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Barely two months later, the Ungers were informed that when George turns 65 in May, his coverage will change and he will have a $10,000 lifetime benefit maximum.

Unger was a fire safety engineer. His employer's group insurance policy paid for his care when he went on long-term disability. Neither Unger nor his wife knew that when he turned 65, his coverage would change. Manulife didn't see fit to mention it on his first letter, issued when he was 64 years and seven months old.

Manulife Financial could not comment on Unger's case, but specified that long-term disability coverage typically terminates when an individual turns 65. "The employment status and the resulting eligibility for health benefits after age 65 is determined by the plan sponsor (employer)," wrote spokesperson Jana Miller.

If a patient is considered a palliative case, there's no limit to the care they can receive, said Barbara Busing, vice-president of clinical operations with the Niagara Region's Community Care Access Centre. "Most people want to be at home and we do everything we can to help them live out that aspiration," she said. Since a 2005 funding boost to end-of-life care, 6,000 more Ontarians are treated at home or in a hospice, said Health Minister Deb Matthews.

"Providing a loved one with the most appropriate, compassionate and comfortable care at the end of their lives is the right thing to do . . . and lifting the service maximums for CCAC delivered palliative care is part of that," she said in an emailed statement.

The overall trend, she said, is a home care budget that doesn't live up to expectations.

"Verbally we see a commitment to shifting more care towards the home," Henningsen said in a telephone interview. "What we noticed from putting this report together is that the percentage of the public funding certainly didn't reflect those messages or that direction."

The report said demand for home care is soaring as Canada's baby boomers enter their twilight years. About 1.4 million people accessed home care services in 2011, up 55 per cent from 2008.

Henningsen said the association would like to see all orders of government redistribute their health care budgets to make home care a higher priority

She said new cash would not be necessary, adding reallocating funds currently devoted to other areas would go a long way towards addressing the shortfall.

But it falls short of the oft-repeated "five-day home-care guarantee" Horwath has been pushing since shortly after Premier Kathleen Wynne took over from Dalton McGuinty.

In addition, close to two thirds of respondents believed there is currently insufficient qualified staff available in both home care (68.4 per cent) and long-term care (63.7 per cent) settings.

An overwhelming 77.6 per cent of respondents identified a strong preference for home care over institutional care.

The highest rating in the survey, 96 per cent, was given to the importance of having a qualified nurse on duty.

Community Care Access Centres will receive $33 million in additional funding to reduce the waitlist for in-home physiotherapy services, which will help to keep more seniors and eligible patients healthy and at home longer. Up to 60,000 more people, mostly seniors, will receive physiotherapy in the comfort of their own homes, benefitting 150,000 people in total.

Over the coming months, the Ministry of Health and Long-term Care and the LHINs will engage physiotherapy providers and community partners interested in delivering these services in communities across Ontario.

Until now, a small number of for-profit companies have had almost exclusive control over the delivery of publicly-funded physiotherapy.

Unger's wife, Lynda, got a letter from his employer's insurance company pledging to provide 24-hour nursing services at home with no deductible and no limit. With this letter, Unger was discharged from Sunnybrook Hospital and allowed to go home to live out his days surrounded by family in a comfortable setting.

Barely two months later, the Ungers were informed that when George turns 65 in May, his coverage will change and he will have a $10,000 lifetime benefit maximum.

"I feel bamboozled by the insurance company," Lynda said. "I can't believe they would leave us like this. They should continue to pay for his nursing because they agreed to it."

Neither Unger nor his wife knew that when he turned 65, his coverage would change. Manulife didn't see fit to mention it on his first letter, issued when he was 64 years and 7 months old.

The workers depended upon to deliver that front-line care in most cases are personal support workers. But according to Service Employees International Union Healthcare president Sharleen Stewart, who represents approximately 8,000 PSWs, their work is under-appreciated and under-funded.

Stewart says being a personal support worker is far from a path to financial security. Workers who deliver home care make between $12 and $14 an hour on average. That compared to $17 to $20 an hour working in a nursing home or $20 to $25 an hour working in a hospital. Stewart says increasingly young workers train in home care and then leave. According to a study done by Personal Support Network of Ontario, 7,000 PSWs are trained every year in Ontario, 9,000 leave the profession annually.

Stewart’s concerns are echoed by one of the country’s largest not-for-profit home care providers, the Canadian Red Cross. National director of health programs Lori Holloway says any plan to make Canada’s health care system sustainable has to include a human resources plan the focuses on retention, and that includes PSWs specifically, she said.

Ontario Home Care Association executive director Sue VanderBent says the disparity between PSW wages has been created by a traditional view of the sector, which have always seen it diminished or funded after other areas like nursing homes and hospitals.

