settings:
Challenges and Solutions
Dorothy A. Forbesa; Dana S. Edgeb
a Arthur Labatt Family School of Nursing, The University of Western Ontario, Health Sciences
Addition, London, Ontario, Canada b School of Nursing, Queen's University, Kingston, Ontario,
Canada
To cite this Article Forbes, Dorothy A. and Edge, Dana S.(2009) 'Canadian Home Care Policy and Practice in Rural and
Remote Settings: Challenges and Solutions', Journal of Agromedicine, 14: 2, 119 — 124
To link to this Article: DOI: 10.1080/10599240902724135
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Journal of Agromedicine, 14:119–124, 2009
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ISSN: 1059-924X print/1545-0813 online
DOI: 10.1080/10599240902724135
119
WAGR Canadian Home Care Policy and Practice in Rural
and Remote Settings: Challenges and Solutions
Rural and Remote Home Care Dorothy A. Forbes, RN, PhD
Dana S. Edge, RN, PhD
ABSTRACT. With the aging of the population, especially in Canadian rural areas, providing home
care services will be particularly challenging as care is needed by increasingly vulnerable rural older
adults in increasingly vulnerable rural settings with fewer services, supports, and caregivers. The pur-
pose of this paper is to present examples of the federal (e.g., First Nations and Inuit Home and Com-
munity Care) and provincial (e.g., Ontario’s Community Care Access Centres) home care policy
context in which Canadian home care is provided, to identify the challenges faced by home care pro-
viders in meeting the needs of rural residents, and to offer solutions to these challenges. The most
pressing challenges in aging rural settings are to ensure effective access to quality health care services
and to address the shortage of home care providers, especially registered nurses. Provincial and federal
home care models would be enhanced by an integrative model of continuing care and a national home
care framework that would address the broader funding and human resource issues. Other uniquely
rural recruitment and retention strategies are suggested such as maximizing the “fit” between the home
care provider’s attributes and the needs and expectations of the rural community. Sufficient public
funding and resources for rural and remote home care programs are needed to develop and implement
(1) the expanded role of case managers; (2) health care teams that include both professionals and para-
professionals; (3) standardized assessment tools and reporting systems; (4) innovative use and training
in the use of technology; and (5) partnerships that optimize resources and build support networks for
rural home care providers, clients, and family and friend caregivers.
KEYWORDS. Home care, rural and remote, community-based service provision
INTRODUCTION
Many Canadian rural and remote communi-
ties are experiencing both declining popula-
tions and a faster growing proportion of seniors
than in urban areas because of the out-migration
of youth, lack of in-migration, and the attrac-
tiveness of some rural communities for retirees.
By 2021, one in four seniors will live in a rural
setting and 30% to 40% of people who live in
rural and remote areas will be aged 65 years
and over.1 This proportion will only increase
with the baby boomers approaching 65 years
of age.
Rural Canadians are more likely to report
poorer socioeconomic conditions, lower educa-
tional attainment, exhibit less-healthy behaviors,
receive fewer formal services, and have higher
Dorothy A. Forbes is a CIHR new investigator and Associate Professor at the Arthur Labatt Family
School of Nursing, The University of Western Ontario, Health Sciences Addition, London, Ontario, Canada.
Dana S. Edge is Associate Professor at the School of Nursing, Queen’s University, Kingston, Ontario,
Canada.
Address correspondence to: Dorothy A. Forbes, Arthur Labatt Family School of Nursing, The University of
Western Ontario, Health Sciences Addition, London, Ontario, Canada, N6A 5C1 (E-mail: dforbes6@uwo.ca).
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120 RURAL AND REMOTE HOME CARE
overall mortality rates compared to their urban
counterparts.2 Indeed, because the life expect-
ancy of First Nations and Inuit is shorter than in
other populations, Aboriginal seniors are
defined as 55 years and over.3 In addition,
recent Statistics Canada4 evidence has revealed
that rural family and friend support networks
may not be as different from those in urban
communities as previously thought. Thus,
strong family and friend-based sources of sup-
port in rural areas should not be assumed to be
able to compensate for the lack of home care
services. Providing home care services is/will
be particularly challenging in rural and remote
areas as care is needed by increasingly vulnera-
ble rural older adults in increasingly vulnerable
rural settings with fewer services, supports, and
caregivers.
