Policy and Practice Note: Policy, Safety, and Regulation with Regard to Ontario Home Care Clients and Personal Support Workers

Abstract

In light of COVID-19 and elevated concerns for the health of older Canadians receiving care, this Policy and Practice Note explores the confluence of the current home care policy landscape and the organisation of personal support worker (PSW) work, and highlights the need to consider governance of PSW work generally, and in-home and community care especially. PSWs are currently not professionally regulated, nor is there a central site documenting location, education, or any form of verification of the PSW workforce. Home care PSWs often provide physical care in isolated settings with no in-person supervision. In home and community health care, complaints about PSWs can be scattered among different service providers or client files not linked to or searchable by PSW name. This policy note explores how these factors and the currently unregulated status of PSWs affect home care safety in general as well as in the context of COVID-19, Ontario’s decentralised home care system, and efforts towards professional regulation.

Résumé

À la lumière de la pandémie de COVID-19 et des préoccupations accrues pour la santé des Canadiens âgés qui reçoivent des soins, cette « Note sur les politiques et pratiques » explore le contexte des politiques de soins à domicile actuelles en lien avec l’organisation du travail des préposés aux services de soutien à la personne (PSSP), et souligne la nécessité d’envisager la gouvernance du travail des PSSP en général, mais aussi dans les soins à domicile et en milieu communautaire, en particulier. Les PSSP ne sont pas actuellement réglementés professionnellement, et aucun site centralisé ne documente la localisation, la formation ou toute vérification concernant les PSSP. Les PSSP œuvrant dans les soins à domicile offrent souvent des soins physiques en milieux isolés sans être supervisés en personne. Dans les soins de santé à domicile et en milieu communautaire, les plaintes contre des PSSP peuvent être fragmentées entre divers fournisseurs de services ou dossiers de clients qui ne sont pas associés ou repérables en fonction du nom du PSSP. Cette note explore comment ces facteurs et le statut non réglementé des PSSP affectent la sécurité des soins à domicile en général et, dans le contexte de la COVID-19, le système décentralisé de soins à domicile de l’Ontario, ainsi que les efforts déployés en vue d’une réglementation professionnelle.

Introduction

The COVID-19 pandemic has highlighted pre-existing issues in Ontario’s long-term care (LTC) and home care sectors. Key safety concerns include multi-site workers, chronic worker shortages, and the inter-relatedness of personal support worker (PSW) work and client health and safety (Denton, Zeytinoglu, Brookman, Davies, & Boucher, 2018; Gruben & Bélanger-Hardy, 2020; Hignett, Edmunds Otter, & Keen, 2016; Ontario Personal Support Workers Association, 2020a). Providing safe care requires Ontario to have policies that will ensure safe practices. To achieve this, we argue that we must support a PSW workforce in order to be capable of meeting our aging population’s demand for care.

Medicare coverage for home care is not federally mandated. With home care excluded from the Canada Health Act, heterogeneous home care systems exist across the country (England, Eakin, Gastaldo, & McKeever, 2007). In the case of Ontario home care, the policy and practices governing PSWs is fragmented across multiple administrative tiers: provincial funding from the Ministry of Health is administered by local health integration networks ¹ (LHINs), which engage service provider organisations ² (SPOs) via contracts, which in turn employ PSWs (Saari et al., 2017, 2018). This decentralisation was developed alongside “managed competition” and the premise that a market-model approach would help reduce costs and make home care more efficient (England et al., 2007). However, this model has devolved, as the competitive component has been nearly eliminated over the last decade (Wojtak & Stark, 2016). Despite this, Ontario’s model of home care delivery continues to rely on thousands of contractual agreements where SPOs provide care or services in the home and community sector (Wojtak & Stark, 2016). This government outsourcing has been criticized as neoliberal privatisation (Yakerson, 2019) with governments transferring a set amount of funding to private agencies (SPOs) which then assume associated risk (Martin-Matthews, Sims-Gould, & Tong, 2012). One article referred to the outsourcing of home care services as “Uberizing” home care, noting that meeting targets of service provision has become the focus, and a flat rate per visit detracts from the importance of measures such as effectiveness and service quality (Wojtak & Stark, 2016).

