Healthy competition is key to self-directed home care

Audrey, who is 82, diabetic and wheelchair-bound, lives at home and receives home care services several times a week. Yet given the agency’s staff shortages and scheduling conflicts, Audrey often sees as many as 20 different people come through her door in a single month. She is frustrated to constantly repeat information to new support workers, and needs time to build trusted relationships with her caregivers.

Her well-meaning daughter-in-law suggests Audrey hire someone privately and researches promising-sounding candidates on a local online classified site who are willing to work for minimum wage. Surely someone suited to Audrey’s preferences and schedule would better meet her needs.

While the above scenario is fictional, stories like this sadly play out far too often in today’s rapidly changing homecare landscape, where the demand for qualified workers and personalized care often outstrips supply. The casualty: quality care. On one side, an agency may be stretched to its limits, sending whatever workers are available to meet the basic needs of a client, unable to fulfill the need to develop true relationships that are so vital to good care. On the other, clients pursue unstructured, self-directed care from a source with little to no accountability, potentially putting their health and wellbeing at risk.

This lays amid an ongoing, vital discussion: what could and should the future hold when it comes to providing optimal care for not only an aging demographic but others who require continuous care. From my perspective, the best step forward is optimally structured self-directed care, which flows with clients wishing and deserving more control over the services they receive. Such a move would require home care agencies to continue being the bodies that organize the care: the bridges between caregivers and clients.

To make this happen, healthy competition must become the norm.

Self-directed care leads to equitable access

Self-directed, or self-managed care, which allows clients to plan and receive the services they need in their own home, has been recognized around the world as a solution that can help eliminate many of the current inequities that exist.

While such an approach is spreading through Australia and many European countries, it has not done so in Canada -- but change is afoot. Ontario recently launched Self-Directed Personal Support Services (PSSO), billed to be the largest self-directed care program in Canada. Yet this program has not been without controversy. Agencies have launched legal action against the program, which would directly employ personal support workers though a new self-directed funding model, resulting in increased competition. 

Competition, though, is a good thing because choice places consumers at the centre of care. Despite concerns, the reality is we can work in harmony at the intersection of the public and private model. Overall, it’s about adapting to what is best for everyone.

Here are the keys to a successful self-directed care program:

Publicly-provided assessments: With a framework for public funding for homecare, assessments must be made by those who hold the purse strings. There is nothing wrong with putting oversight for the kind of care someone needs with the funder. At the same time, there is great value in also certifying private providers who deliver public care, especially with taxpayer dollars involved. One only has to look at the issues with Medicaid and the introduction of the CURES Act in the U.S., which is mandating providers implement Electronic Visit Verification to help combat fraud.

Caregiver fit: With consumers at the centre of care, different market segments would then cater to different priorities. Healthy competition ensures the right caregiver is matched with the right care seeker, not to mention optimally timed visits, punctuality and everything else that goes into a high-quality visit. In an open market, the caregiver and the quality of their care is the product, making home care agencies the intermediary that ensure the product is reliable, safe, quality and meeting the needs of both caregiver and the care seeker -- yet the control still rests with the latter over the final product. If agency X isn’t working out, they can try agency Y. Tapping an open market means clients will get what they need, and agencies can adapt to an atmosphere of friendly competition.

 Variable pricing: We are facing a fundamental mismatch between supply and demand in home care. For instance, many clients want care first thing in the morning and possibly again in the evening. While there is little demand for 3 p.m. visits, caregivers want and deserve a consistent eight-hour shift. The answer to fixing supply and demand when consumers hold the reigns, is variable pricing not unlike Uber’s surge pricing model. Should a 9 a.m visit cost more than a 3 p.m. visit? In a competitive market, I would suggest yes.

 Modern tools: Uber and other fast-moving companies like Amazon have raised the stakes in terms of consumer expectation. People expect visibility and control over the services they receive. For agencies operating within a realm of client-directed care, modern tools are required to meet those expectations. The time is now to reflect upon legacy technology for everything from back office functions to electronic health records, real-time updates, family portals and other elements that allow consumers to be active participants in the care continuum. Cloud-based computing also enables greater efficiency, transparency and, ultimately, optimal client care.

 Measurable outcomes: For programs to receive funding, a framework must be in place to measure how effective the resulting care is. A self-directed care model that reports key metrics back to the funder will be one that will be most effective and durable. Client satisfaction surveys with transparent results and standardized assessments for funding are just two examples of how key metrics can be captured and reported.

 Change always begets uncertainty and fear -- that’s a given. But the home care landscape is changing whether we’re ready or not, at a rapid pace. Ultimately, we live in a free market society were healthy competition means better outcomes for consumers. Both agency and client can reap benefits from this open model, where healthy structured competition straddling public and private care ensures that receptive care -- rather than prescriptive care -- becomes the norm.