The purpose of this paper is to present exam-
ples of the federal and provincial home care
policy context in which Canadian home care is
provided, to identify the challenges faced by
home care providers in meeting the needs of
rural and remote residents, and to offer solu-
tions to meet these challenges. Canadian regis-
tered nurses in rural and remote areas defined
“rurality” by identifying four content themes:
community description, geographical location,
health human and technical resources, and nurs-
ing practice characteristics.5 Thus, the defini-
tion of rural to be used in this paper is informed
by Kulig and associates’5 work that describes
rural as encompassing a holistic perspective
that captures the unique attributes in which
health care providers live and work. Canadian
home care is defined as a range of health and
support services that include maintenance,
rehabilitation, long-term supportive care, acute
care substitution, and end-of-life care with
costs being entirely or partially covered by a
national/provincial/territorial health plan. These
services enable clients incapacitated, in whole
or in part, to live in their home environment.6
Home care has three main functions: (1) to pre-
vent premature or inappropriate admissions to
acute care services; (2) to prevent premature
admissions to long-term care; and (3) to support
clients with health and functional deficits in
maintaining their independence or interdepen-
dence and preventing functional decline for as
long as possible.6 Over the last 10 years, due to
a lack of public funding, Canadian home care
programs have increasingly targeted postacute
clients with medical needs, with little remaining
capacity to service persons with chronic condi-
tions who primarily need supportive services.7
FEDERAL AND PROVINCIAL
EXAMPLES OF HOME CARE
Canadian home care was the product of federal/
provincial/territorial cost-sharing arrangements
until the mid-1990s when it became largely a
provincial jurisdiction. In the absence of a
national home care framework and standards,
home care funding levels, models of service
delivery, types of services provided, eligibility
criteria, client fees, and databases and informa-
tion systems vary by province and region, with
fewer services in rural and remote areas.3 Home
care is the largest component of community-
based services and the fastest growing sector of
the health care system. During 1995–2002, the
demand for home care services grew by 60%.8
However, the allocation of public funding to
home care has not kept pace with this increased
demand on home care programs.8
In 1999, Health Canada created the First
Nations and Inuit Home and Community Care
program to meet the urgent health needs in
these communities.9 Home and community care
may include nursing care, personal care (e.g.,
bathing), home support (e.g., meal preparation),
and in-home respite. Since the inception of this
program, most First Nations reserves now offer
referral, assessment and planned care.9 Although
not all reserve communities have a full-time
home care nurse, home care services are avail-
able on a consultation basis. Challenges for this
program include the high turnover of nurses in
the northern communities and the structural
differences in provincial and federal home care
programs that prevent continuity of services in
the north between on and off-reserve clients.10
Indeed, the transfer of health services to First
Nations communities may be premature as
reflected in the words of an Aboriginal nurse,
“they don’t have the capacity to manage a pro-
fessional health delivery system.”11 Funding
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Forbes and Edge 121
issues need to be addressed to meet the urgent
care needs of culturally diverse First Nations
and Inuit clients and families who live in distant
and disperse communities.
In 1996, the most market-oriented home care
model, the managed competition approach, was
introduced in Ontario.7 Community Care Access
Centres distributed throughout the province are
responsible for assessing an individual’s eligi-
bility for assistance and contracting out all the
services to competing provider agencies. Due to
the commercialization of home care, many of
the nonprofit agencies ceased to operate and
those that persisted became more business
focused.7 Many nurses lost their jobs or trans-
ferred to acute care or long-term care facilities,
which pay higher wages and offer improved
benefits.7 During this time, hospital budgets
were cut and hospital care was downloaded
onto the community sector without a correspond-
ing transfer of resources. Home care programs
gave priority to postacute clients discharged
from the hospital, with little remaining capacity
to serve the long-term supportive needs of frail
older people and persons with disabilities.7 In
2004, the First Ministers’ Accord on Health
Care Renewal recommended first-dollar cover-
age for short-term (2 weeks) acute home care,
community mental health, and end-of–life care
be available by 2006. The needs of persons with
ongoing chronic conditions and disabilities and
their family caregivers were ignored in these
recommendations. This is concerning given that
this is the population that consumes the major-
ity of health care resources. Indeed, for rural
seniors with chronic conditions, this restructur-
ing of health care services makes some vulnera-
ble to more costly institutionalized care that is
likely at a distance from their families and
communities.