Forty-seven different SPOs across Ontario have home care services provided by PSWs (Health Shared Services, 2020) although with the inclusion of all services such as meal delivery programs and adult day programs, there are nearly 1,000 agencies engaged in contracts with the 14 local LHINs across the home and community support sector (Wojtak & Stark, 2016). The contracts (and other documents related to the contractual relationship, such as memorandums of understanding) between SPOs and LHINs are not publicly available, despite the public source of funding. Legislation introduced in 2020 is expected to move contract management to a more local level, ³ creating even more contracts (Standing Committee on the Legislative Assembly, 2020). Although SPOs sign contracts and agreements with LHINs, each SPO presumably creates their own standards for managing their employees, such as PSWs providing home care.

With the majority of direct care being provided by PSWs, it is critical to examine how workers in this unregulated profession are situated and managed in Ontario’s health care sector, particularly as care provision has become an elevated concern during the COVID-19 pandemic (Gruben & Bélanger-Hardy, 2020). However, original data about the Ontario PSW workforce is limited, with multiple articles frequently sharing the same sources. For example, a 2009 survey of Ontario PSWs (Lum, Sladek, Ying, & Holloway Payne, 2010) is cited in multiple articles referenced in this article. The sparse data about Ontario PSWs reflect the lack of system organisation and a dearth of research with these under-studied workers (Berta et al., 2018). Any form of regulation may improve access to access to data on PSWs.

PSWs and Demand for Care

Home care is often credited with providing support that allows clients to remain at home, contributing to reduced strain on hospitals and LTC homes; however, resources to provide home care are not always adequate, given estimations that up to 23 per cent of Ontarians admitted to LTC could remain at home if appropriate support was available (Canadian Institute for Health Information, 2017). An Ontario study also suggests that providing equivalent care at home is estimated at 20 times less expensive than hospital care, although the home care sector receives 5% or less of the total provincial health care budget and thus rations care based on available funding rather than need (Home Care Ontario, 2018). A July 2020 poll reported that 91% of adults over 55 would prefer to age at home for as long as possible (Home Care Ontario, 2020). As such, both economic and person-centered goals support the need to provide adequate PSW support for the safe delivery of home care (Saari et al., 2018; Williams et al., 2009). PSWs are an important part of Ontario’s healthcare infrastructure, caring for vulnerable populations including our growing population of adults 65 years of age and older (Canadian Institute for Health Information, 2017). Despite their key role in providing home care services to older individuals living in the community, PSW work has been regularly and systemically undervalued (Afzal, Stolee, Heckman, Boscart, & Sanyal, 2018; Zagrodney & Saks, 2017). Home care PSWs (who are disproportionately female, older, and racial minorities) work under precarious employment conditions, with low wages, irregular scheduling, part-time positions, and no extended health benefits (Zagrodney & Saks, 2017). Research cites these employment conditions to explain why PSWs leave the workforce (Barken et al., 2018; Keefe, Martin-Matthews, & Legare, 2011; Lee & Jang, 2016; Lum et al., 2010; Panagiotoglou, Fancey, Keefe, & Martin-Matthews, 2017; Sims-Gould, Byrne, Craven, Martin-Matthews, & Keefe, 2010; Zeytinoglu & Denton, 2006; Zeytinoglu, Denton, Plenderleith, & Chowhan, 2015). In 2014, the Ministry of Health and Long Term Care estimated PSW turnover to be 60 per cent annually (Ministry of Health and Long Term Care, 2014, 2016). Home care PSW’s work hours vary depending on the needs of clients, and can be modified with little notice when client circumstances change (Zeytinoglu et al., 2015). A further aspect of poor PSW working conditions is travel, with unpaid time to and from client homes, no compensation for the cost of operating a vehicle or taking public transit, and no allowance for hazardous weather conditions (Fitzpatrick & Neis, 2015; Lippel & Walters, 2019) Schedules that are disrupted by last-minute cancellations and additions and include large gaps in the middle of a day, together with obligations to keep certain days and times free for potential client need, reduce worker satisfaction (Lum et al., 2010; Panagiotoglou et al., 2017). PSW retention has been evaluated from numerous angles, yet Ontario (as well as other jurisdictions) continues to have an acute shortage of PSWs. Pandemic-era wage increases and bonuses have been introduced by governments and industry in efforts to recruit, retain, and re-engage workers; however, these reactionary measures fail to address a myriad of other issues, such as insecure part-time schedules and unpaid sick time (Standing Committee on the Legislative Assembly, 2020).

