Introduction
With global population aging, there is a growing need for home-based care to address the health needs of older adults. It is estimated that there are nearly two million users of publicly funded home care services in Canada, with 70 per cent of the recipients age 65 years and older (Canadian Home Care Association, 2016; Government of Canada, 2016; Turcotte, Reference Turcotte2014). Home care supports and services are designed to enable older adults to remain safely in their own homes for as long as they can, by providing support services such as nursing; rehabilitation; personal support services such as bathing, transferring, and repositioning; grooming assistance; and caregiver respite and support (Ayalon, Fialová, Areán, & Onder, Reference Ayalon, Fialová, Areán and Onder2010; Government of Canada, 2016).
Although Canadians consider home care to be an integral component of the health care system, it is not part of the so-called “Medicare core” (Marchildon, Reference Marchildon2013) and is not subject to the national standards of the Canada Health Act (CHA). The core services, essentially those provided by physicians and hospitals, are subject to first dollar coverage under provincial health insurance schemes supported by provincial tax dollars and federal transfers. Thus, each province is left to decide and design how and to what extent it will provide home care services and how it will pay for them. Not surprisingly, a recent environmental scan showed considerable variability in service provisions and priorities (Johnson et al., Reference Johnson, Bacsu, McIntosh, Jeffery and Novik2017). Since 2007, Ontario, Manitoba, Quebec, and Prince Edward Island do not charge any direct fees for home care services (Mery, Wodchis, & Laporte, Reference Mery, Wodchis and Laporte2016). The other provinces have systems that determine a fee based on income testing.
Given the aging population, the demand for home care has been identified as a top challenge in Canada (Canadian Home Care Association, 2016). Older adults living with chronic conditions and disabilities have the greatest need for home care (Carpenter et al., Reference Carpenter, Gambassi, Topinkova, Schroll, Finne-Soveri, Henrard and Bernabei2004; Turcotte et al., Reference Turcotte, Larivière, Desrosiers, Voyer, Champoux, Carbonneau and Levasseur2015). Recently, a national study showed that approximately 40 per cent of those who were receiving home care had unmet needs related to mobility, fitness, and social activities (Turcotte, Reference Turcotte2014). These and other challenges have resulted in urgent and repeated calls to strengthen home care in Canada (Canadian Home Care Association, 2016; Conference Board of Canada, 2015).
When asked how important home care is as a health policy priority, Canadians have tended to put it somewhere in the middle among general concerns such as “better access” or “more medical equipment”. When asked specifically to rank home care against other policy options and priorities such as pharmacare or electronic health records, home care “was one of the foremost issues ... [and] there is strong support for the development of further home care programs” (Siroka, Reference Siroka2007, p. 16).
In 2002, the federally appointed Commission on the Future of Health Care in Canada (CFHCC) acknowledged the growing significance of home care and recommended revisions to the Canada Health Act (CHA) to include home care as an entitlement (Romanow, Reference Romanow2002). Subsequent work by the Health Council of Canada/Conseil canadien de la sante (HCC/CCS) has reaffirmed the importance placed on integrating home care into the Canadian Medicare core (HCC/CCS, 2005; 2012). In the most recent health accord negotiations in Canada, home care was a priority in the discussions of the Canada Health Transfer payment program between the federal and provincial/territorial governments. In recognition of the growing importance of home care, the federal government committed to contributing $3 billion to home care over four years (Sibbald, Reference Sibbald2015).
With the increasing demands and challenges, there is a growing call to evaluate the current home care system to identify cost-effective and innovative ways to improve processes and services offered. Although there have been reviews of research related to home-based care in Europe and the United States (Ayalon et al., Reference Ayalon, Fialová, Areán and Onder2010; Burton, Lewin, & Boldy, Reference Burton, Lewin and Boldy2015; Genet et al., Reference Genet, Boerma, Kringos, Bouman, Francke, Fagerström and Devillé2011; Rosenfeld & Russell, Reference Rosenfeld and Russell2012), there has not been a systematic review of the research related to home care in Canada. Given Canada’s aging population and the increasing need for home care services, such a review is timely to inform and support future home care policy, practice, and programs across the country.
Methods
This systematic review was conducted by a team of six experts in the fields of aging, public policy, and population health research with their involvement in different phases of the project. This combined effort followed the guidelines recommended by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) to ensure transparency and complete reporting (Moher, Liberati, Tetzlaff, & Altman, Reference Moher, Liberati, Tetzlaff and Altman2009). This systematic review focused on addressing the research question: “What is known from the existing literature on home care for older adults in Canada?”
We aimed to examine how the existing literature characterizes older adults, focusing on topics such as home care users, challenges and gaps in home care, and interventions used to support home care services for older adults.
Study Inclusion and Exclusion Criteria
The research parameters included records of any study about home care in Canada or part of Canada with the study population of older adults aged 65 years or older. The records included studies of any research designed and published in the English language between 2000 and 2016 that were scholarly and peer-reviewed. Focusing on the past 16 years helped to ensure that this synthesis included the most contemporary and up-to-date studies. The search excluded studies in the context of long-term care, nursing homes, or care provided in a hospital or in the community exclusively by family and/or friends (e.g., informal caregivers).
