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The CCAC Audit: coming home to roost

There are 14 Community Care and Access Centres (CCACs) in Ontario. CCAC provides free home and community-based health care and related social services to eligible Ontario residents outside of hospital settings. CCACs spend $2.36 million on this endeavour last year, which funding they receive from the Ministry of Health and Long-Term Care (the Ministry) through Local Health Integration Networks (LHINs).

We all know of – or are – someone with a relative who was discharged home from Hospital despite the need for a degree of supplementary health care that could not be provided by family members. Not every family can afford to pay for private supplementary care, so our reliance on CCAC is acute.

Yet, in speaking with clients, it appears as though no family feels that they get enough of what they need from CCAC.

Why not?

In 2014, the Legislature’s Standing Committee on Public Accounts requested an audit of CCAC, primarily in response to demands from the NDP and Conservative parties in response to criticisms stemming from the disproportionate salaries paid to some CCAC CEOs.

In September of 2015, the Auditor General released the first of her two reports – the first reviews financial operations and service delivery at CCACs, the second, due in December, focuses on broader aspects of CCAC home-care services.

The Auditor concluded that “the way in which CCACs operate and deliver services needs to be revisited.” The Report recommends streamlining the current LHIN/CCAC structure so that a greater proportion of funding will be spent on direct care for patients instead of administrative costs and the profits of contracted service providers.

Streamlining: what does that mean?

Currently, 62% of CCAC’s expenses are paid to contract service providers. This excerpt from the Auditor’s report provides further commentary on the issue of streamlining:

As described in Section 2.1, there are 14 CCACs responsible for direct home- and community-based health care in Ontario. Each employs nurses and nurse practitioners who provide direct-nursing services under three Ministry-directed programs, and five CCACs also employ their own therapists.

In addition, CCACs contract services out to 160 private-sector service providers that are either for-profit or not-for-profit.

In such a service-delivery model, administrative and overhead expenses are incurred multiple times at each organization, and some service providers also profit from the payments they receive from CCACs for providing CCAC-funded services. As we’ve discussed, the result is that about 72% of every dollar in funding is spent on activities that involve direct patient contact. This percentage is considerably lower than the 92% that the CCACs operating under this service-delivery model consider is being spent on direct patient care.

As reforms and reports on health care, including home and community care specifically, are currently under way in Ontario, this is an opportune time to assess whether the current delivery model—where direct care is spread out over a vast array of organizations, some of which profit from CCAC-funded services and some of whose services could be seen to overlap—could be streamlined for the benefit of patients needing effective health care at home and in the community [page 36].

Why did we contract out our CCAC healthcare in the first place?

CCACs were established in 1997, when the existing Home Care Programs, which provided nursing and homemaking, were consolidated with Placement Coordination Services, which managed admissions to long-term care.

In 1997, the government adopted a competitive bidding process in which private companies could compete for contracts with CCAC to provide health care services that had formerly been provided directly by the province. This movement reflected our collective acceptance of the proposition that privatisation of government services was a more cost-effective model of governance.

The bidding process forced service providers to lower their wages and the standards of working conditions in order to keep their bids competitive. Many non-profits were completely eliminated from the process. In 2003, the government recognized the erosion of quality in contracted health care services and froze the procurement process.

The Auditor’s report confirms that nurses and therapists employed directly by CCAC earn more per hour than similarly credentialed contract service providers. But the Auditor questions the expense and administrative duplicity of 14 CCACs conducting request for proposals and overseeing the contracts of the 160 private companies that provide contract CCAC services.

Might that expense be mitigated by directly employing more nurses and therapists?

Notably, the Auditor questioned the 95% increase in salary ranges available to CCAC CEOs between 2009 and 2013. The average salary paid to the CEOs was $245,000.00, and the pay range for senior executives was $118,000 to $190,000. The pay range is based on a framework that takes into account the complexity of the role.

Would the complexity of these executive roles be reduced if they were not overseeing contracts with 160 different private companies who provide the contract service providers?

Direct patient-care costs: where does that $2.36 million go?

The Auditor reviewed CCAC’s definition of direct patient-care costs. CCAC reports that 92% of their expenses ($2.36 million last year) are considered direct patient-care costs. However, CCAC includes the overhead and profits paid to their contract service providers in their definition of “direct-patient-care costs.” In other words, for every dollar paid to a contract service provider, some portion pays for the overhead of the contract employees employer, and some of it is profit for that the employer. The Auditor founds that excluding the overhead and profits of contract service providers reduces the direct patient-care costs to only 71.5% of CCAC’s expenses.

In the final analysis, CCAC spends almost 30% of its annual expenses ($2.36 million) on the overhead and profits of their contract service providers, while at the same time it has increased the salaries paid to executives and CEOs in part due to the complexity of overseeing these contract service providers.

Direct patient-care costs: what are we actually getting?

A frail, older adult who needs assistance with wound care, medication, ambulation, bathing, eating and dressing will be discharged home from hospital and will likely receive only a few hours of CCAC care per day. That care will likely be provided by a contract employee, who works night shifts and on-call, and may travel for miles from one patient to the next, many of whom earn roughly $20,000 per year, regardless of whatever hourly rate CCAC actually pays to their employer. The Auditor notes that CCAC pays $3 more per hour to nurses employed by CCAC compared to nurses provided by contracting companies – clearly, the contract nurses are not receiving all of the wages paid by CCAC.

The rest of the care required by that older adult will be met by family members, who will squeeze in a few hours here and there between their own jobs and families.

We wrote previously about the Globe’s coverage of the CCAC crisis:

More aggressively than any other province, Ontario is shifting health care out of hospitals and long-term-care facilities, and into people’s homes. It now has the fewest hospital beds per capita of any province in Canada – if Ontario were a country, only Chile and Mexico would rank lower in beds per capita among the 34 nations of the Organization for Economic Co-operation and Development.

In a cascade effect, the resulting spike in demand for home care is leading some cash-strapped community-care centres to change assessment standards, reduce services and cut clients off. In some cases, the CCACs are pressuring reluctant patients and their family caregivers to dress wounds, change intravenous medicine bags and perform other medical tasks in a bid to cut back on expensive in-home nursing visits. Meanwhile, more than 4,500 people across the province are languishing on waiting lists for publicly funded personal-support services in their homes – some of them high-needs patients.

Bear in mind this crunch on healthcare services is only just beginning – as this weekend’s Globe reports, only 18% of the population is over the age of 65. By the 2030s, it will be closer to 25%.

Are we responsible?

As a society have a tendency to devalue care providers. We voted for the government that established CCAC in 1997 and opened up our healthcare regime to private service providers. We accepted the questionable proposition that paying a lower hourly wage to contract service providers is the most cost-effective delivery model for healthcare. We have been aware of the demographic shift for decades, and have long been apoplectic about the shortage of CCAC services and hospital and long term care beds, yet our response to that inevitability is reactive, at best.

Our healthcare system is undeniably complex, which makes it difficult for end-users to inform themselves about how the system works, or doesn’t work, as the case may be. We do not tend to think about CCAC services until there is a crisis in our own family, at which point we are too overwhelmed to think about public policy, healthcare infrastructure, and government spending.

For this reason, these reports from the Auditor are so valuable; they provide us with insight and analysis that we wold otherwise not be privy to. We look forward to reading the second CCAC report from the Auditor next month.


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