Directly-Funded Home Care for Older People in Canada

Most people want the choice to “age in place” at home and in their community, and home care is key to supporting this choice. A growing alternative to government-organized home care is “directly-funded” (DF) or self-managed home care, which provides individuals with cash to arrange their own home care services. Using feminist and disability care frameworks, this project involved a national environmental scan, 13 key informant interviews with government experts across the country, a survey of 95 workers, and 47 lived experience interviews with clients, caregivers, and workers. This project asked a variety of questions including: What are the features of DF programs across Canada? What are the emerging issues related to program design and policy development? Who are the workers in DF home care, and what are the working conditions? How does DF home care support and/or place demands upon family caregivers? Does DF have theoretical implications for social movements among older and disabled people in need of home-based support?

What we learned

Policy trends.
DF is growing across Canada particularly among older clients and their families. The evidence suggests that the policy mechanism may provide a short-term solution for inequitable access to services in rural areas, and can improve social outcomes for some client groups such as people from sexual, linguistic, and ethnic minorities. There is also a suggestion that clients who use DF programs are disproportionately represented by people from higher socio-economic backgrounds and with well-developed problem-solving and decision-making skills.
Worker experiences.
Compared to working for an agency or the health system, workers in DF are much more likely to be involved in the work of keeping households running, keeping DF home care services running, and supporting social and community interactions – we refer to this a ‘social task shifting.’ At the same time, relationships with DF clients can become extremely complex, which some experience as exploitation, while for others their work can result in meaningful personal relationships with important emotional rewards.
Client and family experiences.
DF enhances choice and flexibility of home care services, particularly in terms of what gets done when, leading to greater satisfaction and a sense of improved care quality among both clients and caregivers. DF can also reduce caregiver burden, although we identify areas were caregiver support can be improved.