Search Strategy
In order to identify relevant studies, we searched seven electronic health science databases including MEDLINE, PubMed, Embase, CINAHL, Web of Science, Global Health, and Cochrane Library. We used health science databases for this review as home care is primarily identified as a health care issue. In addition, we hand-searched reference lists of relevant studies. We initially developed the search strategy for MEDLINE with the help of an academic librarian, guided by three components: a focus on home care; a target population of community-dwelling older adults; and the study location focused within Canada. The search criteria and databases were circulated to the team members for feedback prior to finalizing for use in this study. The search strategy developed for MEDLINE is shown in Table 1. We then adapted this strategy for use with six other databases. We conducted the final search in December 2016.
Table 1: Search strategy developed for MEDLINE
Note. The slash symbol – / – denotes a Medical Subject Headings (MeSH) heading; .mp. denotes a multi-purpose keyword search.
Data Extraction
We used RefWorks to store and organize all of the studies retrieved from the seven electronic databases. RefWorks let us conduct a systematic de-duplication to remove duplicate citations. Two independent reviewers screened for titles and abstracts. A full-text review for eligibility was then carried out by one author and results confirmed by another author. Uncertainties relating to the eligibility of studies were discussed between the two reviewers before they came to a conclusion. We hand-searched the reference lists of eligible studies to identify further studies which were added to the same pool. The RefWorks folder was shared among the reviewers to provide additional information on the data records. One of the authors carried out a methodological quality assessment of the quantitative studies with the Effective Public Health Practice Project (EPHPP) Quality Assessment Tool and the accompanying dictionary (Effective Public Health Practice Project, 2009; National Collaborating Centre for Methods and Tools, 2016). After the initial identification of the study records, the two primary reviewers discussed the data extraction process for summarizing the studies. Data was collected on the study location, design, target population, and main study findings. For the quantitative studies, we also collected data to complete the methodological quality assessment scores such as selection bias, confounders, blinding, data collection, withdrawals/dropouts, and global rating. We then extracted the data onto a data extraction sheet, which was subsequently converted into the manuscript’s tables before we developed the synthesis of the study’s results. Following this step, one of the primary reviewers and an additional author of this article cross-checked and reviewed the data extraction sheets. The remaining team members reviewed and provided feedback to ensure clarity of the synthesis findings.
Results
The initial search of seven electronic databases resulted in a total of 1,814 records. This number was reduced to 1,153 once the duplicates were removed. A screening of the titles and abstracts identified 1,073 records that were not relevant and were consequently removed, leaving 80 records for full-text review. During this step, 30 records were excluded as they were not relevant to this review based on pre-set inclusion and exclusion criteria. The reasons for exclusion were because they were (a) not peer-reviewed studies (2 studies), (b) published before the pre-determined year of publication (11 studies), (c) not specifically about home care (5 studies), (d) not in full-text English (3 studies), (e) not focused on the Canadian context (2 studies), (f) focused on different study populations (4 studies), or (g) were study protocols (3 studies). At the conclusion of this step, 50 relevant studies remained. The results of this systematic review are shown in Figure 1.
Figure 1: Flow diagram of the article selection process
Methodological Quality Assessment Results
Of the 50 reviewed studies, 36 underwent a methodological quality assessment using the EPHPP Quality Assessment Tool. Thirteen studies did not undergo this assessment process as they were qualitative in nature. One study was an evaluation of three other studies, thus was not subject to quality assessment. Of the studies that were assessed with respect to methodological quality, three (8.3%) were rated as “strong”, 11 (30.6%) as “moderate”, and 22 (61.1%) as “weak”. Note that several studies did not address the issue of confounders and blinding of study participants or researchers. The information for the methodological quality assessment results of the individual studies is shown in Table 2.
Table 2: Methodological quality assessment scores of individual studies
Note. 1, 2, and 3 within square brackets in each of the components represent strong, moderate, and weak component ratings respectively.
Study Setting
Eighteen studies were published between 2013 and 2016; 14 studies, between 2008 and 2012, and 18 studies, from 2000 to 2007. Half of the studies focused on Ontario (25), with the remainder from British Columbia (9), Quebec (4), and Nova Scotia (2). There was one study each from Alberta and New Brunswick. Six studies were conducted across multiple provinces using existing data sets. Characteristics of the individual studies are shown in Table 3.
Table 3: Characteristics of individual studies from the systematic review of seven databases
Study Design
The majority of the research (38 studies) involved observational studies. In addition, there were 12 intervention studies on home care clients. Further, 17 studies used the Resident Assessment Instrument-Minimum Data Set (RAI-MDS) for Home Care data that is provincially mandated for home care clients in Canada. Others used clients’ or deceased clients’ health records. A total of 11 studies focused on home care staff (e.g., case managers, dietitians, home care nurses, or home support workers).
Study Findings
Here we discuss the four primary themes that we examined within the systematic review: older adult client-level predictors; unmet needs; home care interventions; and home care issues and challenges. Each of the themes includes various subthemes. For example, the theme of older adult client-level predictors consisted of four subthemes: (a) cognitive impairment, mobility issues, and chronic conditions; (b) location of residence; (c) gender differences; and (d) mental health and well-being. Five subthemes were identified under unmet needs: nutritional health; mental health; primary treatment and heart failure; limited funding and eligibility criteria; and home care satisfaction. Home care interventions included three subthemes: (a) nurse-led interventions; (b) exercise, fall prevention, physiotherapy, and occupational therapy; and (c) technological interventions. Home care issues and challenges consisted of four subthemes: lack of knowledge and education; organizational issues; ethical challenges; and safety issues. The primary themes and their respective subthemes are discussed next.
