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Substudy 8 Executive Summary

Substudy 8: Eligibility for Community, Hospital and Institutional Services in Canada: A Preliminary Study of Case Managers in Seven Provinces

by John Hirdes, Erin Y. Tjam, and Brant E. Fries

In light of the challenges facing health care in Canada, many provinces have begun work to create eligibility systems for community, hospital and institutional services. Such eligibility systems have the potential to increase both the cost-effectiveness and equity of health care. However, eligibility for services is often a value-based decision reflecting policy choices about who should get what services. Therefore, one might expect to see regional differences in eligibility and access to services across Canada.

The present study involves 60 case managers from seven provinces responding to a series of questions about the types of services persons in their jurisdiction would be eligible for. Each case manager evaluated 16 different standardized vignettes describing persons in the community with different social, psychological, medical and environmental characteristics. For each vignette, the case managers indicated the level of care the person would be eligible for in that jurisdiction when blinded or not blinded to informal support. In addition, they also reported on waiting times, duration of services, types of professionals involved, co-payments and availability of services.

The analysis of this data illustrated regional differences in eligibility and access to services. In some regions, (e.g. Manitoba) there was a somewhat greater emphasis on community-based care, whereas other provinces (i.e. Ontario, Alberta, British Columbia) tended to have a somewhat higher level of resource intensity based the types of professionals likely to be involved in care. British Columbia and Ontario were more likely to have admissions to institutions or hospital settings recommended. Clients in Nova Scotia were much less likely than other provinces to be eligible for rehabilitation services.

The differences noted between provinces were not radical, but were sufficiently important to warrant careful consideration within each jurisdiction as to what approach their eligibility system should employ. That is, one cannot assume that an eligibility system designed for one jurisdiction necessarily applies fully to another.

The results also suggest that the role of informal support in any eligibility system requires careful evaluation. The present eligibility results differed when blinded and not blinded to informal support. However, the direction of change was not uniform, suggesting that informal support is best considered on a case by case rather than as part of an automated eligibility system. In all cases, the precise services needed by a given client should remain to be a clinical decision by a health professional in consultation with the client and family.

Future research in this area should use data from actual home care clients in different provinces to determine what services are provided across Canada. Such comparisons must be based on standardized assessment systems like the MDS-Home Care.