Worker shortages are particularly concerning given that demand for PSWs will only increase as the population ages. By 2030, it is projected that people over the age of 65 will account for approximately 22 per cent of Canadians, up from 17 per cent in 2018 (Statistics Canada, 2019). Echoing population demographics, home care clientele are also increasingly older. During the 2009–2010 business year, approximately 325,910 Ontarians 65 years of age and older made up 54 per cent of all publicly funded home care service users, increasing to 459,495 or 63 per cent of all publicly funded home care service users by the end of 2015–2016 (Home Care Ontario, n.d.). Among all Ontario home care clients, an estimated 15 per cent are children, 20 per cent are adults 18–64 years of age, and 60 per cent are 65 years of age and older, with palliative clients comprising the remaining 5 per cent (Home Care Ontario, 2018).

A Case for Regulation

PSW work conditions are interwoven with client safety. This has become increasingly evident during the COVID-19 pandemic. Health care workers face challenges such as: insufficient personal protection equipment; increased risk of exposure, illness, and even death; stress and exhaustion; and ongoing violence, conditions described in The Lancet prompting authors to state unequivocally, “…healthcare workforce safety is patient safety. One cannot exist without the other” (Shaw, Flott, Fontana, Durkin, & Darzi, 2020, para.8).

Bearing worker and client safety inter-relatedness in mind, supporting and protecting the workforce requires a comprehensive understanding of PSW work within the health care system. A lack of data pertaining to PSWs suggests that we cannot know what we might (or might not) be missing when it comes to home care client safety and PSW-provided care.

LHIN tracking mechanisms and client-based record keeping miss tracking data as they relate to home care worker presence or involvement in adverse events such as falls, medication errors, and injury (Ontario, Commission for the Long-Term Care Homes Public Inquiry, 2018). There is also no aggregate measure or transparent reporting of theft, fraud, or other types of incidents involving PSWs providing home care. However, a paucity of information should not be interpreted as reflecting the absence of these issues. The 2015 National Survey on the Mistreatment of Older Canadians reported that the prevalence of abuse (physical, sexual, emotional, and financial) and neglect among older Canadians was 8.2 per cent in the previous year (McDonald, 2018). Paid caregivers were found to be responsible for just 1 per cent of physical abuse incidents, zero instances of sexual, financial, or psychological instances, and 9 per cent of neglect instances (McDonald, 2018). In all types of abuse, these figures were eclipsed by abuse by adult children and grandchildren, spouses, and siblings (McDonald, 2018), making the role of PSWs and other staff in identification and reporting of suspected abuse a key safety measure. Although these figures reflect well on paid care providers, some differences do exist between the prevalence study sample (55 years of age and older and described as “cognitively intact”) and home care clientele, the majority of whom are adults 65 years of age and older. Response bias (e.g., lower participation in answering phone calls) or other factors may also affect the transferability of the prevalence study data.

Complaint processes and tracking further impede a full understanding of safety and PSW-provided home care. Home care complaints and investigation involving PSWs may be addressed by SPOs, LHINs, the Ministry of Health, the patient ombudsman, or police, in criminal investigations. Although estimating the prevalence of abuse among home care recipients is thus complicated, some additional information contributes to our knowledge:

1. 1. The Ontario Patient Ombudsperson reported 226 complaints in 2018 related to LHIN Home and Community Care, of which 43 per cent related to personal support services; however, the majority of these related to service levels and consistency (Patient Ombudsman, 2020). For LHIN-coordinated home care, in the recent periods June 2018 to June 2019 and June 2019 to June 2020, the patient ombudsman received “less than five complaints related to personal security or safety” (G. White, personal communication, September 30, 2020).