Older Adult Client-Level Predictors
Cognitive Impairment, Mobility Issues, and Chronic Conditions
Many of the studies focused on describing the predictors and characteristics of home care recipients in Canada. Older adult client-level predictors typically included factors such as cognitive impairment, mobility issues, chronic conditions, and age. For example, Armstrong, Zhu, Hirdes, and Stolee (Reference Armstrong, Zhu, Hirdes and Stolee2012; Reference Armstrong, Zhu, Hirdes and Stolee2015) used RAI-HC data of home care clients to identify relatively homogeneous client-level predictors for home care usage such as cognitive impairment, being female, requiring assistance with instrumental activities of daily living (IADL) and/or some activities of daily living (ADL), and mobility issues (Armstrong et al., Reference Armstrong, Zhu, Hirdes and Stolee2012; Reference Armstrong, Zhu, Hirdes and Stolee2015). A longitudinal study found that those with at least one chronic condition, who were older, newly dependent on others for help with daily activities, had been hospitalized in the previous year, and had a low income were more likely to use home care (Wilkins & Beaudet, Reference Wilkins and Beaudet2000). In a study of older home care clients in Ontario and the Winnipeg Regional Health Authority of Manitoba, almost 69 per cent of home care clients were female and had a mean age of 83.2 years; approximately 60 per cent of home care clients were divorced, separated, or widowed (Mofina & Guthrie, Reference Mofina and Guthrie2014). This study also revealed that almost 50 per cent of clients had some degree of cognitive impairment, nearly all (92.4%) required full assistance with IADL, and 35 per cent had impairments with ADL (Mofina & Guthrie, Reference Mofina and Guthrie2014).
Location of Residence
Only two studies examined home care usage in relation to location of residence. A longitudinal follow-up study of older adults found that proportionately more urban older adults were receiving home care (16%) compared to those in small towns (11%) or rural areas (9%) (Mitchell, Strain, & Blanford, Reference Mitchell, Strain and Blandford2007). This study further reported that being older and having physical and/or cognitive impairments predicted the use of home care services among seniors (Mitchell, Strain, & Blanford, Reference Mitchell, Strain and Blandford2007). Another study described regional issues of access to rehabilitation therapy for home care clients living in different health regions across Ontario (Armstrong, Zhu, Hirdes, & Stolee, Reference Armstrong, Zhu, Hirdes and Stolee2015). However, Armstrong et al. (Reference Armstrong, Zhu, Hirdes and Stolee2015) asserted that home care clients should have equal access to rehabilitation services irrespective of where they reside.
Gender Differences
Some studies described home care usage in terms of gender differences. A study by Tousignant, Dubuc, Herbert, and Coulombe (Reference Tousignant, Dubuc, Hébert and Coulombe2007) found that older home care clients with disabilities were mainly female (68%), and 46% primarily had IADL problems while 36 per cent had motor disabilities and 14 per cent had mental disabilities. The research also identified differences among men and women in home care performance indicators such as improvements in ADL, cognitive functions, depressive symptoms, and pain management (Lo, Gruneir, Bronskill, & Bierman, Reference Lo, Gruneir, Bronskill and Bierman2015). In a separate study, male clients were found to be highly likely to receive both services of home health care and homemaking or personal support (Mery, Wodchis, & Laporte, Reference Mery, Wodchis and Laporte2016).
Mental Health and Well-Being
Some studies described home care recipients in terms of mental health and well-being. A study by Szczerbinska, Hirdes, and Zyczkowska (Reference Szczerbinska, Hirdes and Zyczkowska2012) found that the prevalence of depressive symptoms among home care clients was 12 per cent, which decreased with age. Among clients with complex health conditions, however, the rate was higher at 23.6 per cent (Szczerbinska, Hirdes, & Zyczkowska, Reference Szczerbinska, Hirdes and Zyczkowska2012). Analysis of hospital records of home care clients identified intentional self-harm in 9.3 cases per 1,000 clients (Neufeld, Hirdes, Perlman, & Rabinowitz, Reference Neufeld, Hirdes, Perlman and Rabinowitz2015). Younger clients with psychiatric conditions, alcohol use and dependence, and depressive symptoms were at a higher risk for intentional self-harm behaviours, whereas marital status and positive social relationships were protective of self-harm (Neufeld, Hirdes, Perlman, & Rabinowitz, Reference Neufeld, Hirdes, Perlman and Rabinowitz2015).
