How to improve health care safety in the home

More than one million Canadians receive health care services in the home and new research from the University of Toronto shows that each year 10 to 13 per cent experience an adverse event, such as an injury or medication problem.

Lawrence S. Bloomberg Faculty of Nursing’s Professor Emerita Diane Doran has released Safety at Home: A Pan-Canadian Home Care Study through the Canadian Patient Safety Institute (CPSI). Doran, along with co-lead researcher Régis Blais of Université de Montréal, spent two years looking at the prevalence, magnitude and risk of incidents in home care across Canada. 

Writer Kendra Hunter asked Doran about the findings and the safety recommendations from this study, the first of its kind in scope, and what this means for the future of home care and an aging population.

Why is this research important?
Ageing in Canada is reaching unprecedented levels in our country and, with people more determined to stay in their homes, it’s important that we study the home care model and how it’s working. We know that in 2011, there were 1.66 million Canadians receiving home care services and this number is expected to almost double to 2.78 million by 2036. Currently we know that 70 per cent of home care clients are over 75, mostly female with 20 per cent having a dementia related diagnosis such as Alzheimer’s.

With figures already this high, changes are needed in home care to accommodate this swell of clients and minimize risk.

What did your research uncover?
Namely that four out of every 100 clients admitted to home care experience an adverse event, such as a fall, infection, medication-related or other injuries, and that approximately 50 per cent were judged preventable. We determined that harmful incidents in home care could result from inconsistencies in care planning and delivery, poor standardization of processes and medication packaging, to name a few.

The consequences of these adverse events meant an increase in using health care services, disability or death.

How does this affect clients and families?
One of the main issues we uncovered was a high level of caregiver distress. As it stands, caregivers and clients have to deal with a patchwork of services due to the way the system was designed. Home care in Canada is defined as an “extended health service,” and is therefore not an insured health service under the Canada Health Act. Each province and territory administers its own publicly funded home care programs and services and they vary in terms of levels of coverage, eligibility criteria and funding. Some provinces and territories contract out a portion of their home care service to private agencies, so caregivers and clients have the additional task to manage a variety of care providers, from different agencies, in their homes all providing a separate, but yet related service.

Another very understandable issue that arises is that many clients don’t want to admit they need help or that something is wrong, for fear of being told they can no longer live independently. As a result, an adverse event can occur, which could leave the client in a position where they have no choice but to go into long-term care.

Is home care more hazardous than institutional care?
Home care is, in fact, safer for most patients than hospital stays. To put the findings in context, we found the rate of adverse incidents in home care to be 4.2 per cent.

A landmark national study by Baker, Norton, and colleagues published in the Canadian Medical Association Journal, entitled “The Canadian Adverse Events Study,” found that 7.5 per cent of patients experienced adverse events in hospitals. Most patients stay in hospital less than a week, while many people receive home care for months or years.

What can be done to make home care safer?
Some of the recommendations we’ve put forward are:

• Better communication across the board, between health care teams, health care facilities, with the clients, with their families – all of that is needed in order to ensure consistency of care delivery.
• Provide support for caregivers to give them better training, the opportunity for counselling, needs assessments, so they can manage the complexities and sometimes stressful elements of this care.
• Build integrated, interdisciplinary health care teams.
• Use a standard assessment tool to identify clients at risk and so that caregivers can know what signs to look for to identify if a client is declining.
• Provide opportunities and incentives for collaboration among health care sectors to find collaborative ways to ensure the best care possible.

Kendra Hunter is a writer with U of T's  Lawrence  S. Bloomberg Faculty of Nursing.