2. 2. Clients may turn to legal clinics such as Advocacy Resource Centre for the Handicapped (ARCH) Disability Law Centre or the Advocacy Centre for the Elderly (ACE). ACE Lawyer Jane Meadus presented the following information at a June 13, 2020 parliamentary committee meeting regarding home care legislation:

   We take over 4,000 calls annually on individual matters on a variety of seniors’ issues. We get many calls regarding home care. Examples of those issues would be inaccessibility to home care due to wait-lists, insufficient care, poor quality of care, staff not showing up, inconsistent staffing. (Standing Committee on the Legislative Assembly, 2020, p. M-105).

3. 3. Although not specific to paid caregivers, Statistics Canada reports that older adults (not living in an institution) with a cognitive or mental health disability are as much as four times more likely to have reported abuse by a caregiver (Statistics Canada, 2014).

4. 4. There is no way to assess the amount of alleged or actual health sector crime that occurs, based on what is reported in media (i.e., PSW assault, sexual assault, fraud, and theft ⁴ ).

In a decentralised home care system with no tracking mechanism for PSWs and a lack of standard data collection, it is difficult to fully assess abuse, neglect, or events such as falls or missed visits in PSW-provided home care. This general gap in available information draws attention to the need to better understand the context of PSW-provided home care.

During the COVID-19 pandemic, the plight of precariously employed health workers prominently entered the public sphere of awareness. Issues such as PSWs working for multiple employers and the tension between health care workers’ duty to care and their rights to safe work conditions received fresh attention in Canada (Gruben & Bélanger-Hardy, 2020). As unregulated care providers, PSWs do not face the same legal obligations as regulated professionals, such as nurses or physicians, yet are often expected to adhere to the same ethical standards (Gruben & Bélanger-Hardy, 2020). The unregulated status of PSWs has persisted despite years of discussion and debate about personal support work as a profession, and types of regulation (Kelly & Bourgeault, 2015b) including the 2006 Health Professions Regulatory Advisory Council (HPRAC) rejection of PSW as a profession (Health Professions Regulatory Advisory Council, 2006). The Ontario Personal Support Workers Association (OPSWA), a voluntary PSW association for paying members, has recently been campaigning for self-regulation for PSWs. A July 22, 2020 newsletter from OPSWA states:

For the last few months, the OPSWA has continued our battle for Self Regulation of the PSWs in Ontario. This battle has been steady and we are happy to inform you all that conversation surrounding Regulation of PSWs have begun. (Ontario Personal Support Workers Association, 2020b, p.1).

Also, in July 2020, OPSWA published a Call to Action, informing members they were in the “home stretch for Regulation, Recognition and Professional Respect” (Ontario Personal Support Workers Association, 2020a, para.1). While promoting self-regulation, OPSWA simultaneously provides access to liability insurance and other associated benefits such as annual police checks for its paying members. New sections of the Web site (https://ontariopswassociation.com/) added between July 22 and August 5, 2020 offer different membership types, such as organisation-level memberships for agencies at the regional, provincial, and national levels. The OPSWA Web site also contains a copy of their bylaws, approved July 30, 2020.

The OPSWA has suggested implementing an oversight body (The Personal Support Workers Institute of Canada) and utilizing their membership body, OPSWA, to facilitate PSW self-regulation. In their proposal for self-regulation (accessed July 22, 2020), the OPSWA stated: “[OPSWA] has established an independent and separate Board of Directors, President and administrative body prepared to monitor complaints and enforce discipline which will be known as The Personal Support Workers Institute of Canada” (Ontario Personal Support Workers Association, n.d.). However, a previously available page providing details about how OPSWA proposed to handle complaints using a separate board (formerly published at http://www.ontariopswassociation.com/complaints-discipline) was no longer available, at the time of writing (September 11, 2020). According to the Federal Corporation Web site, The Personal Support Workers Institute of Canada was registered (in the name of Ian DaSilva, OPSWA’s Director of Operations) as Corporation #11471422 with Corporations Canada on June 18, 2019 (Federal Corporation, n.d.). If and how PSW regulation is constructed will be a key component in safe home care provision: one that health system and policy experts might wish to evaluate, given OPSWA’s claim of being in the “home stretch” towards self-regulation (Ontario Personal Support Workers Association, 2020a). Although OPSWA has expressed an interest in both the registration and regulatory aspects of self-regulation, greater separation of these roles may be needed to ensure true independence and avoid any conflict of interest, real or perceived.