Unmet Needs
Nutritional Health
The issue of unmet needs among home care recipients is highlighted in several studies ranging from topics on nutritional health to mental well-being. Although few studies examined the nutritional health of home care recipients, existing literature suggests that there are unmet nutritional needs. For example, a study found that both the micro- and macro-nutrient intakes of home care recipients were inadequate, yet the protein intake was reported to be at more than the required amount (Johnson & Begum, Reference Johnson and Begum2008). The study further reported that 23.9 per cent of participants were overweight and 29.9 per cent were obese, emphasizing the need to evaluate the nutritional adequacy of older home care clients (Johnson & Begum, Reference Johnson and Begum2008). Another study identified that risk factors of malnutrition among home care clients included health status, functional ability, self-reported poor health, mood status, social function, and cognitive performance (Bocock, Keller, & Brauer, Reference Bocock, Keller and Brauer2008). A cross-sectional study involving older home care clients identified that those clients with nutritional problems were 2.58 times more likely to use acute health care services (Paddock & Hirdes, Reference Paddock and Hirdes2003). An intervention study on the nutritional supplementation for older home care clients at high risk for under-nutrition showed significant improvements in total energy intake and weight gain in the short term (Payette, Boutier, Coulombe, & Gray-Donald, Reference Payette, Boutier, Coulombe and Gray-Donald2002).
Mental Health
Unmet home care needs surrounding mental health issues were identified in the literature. For example, a cross-sectional study of clients with depressive symptoms found that 64.5 per cent of clients received potentially inappropriate pharmacotherapy including under-treatment (Dalby et al., Reference Dalby, Hirdes, Hogan, Patten, Beck, Rabinowitz and Maxwell2008). Unmet needs were also described in terms of client safety and post-discharge care. A retrospective cohort study on home care client safety reported that 4.2 per cent of recently discharged patients experienced adverse events such as psychosocial, behavioural, and/or mental health problems, falls, wound infections, and medical error-related issues (Blais et al., Reference Blais, Sears, Doran, Baker, Macdonald, Mitchell and Thalès2013).
Primary Treatment and Heart Failure
Two studies focused on unmet care requirements and the issue of heart failure among home care recipients. In Ontario, research found that almost a third of home care clients did not receive the recommended primary treatment for heart failure with a prevalence of 12.4 per cent (Foebel, Heckman, et al., Reference Foebel, Heckman, Hirdes, Tyas, Tjam, McKelvie and Maxwell2011) and 14.9 per cent (Foebel, Hirdes, Heckman, Tyas, & Tjam, Reference Foebel, Heckman, Hirdes, Tyas, Tjam, McKelvie and Maxwell2011). Further studies that focused on seriously ill home care clients identified that those with heart failure were faced with greater disability in their daily activities, decreased cognitive functions, health instability, and co-morbid conditions compared to other clients (Fernandes & Guthrie, Reference Fernandes and Guthrie2015; Foebel, Hirdes, et al., Reference Foebel, Heckman, Hirdes, Tyas, Tjam, McKelvie and Maxwell2011); however, heart failure patients were not typically identified as having a terminal prognosis.
Limited Funding and Eligibility Changes
Existing literature suggests that financial cutbacks and changes to eligibility criteria have contributed to unmet home care needs among older adults. Provincial budget cuts to home care services and the resulting changes to the eligibility criteria along with eliminating a certain level of services have led to discharge of senior clients from the service. A qualitative study investigated coping strategies among those clients and revealed that 34 per cent were suffering in silence with feelings of abandonment, loneliness, and betrayal (Livadiotakis, Gutman, & Hollander, Reference Livadiotakis, Gutman and Hollander2003). Another 29 per cent were receiving assistance from informal sources or were paying for private care, while 28 per cent adapted to doing the activities previously supported through home care by themselves (Livadiotakis, Gutman, & Hollander, Reference Livadiotakis, Gutman and Hollander2003).
Home Care Satisfaction
There is a growing body of research on satisfaction with home care services and supports. A national study reported that approximately 40 per cent of home care recipients had unmet needs related to social interaction, mobility, and physical activity (Turcotte, Reference Turcotte2014). Contrary to this study, Kadowaki, Wister, and Chappel (Reference Kadowaki, Wister and Chappell2015) reported that 71.4 per cent of older adults receiving home care had their needs met with higher levels of life satisfaction, lower levels of loneliness, and perceived life stress, whereas only 28.6 per cent had unmet home care needs. Given this difference between the two studies, more research is required to examine home care satisfaction among older adults.
Interventions
Nurse-led Interventions
The results of this synthesis identified various nurse-led interventions to support older adult home care clients ranging from telephone-support interventions to mental-health interventions. A study on a “surveillance nurse” telephone support intervention for home care clients in British Columbia was found to have a beneficial effect on reducing the rate of service utilization by increasing the duration of the home care visit (Kelly & Godin, Reference Kelly and Godin2015). This intervention involved scheduled telephone calls from a surveillance nurse to regularly assess the client’s well-being, care plan status, use and need for services (e.g., adult day programs, physiotherapy, home support), and home environment (e.g., family caregiver support). The nurse provides the client with information, education, and coaching, and if necessary collaborates with other health care and support professionals (e.g., occupational therapists, physiotherapists, social workers, dietitians, home care nurses, general or nurse practitioners), and community resources (e.g., Alzheimer’s Society, meals on wheels) (Kelly & Godin, Reference Kelly and Godin2015).
