Low pay, a revolving door of workers and the push to improve home care in N.S.

Nova Scotians dealing with the provincial home-care system say they're glad COVID-19 has shed a light on its issues, but real actions are needed to solve problems that have existed long before the pandemic.

Donalda MacIssac of Lower Sackville said after 25 years of navigating the system for a close family member who is disabled and has high needs, she welcomes new research and ideas to improve the system.

"For me, home care is like the Wild West," MacIsaac said in a recent interview. "There's so many things that go on in homes, you know. And it's put underneath this umbrella of long-term care — no, it's not. It's totally different."

In Nova Scotia, publicly funded home care is offered in two streams — nursing and home support — through different service providers like VON, Northwood and local organizations around the province. They are co-ordinated through Nova Scotia Health, which receives funding from the Department of Seniors and Long-Term Care.

Home-support workers do tasks like light housework, cooking for a client or helping them dress and wash. More advanced care performed by nurses includes helping clients with things like catheters and intravenous therapies.

MacIsaac said recent points advocates have raised, including long wait-lists, clients seeing a revolving door of workers and missed appointments, may be exacerbated by staffing issues during the pandemic, but have been happening for decades.

"In 1992 nurses still weren't showing up for shifts, home-care workers still weren't doing this. So all COVID has done is shine a light on home care, the same as it did long-term care," she said.

There's also a long wait-list in Nova Scotia. As of mid-January, there were 1,278 people on the wait-list for 6,928 hours of home support, which includes personal care, respite and essential housekeeping.

The province said about half the people on the wait-list are receiving some services, and some are receiving direct funding to purchase private services while they wait.

Private companies offering higher CCA pay

The private companies who offer home care often offer higher pay than the publicly funded agencies.

Hendrik Botha, the owner of a Nurse Next Door franchise that offers service throughout Nova Scotia, said with about 100 clients and 120 nurses and continuing-care assistants, the company has a good client ratio and has not struggled with staffing shortages in the same way as the public system.

In fact, Nurse Next Door has seen a "big influx" of applications in recent years from workers interested in the company's competitive wages and flexible schedules, Botha said, which has allowed them to send staff to long-term care facilities to fill gaps.

Botha said staff can pick when and where they work, and have the ability to take fewer shifts one month if they need to focus on their mental health or want a better work-life balance.

Online job ads for Nurse Next Door list salaries of up to $45 an hour for registered nurses, and $20 for continuing-care assistants (CCAs), although there were no health benefits listed.

The province is in dire need of more CCAs to fill roles in home care and long-term care, putting out a call last week for workers. Earlier this month it announced $22 million to cover tuition costs for about 2,200 students to take the CCA program over the next two years.

Low pay for CCAs has been an ongoing concern, with the average pay sitting at $17 to $19 an hour. Workers and their unions have called for it to go up to $25 an hour.

Other private companies are offering more than that: Plan A Nova Scotia is advertising up to $29 an hour for CCA jobs, while Greenstaff Medical Canada has $30-an-hour CCA jobs "all over Nova Scotia."

"Everybody is fighting over, you know, the nurses and caregivers that we currently have. So for each company, the only thing you can do is you can increase the piece of the pie that you're having," Botha said.

"Definitely somewhere, somebody is pulling on the short end and somebody is going to be short-staffed because we simply do not have enough nurses and caregivers in the province."

Public system accountability

MacIsaac said CCAs should be making more money, and understands why some go to a private company. But, she's heard anecdotally from others who use private home care that the standard of care is not necessarily better — and comes with less transparency.

"At least in the public system you can point things out and there is a level of accountability," MacIsaac said.

Comparing the private and public systems is a challenge, said Janice Keefe, a professor and chair of the department of family studies and gerontology at Mount Saint Vincent University, and director of the Nova Scotia Centre on Aging.

She said the private system has very little regulation, and its companies don't have to adhere to the same levels of training, performance and oversight as public home-care agencies.

She's looking outside the province for some insight. Keefe is leading a study comparing how older adult home-care clients go through the Nova Scotia and the Winnipeg Regional Health Authority systems.

In Manitoba, home-care services are delivered and assessed through each health authority and don't involve outside agencies.

It is also completely free, which is different from Nova Scotia where people pay a sliding scale amount for home support that's based on their income. Nursing care is always subsidized and free for anyone in Nova Scotia.

"We're wondering, 'OK, does that make the wait time shorter?' In terms of access to services, if you're both working for the same agency then you have the same interpretation of rules," Keefe said.

"What happens in Nova Scotia is you have the policies of Nova Scotia Health, but then you have the policies of the agency."

N.S. clients have higher needs

Although the study won't be complete until next year, Keefe said they have some preliminary findings that clients in the Nova Scotia system have a "higher level of needs" than those in Winnipeg.

They don't know yet why that is, Keefe said, but it could be related to the cost. People in Nova Scotia might only use home care when in crisis, whereas in Winnipeg it's seen as an ordinary option whenever one needs light amounts of help for a short period of time.

MacIsaac, who advocates for home care and other issues on committees within Nova Scotia Health, said she'd love to see the province adopt a model like Manitoba's where silos are broken down and everything is under one umbrella.

The province is currently redesigning home care to place clients at the heart of a more flexible system, following criticism in a November 2017 audit of home-care support contracts by the province's auditor general.

A provincial government spokesperson told CBC recently that work is underway to update legislation and determine a new funding model for home-care agencies.

MacIsaac said changes are needed now, and the pandemic is the perfect time to take such steps since things are moving so quickly and traditional red tape has fallen away. She added there are people within the system "bending backwards" to make things better.

"Change is coming… I am more hopeful now than I was two years ago because I see the efforts now," she said. "We will do this. We will fix this."

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