In lieu of a legally binding framework, Gruben & Bélanger-Hardy (2020) propose guidance for PSWs already occurs in the following four forms:

1. 1. Education standards (e.g., Kelly & Bourgeault, 2015a)

2. 2. Regulated professionals (e.g. nurses) ensuring PSW competency for delegated controlled acts (e.g., Barken, Denton, Plenderleith, Zeytinoglu, & Brookman, 2015; Denton, Brookman, Zeytinoglu, Plenderleith, & Barken, 2015)

3. 3. Supervision through the employer (e.g., Afzal et al., 2018; Lum et al., 2010)

4. 4. Association (e.g., Ontario Personal Support Workers Association) guidelines or codes of conduct (Gruben & Bélanger-Hardy, 2020).

However, our view is that all the forms of guidance presented by Gruben & Bélanger-Hardy (2020) have limitations or caveats, and that some limitations are of elevated concern for home care. Each of these four guidance topics are discussed in the following sections.

Education: Challenging Verification and No Registration

Gruben and Bélanger-Hardy (2020) propose that a PSW education standard, implemented in 2014 in Ontario (Kelly & Bourgeault, 2015a) can increase client safety. However, this applies only to new PSWs and not those employed prior to the introduction of standardised education (Kelly & Bourgeault, 2015a, 2015b). The number of PSWs currently working in Ontario who graduated since the education standard was implemented is unknown, as there is no central database of currently employed, qualified PSWs. A year project to create a registry of PSWs in Ontario ended in 2016 without achieving the goal (Laporte & Rudoler, 2013). Also, an Ontario Liberal government plan to unify PSWs under a single provincial agency was dropped in 2018 when the Conservative party formed the subsequent Ontario government (Crawley, 2017). A “pilot project” for a new provincial registry developed by the Ontario government in cooperation with the Michener Institute was completed in 2019; however, plans to implement this or any registry are unclear (Michener Institute, n.d.).

Although education may provide a PSW-skills baseline, there is a scarcity of information about PSWs’ ongoing practises and the effect of education on the quality of home care provided by PSWs.

Task Shifting: Delegated but Unsupervised

A key challenge to safety in home care is the need for PSWs to meet increasingly complex client care needs and often perform tasks that are beyond their basic training. Gruben and Bélanger-Hardy (2020) suggest that a safety measure would be for them to do these tasks under the direction of a licensed practitioner, an approach called “task shifting” (Afzal et al., 2018; Barken et al., 2015; Denton et al., 2015; Saari et al., 2018; Zeytinoglu, Denton, Brookman, & Plenderleith, 2014). However, which tasks are delegated and which approaches exist to educate PSWs to perform such controlled acts vary among SPOs (Afzal et al., 2018; Barken et al., 2015; Denton et al., 2015). How a registered worker, such as a nurse, can follow up or monitor PSWs performing controlled acts in home care is also elusive in policy. One Ontario study found some concern among occupational therapists, nurses, and supervisors about home care workers lacking the necessary skill level and assessment abilities that are important for some complex tasks that were shifted to home care workers (Barken et al., 2015).

Employer Supervision: Lip Service Only?

In Ontario’s current care system, responsibility for PSWs is considered to be the duty of the SPOs who employ them, and the SPOs themselves are contracted by the regional LHINs (Ontario, Commission for the Long-Term Care Homes Public Inquiry, 2018). Within this layered system, the onus is on individual SPOs to verify PSW applicants’ references and vet their qualifications, as this information is not collected in any central location (Michener Institute, n.d.; Ontario, Commission for the Long-Term Care Homes Public Inquiry, 2018). The multiple parties involved in home care services (Province of Ontario, LHINs, and SPOs) also lack any common source for documenting worker performance issues or client complaints about specific PSWs (Ontario, Commission for the Long-Term Care Homes Public Inquiry, 2018). For example, in the Southwest LHIN, which uses an “event tracking mechanism system” (ETMS), there is no method for recording information according to which workers are involved in any reported client complaints or adverse events documented in client files (Ontario, Commission for the Long-Term Care Homes Public Inquiry, 2018). The ETMS does, however, incorporate SPO staff or LHIN staff reports of suspected client abuse or neglect, something which frontline staff are trained to recognize and obliged to report (Ontario, Commission for the Long-Term Care Homes Public Inquiry, 2018). PSWs often act as advocates for clients and report concerns to supervisors, which are documented at the level of individual client files (Ontario, Commission for the Long-Term Care Homes Public Inquiry, 2018).