A randomized, controlled trial evaluated a proactive nursing health promotion intervention in addition to customary home care in Ontario (Markle-Reid et al., Reference Markle-Reid, Weir, Browne, Roberts, Gafni and Henderson2006). The intervention consisted of a health assessment combined with regular home visits and/or telephone check-ins, coordination of community services, health education to support illness management, and empowerment strategies to promote independence (Markle-Reid et al., Reference Markle-Reid, Weir, Browne, Roberts, Gafni and Henderson2006). The intervention group demonstrated better mental health functioning, reduced depression, and enhanced quality of life and perceptions of social support at no additional cost (Markle-Reid et al., Reference Markle-Reid, Weir, Browne, Roberts, Gafni and Henderson2006). An evaluation of three similar nurse-led health promotion and disease prevention interventions concluded that these interventions are a better way of improving the health-related quality of life (HRQoL) of older home care clients compared to that achieved with the usual home care services (Markle-Reid, Browne, & Gafni, Reference Markle-Reid, Browne and Gafni2013). These interventions are advantageous since they are viewed as highly acceptable by this population and require no additional resources (Markle-Reid et al., Reference Markle-Reid, Browne and Gafni2013). An evaluation of a self-management training tele-home care intervention by specially trained clinicians and technology for home care clients with chronic disease showed reductions in emergency department activity, in-patient activity, emergency department use, and hospitalizations (Mierdel & Owen, Reference Mierdel and Owen2015).
Another nurse-led mental health promotion intervention targeting long-stay older home care clients with depressive symptoms was effective in reducing depressive symptoms and anxiety, number of hospitalizations, use of ambulatory services, and emergency room visits, while improving their HRQoL (Markle-Reid et al., Reference Markle-Reid, McAiney, Forbes, Thabane, Gibson, Browne and Busing2014). This was a multi-component intervention offered by an inter-professional team who provided intensive case management, community navigation of services, psychosocial support and advocacy, and coordinated communication among the client, family, and health care team.
Exercise, Fall Prevention, Physiotherapy, and Occupational Therapy
Other interventions identified in the literature included exercise, fall prevention, physiotherapy (PT), and occupational therapy (OT) programs to support even frail older adults in home care. Johnson, Myers, Scholey, Cyarto, and Ecclestone (Reference Johnson, Myers, Scholey, Cyarto and Ecclestone2003) found that having home care clients do a simple set of exercises during regular home care visits was shown to improve their functional performance in the intervention group compared to a comparison group. A multi-factor intervention on falls prevention delivered by community health workers yielded a 43 per cent reduction in falls during a six-month period (Scott, Votova, & Gallagher, Reference Scott, Votova and Gallagher2006). In addition, an observational study on long-stay home care clients with musculoskeletal disorders reported that those clients who received PT and OT showed significant functional improvements (Cook et al., Reference Cook, Berg, Lee, Poss, Hirdes and Stolee2013).
Technological Interventions
Some studies examined the role of technology in home care interventions for older adults. A study by Lehoux (Reference Lehoux2004) examined four frequently used technology-enhanced home care interventions including antibiotic intravenous therapy, parenteral nutrition, peritoneal dialysis, and oxygen therapy. The study found a tendency among home care clients to withdraw from social activities as a result of intervention-associated technical barriers and social stigmatization (Lehoux, Reference Lehoux2004).
Another technological intervention discussed in the literature was the use of computer-modeling and algorithms to help inform and support clinical decision-making in home care. For example, two studies focused on a single study using computer-modeling techniques and machine-learning algorithms to guide rehabilitation planning and clinical decision-making around home care (Zhu, Chen, Hirdes, & Stolee, Reference Zhu, Chen, Hirdes and Stolee2007; Zhu, Zhang, Hirdes, & Stolee, Reference Zhu, Chen, Hirdes and Stolee2007). In particular, the authors examined the potential of using automatic, data-driven, machine learning algorithms – support vector machine (SVM) and k-nearest neighbors (KNN) – to inform rehabilitation delivery for home care clients. The study concluded that the tested algorithms provided better predictions than the currently used protocols, although the results were less interpretable in some instances (Zhu, Chen, et al. Reference Zhu, Chen, Hirdes and Stolee2007; Zhu, Zhang, et al., Reference Zhu, Chen, Hirdes and Stolee2007).
Home Care Issues and Challenges
Lack of Knowledge and Education
Although literature was limited on home care workers’ education and training, a lack of knowledge among workers was identified as an important issue in areas ranging from falls prevention to cognitive health (Bartfay, Bartfay, & Gorey, Reference Bartfay, Bartfay and Gorey2016; Johnson & Noel, Reference Johnson and Noel2007; McWilliam et al., Reference McWilliam, Vingilis, Ward-Griffin, Higuchi, Stewart and Mantler2014). A Nova Scotia study evaluated perceptions and knowledge related to health of older adults among home support workers (Johnson & Noel, Reference Johnson and Noel2007). The study revealed that the majority of these workers were middle-aged women with low levels of empowerment and health knowledge on issues important to older adults such as general knowledge related to falls prevention, physical activity, and nutrition (Johnson & Noel, Reference Johnson and Noel2007). This review also found that additional education and training in cognitive health is required because home care recipients were generally under-diagnosed in terms of dementia and cognitive impairment (Bartfay et al., Reference Bartfay, Bartfay and Gorey2016).