CHALLENGES FACING RURAL
HOME CARE PROVIDERS
The challenges of ensuring effective access
to quality health care services are most notable
in rural and remote areas.12 Geographic, socio-
economic, and technological barriers face home
care providers. Weather, limited transportation,
cost of long distances, and inadequate or
unfamiliar technology affect the ability of home
care providers to address the needs of rural
residents.12 Complex client and family needs
require an interdisciplinary team approach and
working over long distances presents unique
challenges for teamwork and communication.12
In addition, the lack of intermediary services
(e.g., Meals on Wheels, caregiver respite pro-
grams, supportive housing), specialty services,
and long-term care beds in rural and remote
communities often lead to 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.12
Another very pressing challenge facing rural
and remote home care providers in delivering
complex home care services is the shortage of
home care providers. Over time this shortage
will increase. Data from the Survey of Formal
Caregivers, Canadian Home Care Human
Resource Study, National Population Health
Survey, and Population Projections, Statistics
Canada were used to examine age and sex
utilization ratios by projected age and sex
distributions in future years. The ratio of a
Canadian professional worker, such as a nurse,
to home care clients is projected to increase
from 1:37 in 2001 to 1:76 by 2026. Similarly,
the ratio of a home support worker to home care
clients is projected to increase from 1:17 in
2001 to 1:35 by 2026.3 These ratios are
undoubtedly higher in rural and remote areas.
The Aboriginal Nurses Association of Canada13
reported that 60% of northern nurses consider
their workplaces as understaffed. Temporary
nursing staff is often hired to attempt to fill the
nursing shortage.10 However, this impacts on
continuity of care that detrimentally affects com-
munications, medications management, results
in compromised follow-up, clients’ disengage-
ment, illness exacerbation, and an added burden
of care on family and community members.14
A major contributing factor to this increasing
home care human resource shortage is the limited
public funding to home care. Indeed, the growth
rate of publicly funded home care decreased in
the 1990s whereas private spending almost dou-
bled.3 Other reasons for the increased shortage of
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122 RURAL AND REMOTE HOME CARE
home care providers may be related to the diffi-
culty this sector has in attracting and retaining
young professionals and men, the lack of valu-
ing and regard by the public and government
for those providing home care services, the
unsafe and unsanitary working conditions
encountered in home visiting, the isolation and
lack of support, low wages, poor benefits, and
lack of compensation (e.g., most home support
providers are not compensated for staff meet-
ings or meeting with informal caregivers and
most home care providers spend 5 to 6 hours
per week in uncompensated travel time), lack of
stability in their work employment, and the
emphasis on “time-for-task” rather than conti-
nuity of care.3 A study conducted by Doran and
colleagues15 investigated the impact of the
competitive model for awarding nursing ser-
vices in Ontario and revealed that nurses who
were compensated on an hourly basis rather
than per visit reported higher satisfaction with
the time allowed for care. As well, clients who
received a higher proportion of visits from reg-
istered nurses reported higher psychosocial out-
comes than those who received fewer visits
from nurses.15 The Canadian Home Care
Human Resource Study3 revealed that between
10% and 20% of home care providers plan to
leave their current employer in the next 12
months, primarily because of low wages and
lack of benefits.
INNOVATIVE RURAL AND REMOTE
SOLUTIONS
To ensure that appropriate public funds are
targeted to rural and remote home care, a shift
in values is needed in Canadian health care pol-
icy, from a focus on individual sectors (prima-
rily acute-care) to a broader, integrated model
of continuing care. Hollander Analytical
Services16 correctly argues that administrative
and fiscal control over a large, integrated sys-
tem of care would facilitate the cost-effective
substitution of home care for acute care and
long-term residential care. The essence of the
continuing care model is the integration of
medical, health, supportive, community, and
institutional care into one system. Such a model
would ensure that care continues over time and
across types of service (e.g., hospital to home
care).16 A national home care framework with
national standards is also needed to ensure that
all Canadians have access to appropriate, high-
quality, timely services and a consistent
relationship with a care provider regardless of
where they live. The eligibility criteria for
home care services should be expanded to
increase access for individuals with chronic
diseases and include secondary prevention.12
National standards would focus on addressing
the inconsistencies in service provision across
provinces and regions and the home care
human resource issues.