During the 2018 Long-Term Care Homes Public Inquiry that followed the murder of eight LTC residents in Ontario by nurse Elizabeth Wettlaufer, workers’ self-reporting was referenced in the following excerpt from Day 33 of the public hearings:

Associate Counsel Lara Kinkartz: Is it fair to say that since they’re in the home alone, a service provider staff member’s failure to report may well go unnoticed unless the patient or someone else there decides to make a report?

Donna Ladouceur, vice-president of Home and Community Care, Southwest LHIN: Yes, it could (Ontario, Commission for the Long-Term Care Homes Public Inquiry, 2018, p. 7,708.).

Although staff members’ failure to report would not be addressed by professional regulation alone, a regulatory body with means to document complaints about workers could contribute to validating workers’ past employment records. The LTC inquiry recommends that SPOs maintain permanent employee files documenting performance, complaints, and concerns (Gillese, 2019). We suggest that this would be most effective on a provincial level so that other current and future employers could access information relevant for screening that was not necessarily captured elsewhere, such as a police record check.

Home care settings differ from LTC settings, which are busy environments with family and volunteer visitors, residents, and usually multiple staff, which presents a greater likelihood of workers being observed or supervised in LTC than they would be in a private dwelling. Additionally, LTC facilities (unlike home care settings) are subject to compliance checks and investigations on a regular basis (Gillese, 2019). It is notable that during the COVID-19 crisis beginning in March 2020, LTC homes also drew extensive media attention, while the impact on home care clients receiving PSW-provided care received less public consideration. Lang and Edwards (2006) found that home care services lacked measures to address safety issues because private residences were uncontrolled settings, especially in comparison with the institutionalised settings of LTC and hospitals (Lang & Edwards, 2006). Similarly, Peckham, Rudoler, Li, and D’Souza (2018) found that the home care system is marginalised and fragmented compared with mainstream “organised and institutionalised” entities such as hospitals (Peckham et al., 2018). This circumstance was aptly described by lawyer David Golden when cross-examining Donna Ladouceur, the Vice President of Home and Community Care for the Southwest LHIN during the LTC public inquiry:

And I’m wondering in that context whether you’ve participated with anyone from the Ministry in policy discussions over why the group of vulnerable persons that you’re serving are primarily protected through contracts, whereas the group of vulnerable people in long-term care have this very detailed, regulatory system? Have you participated in any policy discussions that understand why the two groups of vulnerable persons receiving taxpayer money for healthcare are treated so differently from a legislative perspective? (Ontario, Commission for the Long-Term Care Homes Public Inquiry, 2018, p. 7,753).

The LTC Homes Public Inquiry, although focused on LTC and registered staff, highlighted multiple weaknesses in home care safety (Gillese, 2019). To date, there has been less attention given to the implications of public inquiry findings relevant for client safety in the context of PSW-provided home care.

The current organisation of home care delivery by PSWs appears to still encompass the same circumstances that allowed nurse Elizabeth Wettlaufer to work in home care, where she stole medication, entered client homes without authorisation, and attempted to kill a client in the client’s own home (Gillese, 2019). Wettlaufer’s home care sector crime has received little attention in light of her serial killings in LTC, yet her activities still illuminate gaps in policy ensuring the safety and security of home care provision. Wettlaufer was, as a nurse, part of a regulated profession. In contrast, PSWs who are not regulated workers and who do not belong to a college or professional body are subject to even less oversight. However, Wettlaufer’s crimes, undetected in both LTC and home and community care until her confession, demonstrate that professional regulation is not adequate to compensate for the gaps (or chasms?) between service providers in a fragmented system. The Long-Term Care Home Public Inquiry Hearings Day 33 (Ontario, Commission for the Long-Term Care Homes Public Inquiry, 2018) and the LTC Homes Public Inquiry (Gillese, 2019) made explicit that service providers lack a common source of worker verification, and client complaints about workers are buried within client files kept by a patchwork of SPOs in a network of LHINs.