Organizational Issues
Various organizational issues were identified such as poor wages and inconsistent work schedules. A study from New Brunswick reported that 97 per cent of home support workers were middle-aged women, over three quarters of whom identified organizational issues related to poor wages and benefits, inconsistent and/or rotating work schedules, and working far geographical distances from their homes (Nugent, Reference Nugent2007). A study in British Columbia found that almost 91 per cent of workers experienced physical, environmental, relational, and/or organizational issues while caring for their older clients (Sims-Gould, Byrne, Beck, & Martin-Matthews, Reference Sims-Gould, Byrne, Beck and Martin-Matthews2013). These workers followed strategies such as agency protocol, bending or breaking rules, and working to avert the crisis to manage adverse events (Sims-Gould, Byrne, Beck, & Martin-Matthews, Reference Sims-Gould, Byrne, Beck and Martin-Matthews2013). Another study in British Columbia described issues faced by home care workers such as time pressures and tight scheduling when providing care, advantages and disadvantages of having a care plan, and conflicts that arise when working in the private space of clients’ homes (Sims-Gould & Martin-Matthews, Reference Sims-Gould and Martin-Matthews2010).
Additional organizational issues included issues in the delivery and receipt of home support services (Martin-Matthews & Sims-Gould, Reference Martin-Matthews and Sims-Gould2008). Employers found themselves challenged by recruitment and retention of employees and the increasing complexity of client needs (Martin-Matthews & Sims-Gould, Reference Martin-Matthews and Sims-Gould2008). The workers found difficulties arising from scheduling and time demands, tension in providing intimate ongoing care at an emotional distance, and the balance between outlined tasks, needs, and wants of older clients (Martin-Matthews & Sims-Gould, Reference Martin-Matthews and Sims-Gould2008). Moreover, older clients said they found that the ongoing need to prepare for and manage services in relation to inconsistent scheduling was often difficult (Martin-Matthews & Sims-Gould, Reference Martin-Matthews and Sims-Gould2008).
One study focused on addressing organizational issues by assessing the positive factors that attracted workers to home care employment. These factors included (a) enjoyment from working with people, (b) diverse experiences, (c) reliable finances, and (d) job flexibility (Sims-Gould, Byrne, Craven, Martin-Matthews, & Keefe, Reference Sims-Gould, Byrne, Craven, Martin Matthews and Keefe2010). These factors may play an important role in facilitating recruitment efforts of new workers to support the growing demand of home care services in Canada.
Ethical Issues
Home care case managers faced ethical concerns and dilemmas related to issues of equity, beneficence, non-maleficence, and autonomy and power imbalances while providing their services (Gallagher, Alcock, Diem, Angus, & Medves, Reference Gallagher, Alcock, Diem, Angus and Medves2002). Sims-Gould and Martin-Matthews (Reference Sims-Gould and Martin-Matthews2010) identified ethical issues related to social relationships with clients such as a sense of conflict in providing social support to their clients while maintaining a professional distance. In addition, Sims-Gould and Martin-Mathews (Reference Sims-Gould and Martin-Matthews2010) identified ethical issues related to interpersonal conflict such as client refusal of service, or an argument between home care workers and family members.
Only a few studies provided recommendations and strategies for addressing ethical issues. Gallagher et al. (Reference Gallagher, Alcock, Diem, Angus and Medves2002) proposed substantial home care system changes to address ethical concerns and dilemmas among home care case managers. In particular, the authors identified the need for more supportive housing options with on-site management and coordination of services, funding to address the increasing care needs of older adults, better organization of client waitlists to identify those with the greatest needs, and improved interdisciplinary teamwork to support collaborative decision-making to reduce ethical dilemmas. In another study, ethical issues in regards to the family were addressed by respecting decisions of the family, promoting family choice and control, and supporting family independence in the “empowerment” discourse through staff training and engagement (Funk, Stajduhar, & Purkis, Reference Funk, Stajduhar and Purkis2011).
Safety Issues
Safety issues were identified among both home care clients and workers. Tong, Sims-Gould, and Martin-Matthews (Reference Tong, Sims-Gould and Martin-Matthews2016) found that home care clients identified physical (e.g., potential trips and falls), spatial (e.g., unsafe spaces such as bathing and cooking areas), and interpersonal (e.g., those arising from interactions between clients, their family and home care workers) safety concerns in the home care environment. Another study identified safety concerns of the staff while they were serving their home care clients, noting four main types: physical, spatial, interpersonal, and temporal issues (Craven, Byrne, Sims-Gould, & Martin-Matthews, Reference Craven, Byrne, Sims-Gould and Martin Matthews2012). Subsequently, the authors developed a conceptual model to highlight these concerns as well as those factors which intensify or mitigate them (Craven et al., Reference Craven, Byrne, Sims-Gould and Martin Matthews2012). Similarly, the article by Tong et al. (Reference Tong, Sims-Gould and Martin-Matthews2016) described this conceptual model to address client and caregiver safety concerns in home care. The authors noted that some of the mitigating factors to improve safety concerns included home modifications and the presence of home care workers to offer support with physically demanding tasks such as cleaning.
