On September 23, 2015, Ontario's Auditor-General released her long-awaited Special Report (the Report) on Ontario's community care access centres (CCACs). The Report follows an 18-month investigation and calls on the government to take a "hard look" at the current state of home and community care delivery in Ontario.
What are CCACs and How Do They Work?
CCACs are not-for-profit Ontario government agencies that assist eligible patients to access home and community-based healthcare and related social services. The CCAC system was first established in 1996. In 2007, the 42 CCACs then in existence were amalgamated into the 14 CCACs that exist today. CCACs are collectively responsible for 5% of Ontario's healthcare budget (or approximately $2.4 billion in total).
CCACs employ care coordinators who assess patient eligibility to receive CCAC services, liaise and coordinate between service providers and patients and provide other case management support. Most direct care services are, in turn, provided to patients by independent for-profit and not-for-profit service providers who are under service contracts with the CCAC. In all, CCACs manage 260 contracts with 160 different service providers across the province. In recent years, CCACs have also employed nurses and other health professionals to deliver care to patients directly.
What Prompted the Auditor General's Special Report?
On March 19, 2014 the Ontario Legislature's Standing Committee on Public Accounts asked the Auditor General to conduct an audit of CCACs' financial operations and service delivery. The request was prompted by criticism of the CCACs by the provincial New Democratic Party and the Progressive Conservatives, particularly around executive compensation issues. The attention is not new—CCACs have been the subject of considerable debate over their nearly 20-year history.
Key Findings from the Report
The Report makes 14 recommendations in all. The most far-reaching is Recommendation 5, which states:
… the Ministry of Health and Long-Term Care should revisit the service delivery model that currently involves 14 Community Care Access Centres and about 160 private-sector for-profit and not-for-profit service providers.
While the Ministry of Health and Long-Term Care (Ministry) and the Ontario Association of CCACs (OACCAC) have accepted the Report and its recommendations, it remains to be seen how far-reaching their responses will be.
The Report makes various other findings and recommendations, including:
1. Increased Spending and Service Delivery
The Report found that Ministry funding to CCACs increased by 28% from 2009/10 to 2013/14, reflecting a shift in provincial healthcare funding priorities—from hospital and institution-based to home and community care.
In the same period, CCAC expenses rose by 26%. The Report notes that this increase in expenditure was correlated with the provision of 35% more hours of care and 10% more visits to patients. The total number of clients served by CCACs increased by 14%, while the number of patients assessed as "chronic patients" increased by 89% and "complex patients" increased by 77%.
2. Spending on "Direct Patient Care" Was Lower than Reported
While CCACs reported spending an average of 92% of expenses on "direct patient care", the Report argues that service-provider profits and overhead costs should likely be excluded from the calculation. When those amounts are excluded, average spending on direct patient care falls to 81%. If "direct patient care" were to be defined as being limited to direct interaction with patients (excluding certain supporting back office work, travel time, etc.), the average figure falls to 71.5%.
Regardless of the definition used, the Report calls for improved time and performance tracking and benchmarking in relation to direct and care coordination activities and patient outcomes. The aim of increased tracking will be to gather data to support analyses of the relative effectiveness of specific direct care and care coordination activities in relation to patient outcomes and, critically, to inform decisions about where scarce financial resources are best spent.
3. Salaries of CCAC CEOs Increased; Some Inconsistencies in Compensation
The Report found that the salaries of CCAC CEOs rose 27% from 2009 and 2013. While observing that CCAC CEOs appear to earn more than their closest equivalents in the private sector, the Report acknowledges that the comparison is limited because the positions and responsibilities are quite different.
Although a common executive compensation framework for CCACs was developed in 2012 by an independent consultant, the Auditor-General's office found that three CCACs had yet to implement the framework by an independent consultant when it was carrying out its fieldwork (though the OACCAC reported that all CCACs had implemented the framework by the time the Auditor-General's Report was published). The Broader Public Sector Executive Compensation Act—which applies to CCACs—will allow the government to impose new executive compensation frameworks on CCACs going forward.
These changes may also help to address certain inconsistencies in CCAC board compensation decisions that were noted by the Auditor-General. Examples cited in the Report included:
- the awarding of a signing bonus equivalent to 25% of base salary, for the reason of ensuring the CEO's salary for the year would match with other CCAC CEOs;
- the awarding of a full performance bonus even though the CEO did not receive the highest performance rating; and
- in three cases, the awarding of a pay raise or bonus where the CEO turned down the additional amounts citing the need for fiscal prudence.