Ontario’s home care system currently relies on client or family/caregiver complaints for ensuring quality of care (Baxter, 2018; Gillese, 2019). Although complaints about eligibility, the number of hours per month, and frequency of care can be escalated to the Health Services Appeal and Review Board (HSARB), the narrow mandate of the board renders it unable to respond to any complaints or allegations of abuse (Baxter, 2018; Ontario, Commission for the Long-Term Care Homes Public Inquiry, 2018). A scan of hearing proceedings posted by the Canadian Legal Information Institute (www.canlii.org), shows that HSARB regularly states that complaints about service quality are outside of their jurisdiction according to the Home Care and Community Services Act (Ministry of Health and Long-Term Care, 1994). The Health Professionals Appeals and Review Board (HPARB) does deal with complaints and hearings for the 28 different self-regulated professions, such as occupational therapists, dental hygienists, massage therapists, and physicians. However, as unregulated health system workers, PSWs are not covered by HPARB (Health Professionals Appeal and Review Board, n.d.).

Association Guidelines: A Presumptive Compliance

A fourth method that Gruben & Belanger-Hardy (2020) suggest could serve as a form of regulation is the guidance provided to PSWs through membership organisations, such as OPSWA, a voluntary membership organisation with a mandate to support PSWs. However, in Ontario, this clearly covers only the voluntary members, meaning that the same standards do not apply for all PSWs.

Next Steps: Policy and Research

As discussed, education standards, regulated staff delegating controlled acts, supervision through employers, and guidelines created by associations each have limitations, many of which are more apparent in the home care context than in LTC. In light of these limitations, we draw attention to knowledge gaps and explore how policy might address risk and improve safety in home care delivered by PSWs.

There are clear knowledge gaps in what is known about the safety of PSW-provided home care in Ontario. Little research has considered the prevalence of client abuse or neglect by paid home care workers such as PSWs (McDonald, 2018). Studies that consider physical injury (e.g., Doran et al., 2013) do not account for other events that may occur in PSW-provided home care, such as verbal abuse or theft. The taxonomy of safety (such as adverse events) often fails to include aspects such as near misses (Lang & Edwards, 2006). Research about PSWs regularly fails to differentiate between in-home and institutional workers (e.g., in LTC homes), or PSWs and other in-home workers such as nurses and occupational therapists (e.g., Denton, Zeytinoglu, & Davies, 2002; Gilmour, 2018; Home Care Sector Study Corporation, 2003). In one article investigating theories of team-based person-centered care, unregulated home care providers such as PSWs were not considered separately; instead, their role was cited as likely “inherent” to the disciplines who supervised these workers (Giosa, Holyoke, & Stolee, 2019). However, PSWs’ unregulated status is unique, and regularly mismatched with the level of care that these unsupervised workers provide. Regulated professionals (nurses and therapists) in Ontario have described problems with delegating acts or transferring tasks to unregulated care providers, such as training that occurs in usually just one visit, lack of skill to identify changes or assess new issues that arise, and limited opportunity to monitor delegated acts on an ongoing basis (Denton et al., 2015).

Investigation of PSW care and client safety in research studies seldom goes beyond physical outcomes or exploration of events that occur during the provision of care, and is remiss in not considering how the absence of professional regulation of PSWs may impact research into client safety. Research looking at a single aspect of care provision fails to encompass the risk potential in the “policy-system-worker-client” integrated actuality. Policy-oriented literature in this area also falls short of the mark, often approaching issues from economic or organisational standpoints that miss delving into PSW work and its relation to the safety of home care clients (e.g., Forbes & Edge, 2009; Peckham et al., 2018; Wojtak & Stark, 2016). The accountability of home care structure and delivery is a long-standing concern (e.g., Coyte & McKeever, 2001). One study found that although some accountability existed through regulations such as the Occupational Health and Safety Act (Ministry of Labour, 1990), home and community care organisations were primarily held accountable through limited means such as expenditure tools (Steele-Gray, Berta, Deber, & Lum, 2014). Financial accountability and service quantity targets are priority metrics in SPO contracts, and there were almost no requirements or performance measures in place for the quality of care provided to vulnerable populations (Steele-Gray et al., 2014).