Discussion
As Canada’s population ages, the demand for home care services is expected to increase. In 2012, Statistics Canada estimated that more than 2 million people used home care services (Turcotte, Reference Turcotte2014). Recently, home care has been recognized as a national priority in Canada (Sibbald, Reference Sibbald2015); accordingly, research on effective interventions and strategies to support home care is needed to support informed actions and partnerships to advance this priority (Canadian Medical Association, 2016).
We conducted this systematic review to examine the existing literature on home care for seniors in Canada. In particular, we aimed to identify how existing literature characterizes home care users, challenges and gaps in the home care system, and interventions and strategies used to support home care services. After a comprehensive search of seven relevant electronic databases, screening, and assessing for eligibility, we reviewed 50 studies.
This study identified four main themes in the literature including: older adult client-level predictors; unmet home care needs; interventions; and home care issues and challenges experienced by home care staff and/or clients. Each of these themes were broken down into various subthemes. Although each of these themes and subthemes were discussed in isolation for clarity, it is important to note that the themes had significant overlap and interconnections. For example, the themes of unmet needs and issues substantially overlapped with the challenges related to limited worker education and knowledge related to physical activity.
Our review found that there was an imbalance in the source province/territory for much of the relevant literature related to home care in Canada. There were also few comparative national studies. Half of the studies focused on Ontario followed by studies in Quebec and British Columbia, while there was no research which met the inclusion criteria from Newfoundland, Prince Edward Island, Saskatchewan, or the Territories. This has, in our view, certain consequences for future research. First, there is a need to fill in the gaps in our understanding of how home care services are organized, delivered, and experienced in those missing Canadian jurisdictions. This will give us a more robust picture of the variations across the country and allow us to seriously assess what best practices might be in Canada. Second, only with a robust picture of the Canadian scene can we look internationally for additional best-practice models and suggestions for policy and service delivery reform.
No studies focused on home care for older Indigenous adults or among immigrant and refugee seniors in Canada. Beatty and Berdahl (Reference Beatty and Berdahl2011) asserted that policymakers and researchers have paid limited attention to the health care needs of this aging demographic. However, among Indigenous older adults the incidence of chronic conditions such as hypertension, heart problems, diabetes, and arthritis is double or triple the rate of Canadian seniors overall (First Nations and Inuit Health Branch, 1999). Recent government funding cuts have raised substantial concerns with the increasingly higher costs of private and public care being unaffordable and inaccessible for many Indigenous older adults (Beatty & Berdahl, Reference Beatty and Berdahl2011). In addition, older ethno-cultural adults is the fastest growing segment of the population (Johnson, Bacsu, McIntosh, Jeffery, & Novik, Reference Johnson, Bacsu, McIntosh, Jeffery and Novik2017; Statistics Canada, 2011). Future research is needed to address the home care needs of Indigenous and ethno-cultural older adults in Canada. And again, cross-national studies comparing the experiences of older Indigenous populations in Canada and other “white settler colonies” (e.g., Australia, New Zealand, South Africa, and the United States) would be a starting point to identify best practices.
According to the EPHPP Quality Assessment Tool that we used, the majority of the quantitative studies were rated as “weak”; a few were rated as “moderate. Only three of the studies were rated as having “strong” quality. A potential explanation for the low ratings is that most of the studies were observational and relied on secondary data. Moreover, many of the studies failed to address the issue of confounders and blinding of study participants or researchers. However, it is noteworthy that almost all of the studies used reliable and valid data collection tools.
The findings from our review identified useful interventions for supporting older adults’ quality of life and health outcomes (Blais et al., Reference Blais, Sears, Doran, Baker, Macdonald, Mitchell and Thalès2013; Hirdes et al., Reference Hirdes, Dalby, Knight Steel, Iain Carpenter, Bernabei, Morris and Fries2006; Markle-Reid et al., Reference Markle-Reid, Weir, Browne, Roberts, Gafni and Henderson2006, Reference Markle-Reid, Browne and Gafni2013; Mierdel & Owen, Reference Mierdel and Owen2015). A little over one fifth of the studies were intervention evaluations. The intervention studies typically examined simple exercise programs, fall prevention, physiotherapy, occupational therapy, nurse-led interventions such as telephone support, inter-professional collaboration, working with providers with geriatric training and experience, and increased coordination and awareness of community services. These interventions required only minimum additional costs and generally resulted in positive improvements among the home care recipients. This research suggests that slight modifications to home care services could have a strong impact on improving older adults’ health outcomes. Recent studies have evidenced growing interest in the role of technological interventions to support home care needs among older adults.
Many older adults in the studies who received home care suffered from cognitive impairment, mobility issues, and chronic conditions. Additional predictors of home care usage included an urban location of residence, older age, and being female. Home care has been shown to reduce financial costs related to hospitalization of older adults such as palliative care, emergency visits, and length of hospital stay (Canadian Home Care Association, 2016). However, little research is available to understand the gaps in home care utilization related to location of residence, age, and gender. Future policy and programs need to examine how to better address these gaps to support equitable access while also exploring ways to improve value for money to ensure sustainability of the home care system over time.