Whereas the continuing care model and
national home care framework may address the
broader funding and human resource issues, the
provision of quality rural and remote home care
will require additional unique recruitment and
retention solutions. The applications of urban
and market-oriented models are often unsuited
to the needs and realities of rural settings.
Successful rural and remote recruitment and
retention strategies may include (1) targeting
home care nurses who grew up in rural commu-
nities; (2) maximizing the “fit” between the
nurse’s attributes and the needs and expecta-
tions of the rural community; (3) improving
access to education; (4) improving working
conditions and organizational supports and
polices that better support home care providers’
practice; and (5) working with employed home
care nurses and community residents to assist
newly recruited nurses to develop a sense of
belonging and attachment to their community.17
Two additional, uniquely rural and remote
home care human resource strategies include
(1) leveraging partnerships to optimize local
resources, and to build required capacity among
local residents through training programs; and
(2) utilizing case management as a strategy for
systems integration to maximize community
resources, access resources outside the commu-
nity,12 and share resources across communities
and regions. Case managers through colla-
boration with all health care team members
help identify appropriate services, community
resources, and support networks for clients and
family caregivers throughout the health care
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Forbes and Edge 123
continuum, while balancing resource utilization
in order to optimize value for clients and the
health are system.12 Use of standardized assess-
ment tools and reporting systems (e.g., Resident
Assessment Instrument for Home and Commu-
nity Care) also enhance the case management
function in determining client needs, allocating
resources, and planning future community
programs.12
Successful rural and remote home care models
include interdisciplinary teams that are grounded
in a “health” model rather than a “medical”
model, and are committed to solutions that are
based on the needs of the community and
residents.18 Minore and Boone19 correctly argue
for health care teams that include both profes-
sionals and paraprofessionals. Combining the
knowledge, skills, and judgment of health
professionals (most are non-Aboriginal) with
Aboriginal paraprofessionals’ cultural and
community awareness will ensure the delivery
of culturally appropriate home care services in
these communities.19
Innovative use of technology through tele-
health, telehomecare, telemedicine, and telehos-
pice to train, educate, provide service, support
family caregivers and home care providers,
decrease isolation, and build health care teams
will contribute to addressing many of the chal-
lenges related to distance and dispersion.11,12
For example, Ontario’s ‘North Network’ is an
excellent example of the use of communication
and information technologies that assist in the
delivery of clinical care, education, and health-
related administrative services.12 However, we
need to be cognizant that persons living in rural
and remote areas often do not have the tech-
nological platforms and knowledge required to
use these innovations. Funding, training and
educational programs must be available to
assist users to take full advantage of these
technologies.12
CONCLUSIONS
The most pressing challenges facing Canadian
home care programs are the lack of public fund-
ing and the shortage of formal care providers,
especially registered nurses. These challenges
are exacerbated in rural and remote communi-
ties due to geographic, socioeconomic, and
technological barriers. Complex client and
family needs require an interdisciplinary team
approach and working over long distances
presents unique challenges for teamwork and
communication.12 Provincial and federal home
care models would be enhanced by an integra-
tive model of continuing care, a national home
care framework and national standards that
would address the broader public funding and
human resource issues. Sufficient resources for
rural and remote home care programs are
needed to develop and implement the expanded
role of case managers, standardize assessment
tools and reporting systems, support the innova-
tive use and training in the use of technology,
and develop partnerships that optimize resources
and build support networks for home care
providers, clients, and family and friend care-
givers. The time has come for a shift in Canadian
health care policy that values home care as an
essential component of an integrated model of
continuing care. Such a shift would result in
health care system savings as rural and remote
residents would be adequately supported and
cared for and not require premature admissions
to acute care and long-term care facilities,
which are often at a distance from their families
and communities.
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