Some portions of the Home Care and Community Services Act, such as the client Bill of Rights (Ministry of Health and Long-Term Care, 1994) address home care services yet do not address PSW work specifically. The Home Care and Community Services Act also outlines certain elements of the service agreements between LHINs and SPOs, but tends to focus on higher level administrative aspects as opposed to directives about the act of caregiving (Ministry of Health and Long-Term Care, 1994). Legislation has also been criticized for failing to deal with funding and capacity of home care services (Sheppard, 2019). How these issues will play out in Ontario’s pending Connecting People to Home and Community Care Act (Ministry of Health and Long-Term Care, 2020) regulation, and the full impact of the recent Connecting Care Act (Ministry of Health and Long-Term Care, 2019) remain to be seen. Political party mandates after provincial elections or crises may prompt health system change, yet frequent overhaul may unnecessarily increase costs or result in revolving policy modifications. Although policy should respond to changing population needs, it is important to balance this with stability in the system and provide some level of security to enable SPOs to plan for ongoing service provision and the necessary resources. This challenge may be addressed through evidence-based, non-partisan research, organisational planning, and policy development.

Conclusion

This policy and practice note provided an overview of numerous limitations of our current knowledge and policy pertaining to PSW-provided home care and client safety.

We suggest that the complexity of home care client safety in Ontario requires research that bridges inter-related domains (such as client safety, occupational health and safety, and health system organisation) to develop policy interfaces that encompass multiple parties, rather than dispersing responsibility but failing to compensate for the resultant fragmentation. To this end, juxtaposing client rights and PSWs’ occupational rights as conflicting or sometimes mutually exclusive is also problematic. Two groups of researchers have approached this issue by considering multiple parties in conjunction, providing models that might inspire future work. Martin-Matthews, Sims-Gould and Tong (2012) center their inquiry on the experiences of workers, clients and family carers, and managers. Lang and Edwards (2006) developed a patient-safety framework that acknowledged the inter-relatedness of client, caregiver, and provider safety. Later research citing this framework incorporated a “triad” of participants: care recipient, family or informal caregiver, and paid care providers (Lang et al., 2014). We suggest that home care safety may be best served with this or a similarly integrated approach that values the safety of all parties. Further research that considers policy, PSW work, and client safety in conjunction is important for exploring risks in PSW-provided home care and addressing knowledge gaps (e.g., the prevalence of various kinds of abuse and neglect by care providers).

That PSW regulation might improve client safety is something to keep in mind; however, this should be carefully structured. We suggest that if self-regulation of PSWs is implemented, an external regulatory body and legislative change (e.g., Regulated Health Professions Act [Ministry of Health and Long-Term Care, 1991]) are both needed to ensure that PSWs are regulated fairly and fall under The Health Professionals Appeals and Review. ⁵ Any system introduced should include data about Ontario PSWs working for all types of organisations, including the multiple service providers and home and community sector employers. These employers should also be able to verify workers’ qualifications and past performance. As the Wettlaufer crimes demonstrated, registration with the College of Nurses alone failed to protect care recipients. This suggests that alternative solutions or enhancements to a registry or regulatory body may be needed, especially as self-regulating professions are not integrated with the many various private organisations providing care in a decentralised system. To address system-level safety risks, it seems appropriate to consider system-wide safety-related standards as opposed to the current system in Ontario that has hundreds of separate employers and organisations attempting to develop policies and manage these issues. For example, a complaints-based system that fails to widely track complaints about individual workers (Baxter, 2018; Health Professionals Appeal and Review Board, n.d.) is a system-level problem and, therefore, calls for a system-level response.

We cannot afford to underestimate the importance of system design: client safety requires policy that recognizes that the roles of multiple parties, and system design itself, contribute to home care safety (Zeytinoglu, Denton, Brookman, Davies, & Sayin, 2017) and health care safety more broadly. The LTC home inquiry and problems exposed during the COVID-19 pandemic illustrate that current system organisation in Ontario (including the decentralised structure and current accountability mechanisms for non-governmental organisations) do not provide needed safety conditions for care recipients or workers (Gruben & Bélanger-Hardy, 2020). We argue that Ontario requires a robust policy framework that will assure quality and enable our health system to meet increasing demand and sustain safe care in emergency circumstances such as pandemics.