I recently caught up with Dr. Samir Sinha, Director of Geriatrics of the Sinai Health System and the University Health Network Hospitals in Toronto, and Assistant Professor at the University of Toronto and the Johns Hopkins University School of Medicine. He is leading an evidence-based approach to develop a National Seniors Strategy for Canada. Dr. Sinha speaks passionately and with infectious optimism about the need for a paradigm shift in our approach to health care for older adults. There are five principles that are at the core of this new paradigm: Access, Equity, Choice, Value, and Quality.

nearly 40 percent of in-home care workers have to rely on food stamps or other forms of public assistance in order to make ends meet

Click here for her testimony.

Instituting a means test: An equitable system does not mean you have to provide equal services to all at equal cost; user fees and co-payments are not necessarily unfair, but these approaches have to be used smartly

Regulating rather than outlawing private insurance and care. One of the most important lessons we have to take from Europeans is that we need a combination of a well-regulated private system and a well-managed public system.

Every health system worth its salt has a mix of private and public delivery and payment.

The question is not whether or not we have private and public care. It’s getting the mix right.

There are things private enterprise does well. There are things that public and non-profit enterprises do well. Let’s be pragmatic and benefit from both, as most European countries do.

We need to pay much more attention to equity – making sure everyone is cared for – and less to who is delivering the services.

Reform is going to happen only if the political environment changes, if we stop shouting down every proposal for change because it threatens vested interests.

We don’t need more tiresome private-public rhetoric. We don’t need Chicken Little screaming that medicare is unsustainable.

I am the B.C. representative to the Canadian Homecare Association

small army of trained women and men (1,200 in the South Island alone) travelling each day to sometimes eight or nine clients. The work starts as early as a 6: 30 a.m. and can run as late as 11 p.m. As well, there are the dedicated souls who stay overnight or "live-in" for three or four shifts with our most frail clients, often those who are palliative.

On a typical day in the capital region, more than 700 community health workers are on the road. They travel, collectively, 7,000 kilometres and visit 3,000 clients.

Isobel Mackenzie is CEO of Beacon Community Services, a non-profit that delivers home support to clients on the South Island in partnership with VIHA.

the Health Council told us, there remain “clear disparities in the availability of publicly-funded homecare across the country”

The Health Minister, ignoring the 80% of Canadians who want more home and community care added to the health system, has stated flatly that he is “not going to get involved” in home care because he sees it as a provincial matter.  As if to underscore his point, the government has dismantled the Secretariat set up in 2001 to coordinate the development of a national strategy on end-of-life care.

the government has been sitting on the report of the Wait Times Advisor for two full years.  Positive recommendations, including a more multidisciplinary approach and gender analysis, have been side-tracked. 

the federal government’s silence while for-profit forces have exploited public concern over wait times to resurrect their false promise of salvation through parallel for-profit care

after developing the Framework for Collaborative Pan-Canadian Health Human Resources Planning, the action plan so urgently needed has hit the doldrums

The Health Council has said planning remains “fragmented”

urgent need to address the health deficit faced by aboriginal Canadians with improvements to both health services and the determinants of health for aboriginal communities

Although the 10-year Plan includes health care in Northern communities and has incorporated the 2004 Blueprint for Aboriginal Health, the Health Council reports that “preventable health problems… continue to be of concern across the country”, and that “relatively little funding seems to have flowed”.

the federal government’s decentralized approach to national health care priorities has resulted in the loss of a national vision for health care and a directionless, leaderless renewal process at the national level

We recommend, therefore, that the federal government commit itself to a national, pan-Canadian, system-wide approach to public health care renewal anchored in Canada Health Act principles and enforcement, and with the jurisdictional flexibility and asymmetrical federalism found in the 10-Year Plan to Strengthen Health Care.

We recommend, therefore, that the government take urgent actions to get the Plan back on track in each of its areas of focus as quickly as possible, including: acting on the recommendations of the 2006 Interim Report of the National Pharmaceutical Strategy and the Report of the Wait Time Advisor; advancing the action plan under the Framework for Collaborative Pan-Canadian Health Human Resources Planning; energetically pursuing the objectives of the 2004 Blueprint for Aboriginal Health (most particularly where it relates to measures under direct federal jurisdiction); working with the provinces and territories to re-establish the Advisory Committee on Governance and Accountability as a functioning part of the renewal process; and convening a meeting of ministers of health to identify roadblocks that are impeding progress and to develop strategies to overcome these obstacles. 

the Canada Health Act, our main tool in protecting public health care, to which the 10-Year Plan to Strengthen Health Care is committed, is being undermined through inadequate monitoring and enforcement

The for-profit health industry continues to grow unabated

The Canada Health Act annual reports to Parliament do not reflect this due to their limited scope and the government’s failure to make improvements identified by the Auditor General back in 2002.