Ethical and safety issues were key concerns among home care workers. Gallagher et al. (Reference Gallagher, Alcock, Diem, Angus and Medves2002) proposed substantial system changes to address ethical concerns and dilemmas among home care case managers. Other studies developed a conceptual model to support client and caregiver safety concerns in home care (Craven et al., Reference Craven, Byrne, Sims-Gould and Martin Matthews2012; Tong et al., Reference Tong, Sims-Gould and Martin-Matthews2016). Research and knowledge to address safety and ethical issues may play a key role in supporting the recruitment and retention of home care workers.
This synthesis identified a substantial need for more education, knowledge, and training of home care staff or continuing care workers (Johnson & Noel, Reference Johnson and Noel2007; McWilliam et al., Reference McWilliam, Vingilis, Ward-Griffin, Higuchi, Stewart and Mantler2014). In particular, more education and training are required regarding falls prevention, physical activity, and nutrition. Falls and issues of malnutrition can often be prevented through evidence-informed interventions. However, the identification of at-risk older adults is critical in the delivery of preventive interventions. Our review also found that home care recipients were generally under-diagnosed in terms of dementia and other cognitive impairment issues (Bartfay et al., Reference Bartfay, Bartfay and Gorey2016). Subsequently, more training, screening, and education are required to support older adults’ cognitive health as well as the necessary resources to support these activities.
Depression and mental health also emerged in our review as common issues among older home care recipients (Ayalon, Fialová, Areán, & Onder, Reference Ayalon, Fialová, Areán and Onder2010). The World Health Organization has noted that approximately 15 per cent of older adults age 60 and older suffer from a mental health disorder (World Health Organization, 2016). We found only a few studies that examined the issue of mental health among home care recipients (Blais et al., Reference Blais, Sears, Doran, Baker, Macdonald, Mitchell and Thalès2013; Markle-Reid et al., Reference Markle-Reid, McAiney, Forbes, Thabane, Gibson, Browne and Busing2014; Reference Markle-Reid, Weir, Browne, Roberts, Gafni and Henderson2006). Further research is necessary to examine effective interventions for improving depression and mental health issues among home care clients.
Our review did identify some effective interventions and strategies to support home care across Canada; however, more research will enable researchers to fully understand and identify interventions and models that are best suited to supporting home care recipients’ health outcomes over time. Further research is also required to examine best practices to support training, retention, and education of home care staff and workers (Johnson & Begum, Reference Johnson and Begum2008; Johnson & Noel, Reference Johnson and Noel2007; Martin-Matthews & Sims-Gould, Reference Martin-Matthews and Sims-Gould2008).
In moving forward, future research directions could include a synthesis to examine international examples of best practices and innovations from different countries to support effective and sustainable models of home care. In particular, this synthesis could examine how different models of home care are governed, financed, and organized to support older adults’ needs. For example, in Australia the Home Independence program was developed as an alternative model from home care to assist seniors in maximizing their functional independence and well-being. A randomized control study comparing Home Independence clients and those receiving traditional home care found that 12 months after initial recruitment, Home Independence clients were 6.5 times less likely to require ongoing care and 30 per cent less likely to use emergency or hospital services (Lewin & Vandermeulen, Reference Lewin and Vandermeulen2010). Similarly, the United Kingdom has introduced an intensive, short-term (e.g., usually about 6-8 weeks) re-ablement program that generally works with clients after rehabilitation from an acute event to teach clients about managing daily activities, coping at home, and remaining independent. One study reported that 60 per cent of re-ablement clients did not require home care at the end of the program and that 40 per cent of graduates continued to be independent (Glendinning & Newbronner, Reference Glendinning and Newbronner2008). By studying models from different countries, policymakers would benefit by acquiring new insight and innovative knowledge to improve home care services for older adults.
Limitations
Although our review adopted a systematic method, it is not without limitations. For example, we searched only seven electronic databases for published literature in the English language between the years 2000 and 2016. It is possible that relevant studies may have been left out, especially studies from Quebec published in French as the search was limited to English-language articles.
Since home care is primarily identified as a health care issue, our systematic review focused on health science databases. For example, health care budgets and funding for home care typically emphasize post-acute care rather than long-term care that focuses on maintenance of skills and preventive care (Beatty & Berdahl, Reference Beatty and Berdahl2011). In the future, a more comprehensive search strategy should include social science databases, as home care clients often experience socially related challenges such as housing, transportation, and social isolation. In addition, it is possible that we overlooked relevant, grey literature documents because our search focused on journal publications.
Conclusion
As Canada’s demographic ages, the demand for home care will steadily rise. Research on effective and sustainable strategies to support home care is imperative. Currently, there is little knowledge on home care for older adults in Canada related to characteristics of home care users, issues and gaps in services, and interventions designed to support home care clients’ needs. This synthesis examined four main themes in the home care literature including older adult client-level predictors; unmet home care needs; interventions; and home care issues and challenges experienced by home care staff and/or clients. Given Canada’s aging population, this synthesis is timely to inform future policy, practice, and programs on home care across the country.
Although this review identified useful interventions and strategies to support home care in Canada, additional research is needed to identify best practices and models for service provision within unique geographical contexts and among diverse populations. In addition, national standards for home care are required to ensure equity of services across jurisdictions. Although formal home care is often supported at many levels by informal caregivers, the conversation and research should also address the contributions of informal caregivers. Moving forward, research, knowledge, and education are pertinent to fostering innovative strategies and best practices to supporting Canada’s home care system and clients over time.
