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Are Chronically Ill Patients High Users of Homecare Services in Canada?
Donna M. Wilson, PhD, RN; Corrine D. Truman, PhD, RN; Jessica A. Hewitt, BScKin; and Charl Els, MBChB, FCPsych, MMedPsych, ABAM, MROCC
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Are Chronically Ill Patients High Users of Homecare Services in Canada?

Donna M. Wilson, PhD, RN; Corrine D. Truman, PhD, RN; Jessica A. Hewitt, BScKin; and Charl Els, MBChB, FCPsych, MMedPsych, ABAM, MROCC
Assessments of self-care capacity and other measures were the most precise ways to identify individuals who could be classified as chronically ill, in their status as the highest users, both individually and collectively, of homecare services.
In Alberta, homecare client assessments are typically done by registered nurses who have considerable homecare services experience. These assessments result in client selection or a denial of services if homecare is not required or family members can provide them, and with selected clients having the type of services and amount of services predetermined for them. Homecare services are often short term but may be indefinitely provided, with suspension of services occurring when the client is hospitalized, admitted to a nursing home, or dies. Services are most often basic supportive care, such as assistance with bathing and daily medication monitoring, with these services usually provided by nursing care aides.12 Other more technical services, such as dressing changes and oxygen therapy monitoring, require a licensed care provider (eg, respiratory therapist, licensed practical nurse).12 If care needs change over time, the case manager conducts another assessment. As such, clients in need and healthcare system needs for efficient and effective service provision are both addressed.

This study also found that 3 common definitions of chronic illness—all of those based on medical diagnoses and related ICD-9-CM codes or chapters—did not usefully identify clients with substantial homecare services utilization shares. This is not the first time that medical diagnoses have been found unrelated to homecare service needs. A US study of chronically ill older individuals, for example, revealed that their ability to function independently was more important than disease labels for explaining their homecare service needs.27

This Alberta study found that clients who had been classified as long-term clients and clients with service spans of 90 or more days were the highest users of homecare services both collectively and individually. As such, both sets of clients could be considered chronically ill. However, the definition based on the homecare case manager assessment is a more practical and useful way to identify individuals with substantial ongoing homecare service needs. This definition relies on an assessment of each client—one that takes a wide range of health, sociodemographic, and other information into consideration. The client’s self-care capacity, functional limitations, and formal homecare needs in the absence of informal support are likely prime considerations. Another study found self-care incapacity was critical for defining chronic illness.23

Given the conclusion that the homecare pre-admission assessments were the most critical for identifying individuals who were chronically ill—those who would have ongoing homecare service needs and thus subsequent utilization—we believe research is now needed to standardize this assessment. There could be considerable assessment variability across homecare case managers, so standardization is important to assure access equity when homecare services are publicly funded and for access equity and other financial or risk management purposes when homecare services are not. This research should also identify the minimal data that need to be collected to ensure that this assessment is as brief as possible, but also accurate for identifying clients with substantial homecare service needs.

CONCLUSIONS
Chronic illnesses are not easily or simply defined by medical diagnoses, ICD-9-CM codes or chapters, old age, or female gender. Instead, this study revealed that homecare case manager assessments of self-care capacity, and of numerous other measures, are the most valuable in identifying those who could be described as chronically ill. These patients proved to be higher users, individually and collectively, of homecare services. With homecare services expansion already occurring in some countries,28 we must be vigilant to ensure that the right people get homecare services and that these services are enough to maintain them at home.29

Acknowledgments

This research was supported by a Health Canada project grant. The authors also thank Alberta Health for supplying the homecare data, Mike Hewitt for preparing the data for analysis, and the Integrated Centre for Care Advancement through Research for statistical advice.

Author Affiliations: University of Alberta Faculty of Nursing (DMW), University of Alberta John Dossetor Health Ethics Centre (CE), University of Alberta Faculty of Rehabilitative Medicine (JAH), Edmonton, Canada; Alberta Health (CDT), Edmonton, Canada.

Source of Funding: Health Canada provided the funding for this study. The views expressed herein do not represent those of Health Canada, the Government of Alberta, nor Alberta Health.

Author Disclosures: The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (DMW, CDT, JAH); acquisition of data (DMW, CDT); analysis and interpretation of data (DMW, CDT, JAH); drafting of the manuscript (DMW, CE, JAH); critical revision of the manuscript for important intellectual content (DMW, CDT, CE, JAH); statistical analysis (DMW, CDT); provision of patients or study materials (DMW, CDT); obtaining funding (DMW); administrative, technical, or logistic support (DMW); and supervision (DMW, CE).

Address correspondence to: Donna M. Wilson, PhD, RN, Faculty of Nursing, University of Alberta, Edmonton, AB, Canada T6G 1C9. E-mail: donna.wilson@ualberta.ca.
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