We recommend, therefore, that the Health Minister fully enforce the Canada Health Act by: setting data collection standards for reporting and enforcement that capture all for-profit activities that may impact on public health delivery; working collaboratively with the provinces and territories to fill gaps in reporting; stipulating that federal transfers should only be used for non-profit health care delivery; and removing any requirements that health infrastructure endeavours consider for-profit options such as public-private partnerships.

actual cost savings can only be obtained in integrated systems of care that enable trade-offs between lower-cost homecare services and more costly long-term care facilities

Over a 10-year period from the mid-1980s to the mid-1990s, British Columbia had an integrated system that allowed it to restrain the growth of longterm care beds and invest new money into home care, which resulted, after 10 years, in estimated annual cost avoidance of about $150 million.

it is often non-professional supportive care that allows people to continue to function independently

A B.C. study found that people who had been evaluated by nurse assessors as needing homemaking services due to their frailty, and whose home care was discontinued, cost the system considerably more, three years later, than people in similar communities with similar conditions who had been able to maintain a modest level of home-support services over the same period of time.

the deal offered by Mr. Harper’s government is reasonable. It is fiscally responsible, tying spending increases to inflation

It is also politically astute, for a host of reasons:

* It avoids the sordid scene we saw in 2004 when provincial premiers ganged up on prime minister Paul Martin and extorted $41-billion in additional health dollars and a spendthrift 6-per-cent escalator clause on transfers.

* It is a 10-year deal, just as the provinces demanded, allowing some certainty in budgeting.

* It respects Mr. Harper’s election promise to maintain 6-per-cent increases beyond 2014 – at least nominally. (Those who wanted 6 per cent per annum were dreaming in Technicolor.)

* It puts the onus on the provinces to justify why health-care spending should exceed inflation, something they have never been able to do.

* It places no restrictions on how the provinces spend the $40-billion a year they receive in federal health transfers (along with another $20-billion in social transfers for education and welfare programs.)

It should be an instrument for improving health-care delivery, and in that regard, Mr. Flaherty’s offer fails miserably

What the public should expect from Ottawa is that federal funds be used to exercise leadership and foster innovation

The reason Ottawa transfers money to the provinces in the first place (because health is a provincial responsibility constitutionally) is to ensure some semblance of equity coast-to-coast-to-coast. But there are areas, such as catastrophic drug coverage and homecare, where there are gross regional disparities.

This accord will force the provinces to rein in health spending, which is not a bad thing in itself. But one of the consequences will likely be greater disparities in the quality of care and breadth of coverage between the have and have-not provinces.

The great failure here is not refusing to increase transfers by 6 per cent, it is failing to attach strings to the monies.

With this deal, Mr. Harper has shown himself to be politically astute and fiscally prudent, but he has failed to show a commitment to strengthening health care, and medicare more specifically.

Only non-essential workers will be allowed to hit the picket line.

Nova Scotia Government and General Employees Union

Diane Doran, the scientific director of the University of Toronto's Nursing Health Services Research Unit, notes that patients often deal with a rotating cast of nurses and personal-care workers, each with their own style of delivering care.

Doran was one of the co-leads on the two-year Safety at Home study, which found that the most serious adverse events experienced by patients in the home are falls, medication errors and infections ? which are many of the same risks encountered in hospitals.

MacLeod says the organization has vowed to prioritize home-care safety issues over the next five years ? a sign of the times. "There has been a very significant shift from acute care to home care," he says. "The public is demanding this shift."

Doran says that their study of home care across Canada found that often that type of risk assessment wasn't done, but even when it was, it wasn't acted upon because of confusion over whose responsibility it was.

The use of electronic charts would also go a long way to making sure that details about a patient's care don't get lost between the multiple caregivers and transfers.

In 2012, age-related needs were identified as the single most common problem requiring help from caregivers (28%) (Chart 1). This was followed by cancer (11%), cardio-vascular disease (9%), mental illness (7%), and Alzheimer’s disease and dementia (6%).

The majority of caregivers reported providing transportation to their primary care receiver, making it the most frequent type of care provided in the last 12 months (73%)

Most often, caregivers spent under 10 hours a week on caregiving duties. In particular, one-quarter of caregivers (26%) reported spending one hour or less per week caring for a family member or friend. Another 32% reported spending an average of 2 to 4 hours per week and 16% spent 5 to 9 hours per week on caregiving activities.  

The most common types of care were not always the ones most likely to be performed on a regular basis (i.e., at least once a week). For instance, despite the fact that personal care and providing medical assistance were the least common forms of care, when they were performed, these tasks were most likely to be done more regularly.

Emotional support often accompanied other help to the care receiver. Nearly nine in ten caregivers (88%) reported spending time with the person, talking with and listening to them, cheering them up or providing some other form of emotional support. Virtually all caregivers (96%) ensured that the ill or disabled family member or friend was okay, either by visiting or calling.

