Almost Home : Reforming Home and Community Care in Ontario

Table of Contents

• CONTENTS 8
• ACKNOWLEDGMENTS 14
• ABBREVIATIONS 16
• 1 Introduction and Overview 20
• 1.1 From Hospital to Home and Community 20
• 1.1.1 The Medicare Mainstream 22
• 1.1.2 Outside the Mainstream: Community-Based Long-Term Care 26
• 1.1.3 Policy Content: Financing, Delivery, and Allocation 29
• 1.2 The Case of Ontario's Reform of Community-Based Long-Term Care 31
• 1.2.1 Factors Pushing towards Reform 31
• 1.2.2 Models for Reform 33
• 1.3 Looking Ahead: The Making and Meaning of LTC Reform in Ontario 34
• 2 Conceptual Framework 36
• 2.1 Introduction 36
• 2.2 Neo-institutionalism and Policy Communities 39
• 2.2.1 Ideas 42
• 2.2.2 Institutions 48
• 2.2.3 Interests 49
• 2.3 Policy Outcomes: Design Decisions 52
• 2.3.1 The Public/Private Mix 53
• 2.3.2 Financing 56
• 2.3.3 Delivery 59
• 2.3.4 Allocation 62
• 2.4 Summary and Conclusions: Policy Legacy 65
• 3 Research Methodology: The Case Study Approach 66
• 3.1 Qualitative Research and Case Studies 66
• 3.2 Data Sources 67
• 3.2.1 Documents 68
• 3.2.2 Interviews 69
• 3.3 Determination of the Policy Community 69
• 3.4 The Community-Based LTC Policy Community 71
• 3.5 Analytical Strategies 73
• 3.5.1 Historical Review 74
• 3.5.2 Policy Analysis 74
• 3.5.3 Content Analysis 74
• 4 Long-Term Care Reform in the Liberal Period, 1985–1990 76
• 4.1 Long-Term Care Reform under the Liberal Governments 76
• 4.2 Liberal Minority Government, 1985–1987: One-Stop Shopping 78
• 4.2.1 Institutional Changes and Underlying Government Interests 78
• 4.2.2 A New Agenda 81
• 4.2.3 Societal Interests and Influence on Reform 86
• 4.2.4 Assessment of One-Stop Access by Members of the Policy Community 89
• 4.3 Liberal Majority Government, 1987–1990: Service Access Organizations 92
• 4.3.1 Paradigm Shift through Institutional Change 92
• 4.3.2 MCSS Takes Charge 94
• 4.4 Rationale for and Scope of the Reform 99
• 4.4.1 Strategies for Change and the Service Access Organizations 102
• 4.4.2 Service Access Organizations 103
• 4.4.3 Integration of Services through Institutional Change 104
• 4.4.4 Influence of Societal Interests on the Development of the SAO Model 110
• 4.4.5 The Mobilization of Interests 113
• 4.4.6 Assessment of SAO by the LTC Policy Community 115
• 4.4.7 Beginning the Implementation Process for Strategies for Change 119
• 4.5 Conclusions 120
• 5 Long-Term Care Reform under the New Democratic Party, 1990–1993 123
• 5.1 The First Attempt at Long-Term Care Reform under the New Democratic Party 123
• 5.2 The Early Days of the NDP Government, 1990–1992: Delay, Then More of the Same 125
• 5.2.1 Redirection and the Service Coordination Agency Model 127
• 5.2.2 Service Coordination Agency: A Liberal Model in NDP Clothing? 130
• 5.2.3 Consultation with the Community 132
• 5.2.4 Mobilization of Interests 133
• 5.2.5 The Coalitions Propose a New Model 137
• 5.2.6 Institutional Changes within Government: The Shift from MCSS to MOH 140
• 5.2.7 A New Model Begins to Emerge 144
• 5.3 The NDP and the Multi-Service Agency Model 150
• 5.3.1 The Recession and the Social Contract 150
• 5.3.2 The Locus of Policy Development Shifts 153
• 5.3.3 The Partnership Documents 154
• 5.3.4 Anticipating Objections 162
• 5.4 Conclusions 163
• 6 The New Democratic Government and the Multi-Service Agency, 1994–1995 165
• 6.1 The New Democrats and the Multi-Service Agency 165
• 6.2 Bill 173, An Act respecting Long-Term Care 167
• 6.3 Government Interests 171
• 6.3.1 Direct Delivery 171
• 6.3.2 Human Resource Issues: Unionization and Protection of Collective Agreements 173
• 6.3.3 For-Profit versus Not-for-Profit Delivery 177
• 6.3.4 External Purchase of Services 179
• 6.3.5 Mandated Basket of Services 180
• 6.3.6 Entitlement to Home Care 182
• 6.3.7 User Fees 184
• 6.4 Policy Interests of Societal Groups 185
• 6.4.1 'Consumers' 186
• 6.4.2 Providers 197
• 6.4.3 Labour 217
• 6.4.4 Volunteers 223
• 6.4.5 Other Interests 224
• 6.4.6 Activities of the Provider Coalition 225
• 6.5 A Babel of Values 227
• 6.6 Amendments to Bill 173 229
• 6.7 Perceived Influence of Societal Interest Groups 231
• 6.8 Conclusions 238
• 7 The Progressive Conservatives Implement Long-Term Care, 1995–1996 241
• 7.1 The Progressive Conservatives 241
• 7.2 The Progressive Conservatives on Campaign 242
• 7.3 The Progressive Conservatives and the Community Care Access Centres 244
• 7.3.1 The PC Consultation 245
• 7.3.2 The Consultation Report 248
• 7.3.3 Assessment of the Consultations 250
• 7.3.4 The CCAC Model 252
• 7.3.5 Assessment of CCACs 256
• 7.4 Government Interests in the Development of the CCAC Model 265
• 7.5 Societal Interests 269
• 7.5.1 Changing Structure of Societal Groups 269
• 7.5.2 Interests Advanced by Societal Groups at the Consultation 273
• 7.6 Influence of Interests 278
• 7.7 Conclusions 282
• 8 Moving towards Home: Policy Change and Policy Stasis beyond the Medicare Mainstream 285
• 8.1 Reforming Community-Based Long-Term Care in Ontario 285
• 8.2 Summary: Policy Content and Process under Successive Governments 287
• 8.2.1 One-Stop Shopping/Access (Liberal, 1987) 287
• 8.2.2 Service Access Organizations (Liberal, 1990) 290
• 8.2.3 Service Coordination Agency (NDP, 1991) 293
• 8.2.4 Multi-Service Agencies (NDP, 1993) 295
• 8.2.5 Community Care Access Centres (PC, 1996) 298
• 8.2.6 Summary of the Reform Models 301
• 8.3 Ideas, Interests, and Institutions 302
• 8.3.1 Ideas 302
• 8.3.2 Interests 306
• 8.3.3 Institutions 306
• 8.4 Epilogue: Reining in the Community Care Access Centres 309
• 8.4.1 Romanow and the Future of Medicare 313
• 8.5 Whither the State in Health Care? 317
• REFERENCES 324
• INDEX 344
• A 344
• B 345
• C 345
• D 347
• E 348
• F 348
• G 349
• H 349
• I 350
• J 351
• K 351
• L 351
• M 351
• N 353
• O 353
• P 354
• Q 355
• R 355
• S 356
• T 356
• U 357
• V 357
• W 357
• Z 357