4. Inconsistent Billing Rates Across CCACs and Service Providers
The Report highlights disparities in care service costs between and within CCACs. The issue was raised in the Auditor General's report on CCACs in 2010 and remains an area of concern for the Auditor General. For example, one service provider charged $48.98 per hour for personal support services in one part of a region and $29.50 in another part of the same region for the same services.
The reason for this inconsistency is the ongoing government-imposed freeze on competitive procurement for contracted services. When CCACs were established, they conducted competitive procurements of home and community care services with the goal of achieving better value for money in the sector. The competitive bidding process was frozen in 2003, briefly re-opened from 2003 to 2008, and then frozen again as it remains today. The Report acknowledges that the freezes were driven by concerns about disrupting continuity of care and minimizing other negative effects of competitive procurement. However, the Report also notes that the freeze has made it difficult or impossible for CCACs to renegotiate the terms existing contracts with providers.
The Report recommends that the government and CCACs work together to implement province-wide harmonized billing rates for service providers (without specifying how this should be done). It also recommends improved performance and outcomes-tracking to inform funding and contracting decisions.
5. CCAC Nurses and other Allied Health Professionals Earn More than their Service-Provider Counterparts
The Report also notes disparities in costs of professional services provided under contract and directly by CCAC employees. CCAC nurses and allied health professionals employed as part of CCAC direct-care programs were better paid than their service-provider counter-parts in the year ending March 31, 2014.
CCAC nurses were paid an average of $40.80 per hour, compared with an average of $30 per hour for nurses employed by contracted service providers. The Report found these differences were attributable to higher wages negotiated by nursing unions with CCACs, as opposed to substantive differences in functions performed by the professionals. Similar gaps existed for other allied health professionals hired by the CCACs.
The Report recommends further study to assess the appropriateness of current wage rates for CCAC-employed professionals. It also recommends including differences in wage rates as a consideration in an overall system review. The Report questions (without answering) whether service-provider organizations may be better able to deliver cost-effective direct-nursing programs.
6. No Cost/Benefit Analysis of CCAC Direct Care Programs; Concerns about Effectiveness
The Report is critical of certain CCAC direct-care programs (Rapid Response Nursing Program, Mental Health and Addictions Nursing Program, and Palliative Care Nurse Practitioner Program). The programs were established in 2011 in response to a government direction to CCACs to establish the programs and hire professionals directly for these programs. The Report is critical of the fact that the government did not prepare a cost/benefit analysis before issuing this direction (including to assess whether service providers might have been able to provide the programs more cost-effectively). It is also critical of the fact that the programs have not been formally evaluated since they were established in 2011.
The Report notes, for example, that while rapid-response nurses are supposed to visit patients at home within 24 hours of their being discharged from hospital, 47% of patients were not visited within that time frame. The Report contains other instances of lack of service availability and inconsistency of service standards under these programs.
The Report recommends a formal and overarching assessment of the effectiveness of the programs. The Report also includes a variety of practical recommendations, including matching nurse scheduling with times when patients are actually discharged (namely, by providing services on the weekends) and reducing duplication in medication reconciliation services.
7. Variation in the Use of Care Protocols
The Report notes that CCACs and service providers use a variety of clinical-care protocols, but that it is unclear which protocols are best practice and there are no province-wide standards. As a result, patients can receive different types of care depending on where they live and who they receive services from. The Report recommends further review and standardization of these protocols to ensure consistent care standards.
The Auditor-General was specifically directed to consider the cost-savings associated with adopting clinical care protocols and outcome-based pathways. The Report indicates that these tools do not necessarily result in cost savings, but notes that new data collection requirements need to be put in place in order to better evaluate the cost-effectiveness of such tools going forward.
CCACs and the Ministry have accepted the Auditor-General's Report and indicated that they will work to implement its recommendations. The Report follows a number of recent reports and frameworks on home and community care, including the Bringing Care Home report (March 2015) and the Patients First: Action Plan for Health Care (February 2015) which set out the Ministry's framework for home and community care improvements over the coming years. However, neither of these documents includes a review of the CCAC model as comprehensive as that which is called for by the Auditor-General. Despite differences of opinion over the path forward, there is a broad consensus on the need to improve the way home and community care is delivered in the province.
The Report is the first of two on home and community care by the Auditor-General. The second part will be included in the Auditor-General's annual report which is expected in December 2015. The annual report is also expected to include a review of the LHINs.