Overall, caregivers spent a median of 3 hours a week caring for an ill or disabled family member or friend. This climbed to a median of 10 hours per week for caregivers assisting a child and 14 hours for those providing care to an ill spouse (Chart 3).

In addition, about half of caregivers (51%) reported that they performed tasks inside the care recipients’ home in the last 12 months, such as preparing meals, cleaning, and laundry. Another 45% reported providing assistance with house maintenance or outdoor work.

For some, caregiving was a large part of their life - equivalent to a full time job. Approximately one in ten caregivers were spending 30 or more hours a week providing some form of assistance to their ill family member or friend.  These caregivers were most likely caring for an ill spouse (31%) or child (29%).5

The actual time spent performing tasks is often combined with time needed to travel to provide care. Approximately three-quarters (73%) of caregivers indicated that they did not live in the same household or building as their care receiver, meaning they often had to travel to reach the care recipients’ home. Just over half (52%), however, reported having to travel less than 30 minutes by car.  Roughly 12% of caregivers provided help to a family member who lived at least one hour away by car.

Certain health conditions required more hours of care. This was the case for developmental disabilities or disorders, where 51% of these caregivers were spending at least 10 hours a week providing help

Caregivers have multiple responsibilities beyond caring for their chronically ill, disabled or aging family member or friend. In 2012, 28% of caregivers could be considered “sandwiched” between caregiving and childrearing, having at least one child under 18 years living at home

Four provinces had rates above the national average of 28%, including Ontario (29%), Nova Scotia (31%), Manitoba (33%) and Saskatchewan (34%) (Textbox Chart 1). The higher levels of caregiving in Ontario, Nova Scotia and Manitoba were largely related to caring for a loved one suffering from a chronic health condition or disability, whereas in Saskatchewan, the higher level of caregiving was attributed to aging needs. 

Historically, caregivers have been disproportionally women (Cranswick and Dosman 2008). This was also true in 2012, when an estimated 54% of caregivers were women.

Although the median number of caregiving hours was similar between men and women (3 and 4 hours per week, respectively), women were more likely than their male counterparts to spend 20 or more hours per week on caregiving tasks (17% versus 11%). Meanwhile, men were more likely than women to spend less than one hour per week providing care (29% versus 23%) (Chart 5).

For instance, they were twice as likely as their male counterparts to provide personal care to the primary care receiver, including bathing and dressing (29% versus 13%).

Caring for an ill or disabled family member or friend can span months or years. For the vast majority of caregivers (89%), their caregiving activities had been going on at least one year or longer, with half reporting they had been caring for a loved one for four years or more.

The aging of the population, higher life expectancies and the shift in emphasis from institutionalized care to home care may suggest that more chronically ill, disabled and frail people are relying on help from family and friends than in the past. Using the GSS, it is possible to examine the changes in the number of caregivers aged 45 years and older, recognizing that methodological differences between survey cycles warrant caution when interpreting any results.

Bearing in mind these caveats, results from the GSS show that between 2007 and 2012, the number of caregivers aged 45 and over increased by 760,000 to 4.5 million caregivers, representing a 20% increase in the number of caregivers over the five years.

Having less time with children was an often cited outcome of providing care to a chronically ill, disabled, or aging family member or friend. About half (49%) of caregivers with children under 18 indicated that their caregiving responsibilities caused them to reduce the amount of time spent with their children.6

Overall, the vast majority of caregivers (95%) indicated that they were effectively coping with their caregiving responsibilities, with only 5% reporting that they were not coping well.7 However, the feeling of being unable to cope grew with a greater number of hours of care. By the time caregivers were spending 20 or more hours per week on caregiving tasks, one in ten (10%) were not coping well.  

In addition, while most were able to effectively manage their caregiving responsibilities, 28% found providing care somewhat or very stressful and 19% of caregivers indicated that their physical and emotional health suffered in the last 12 months as a result of their caregiving responsibilities.

The health consequences of caregiving were even more pronounced when caregivers were asked specific questions on their health symptoms. Over half (55%) of caregivers felt worried or anxious as a result of their caregiving responsibilities, while about half (51%) felt tired during the past 12 months (Chart 8). Other common symptoms associated with providing care included feeling short-tempered or irritable (36%), feeling overwhelmed (35%) and having a disturbed sleep (34%).8

The financial impacts related to caring for a loved one can be significant. Lost days at work may reduce household income, while out-of-pocket expenses, such as purchasing specialized aids or devices, transportation costs, and hiring professional help to assist with care, can be borne from caring for a loved one. In many cases, financial support, from either informal or formal sources, can ease the financial burden associated with caregiving responsibilities. Overall, about one in five caregivers (19%) were receiving some form of financial support.