Alberta Premier Danielle Smith answers questions during a media availability at the 2024 Western Premiers Conference in Whitehorse on June 10.Crystal Schick/The Canadian Press
Alberta is expanding a new health care program that requires eligible residents to vet and hire private companies to provide them with home care at the expense of the government, rather than receiving services directly from the provincial health authority or its contractors.
The government launched the program, known as client-directed home care invoicing, as a pilot project in Edmonton in the spring of 2022. Residents who qualify essentially receive government vouchers to pay for or subsidize home care provided by businesses of their choosing. Home care duties range from yard work and laundry to monitoring medication and helping patients bathe.
The care providers are not held to the same training and safety protocols of Alberta Health Services and its contractors, which must adhere to the province’s Continuing Care Health Service Standards, the legislated minimum requirements for firms delivering publicly funded care. Patients are also responsible for monitoring the quality of care under the client-directed model.
Critics argue the the lack of standards puts patients at risk, while directing public money to private companies with little oversight.
Advocates, meanwhile, contend the client-directed model is less burdensome by design, making health care more efficient and helping more people live independently, which frees up space in hospitals and other facilities for those who need more support.
The program has expanded rapidly under Premier Danielle Smith, and Alberta intends to broaden access this month, AHS said in a statement to The Globe and Mail.
But Ms. Smith, responding to questions during a discussion with The Globe’s editorial board, indicated the government will review the model and may impose an accreditation system for care providers.
The client-directed model is designed for people with less acute needs. AHS assesses whether prospective patients are suitable and then determines which services, and how many hours of care, the government will cover. Alberta Blue Cross, which administers the program, reimburses eligible firms at the rate of $32.95 per hour, including weekends and statutory holidays. Patients are responsible for any costs above their government allotment.
By way of comparison, healthcare aides who are members of the Alberta Union of Provincial Employees make between $22.30 and $26.55 per hour, plus benefits, overtime and weekend shift premiums.
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Ms. Smith said Alberta should “differentiate” between two types of care delivered in people’s homes.
“There’s medical care, which is one type, and that’s really important to make sure that we’ve got properly trained people so they’re administering medications and monitoring health conditions,” she said. “But there’s also the type of home care where people need their toenails cut and people need to have their meals delivered to them and people need their lawns cut.”
The Premier said that difference is why the Department of Seniors, Community and Social Services needs to be involved. “So that we’re assuring that those who are delivering healthcare services are properly trained and accredited.”
Accrediting care providers and creating training standards would be a sharp break from the model currently in place. The system, according to its supporters, is more efficient and flexible because it faces fewer regulatory hurdles and gives patients more choice.
Alberta’s client-directed program served 2,025 patients in the fiscal year ended March 31, 2024, according to AHS. Total payments to Alberta Blue Cross for the program hit $29-million that year, it said; in the prior 11 months, payments totalled $8.9-million.
In 2016 New Brunswick launched a similar program, which now services 225 people and cost $1.4-million in 2023-2024, according to government spokeswoman Kate Wright. “Individuals opting for self-managed support assume all responsibility for hiring decisions, coordinating and managing their services,” she said. The province’s social development staff will “review expectations” and points of consideration, such as qualifications and verifying references, with prospective patients.
Ontario has a similar system in which the government funds eligible patients to purchase home care services or pay care providers through its family-managed home care program. Ontario did not respond to multiple messages seeking comment.
Zayna Khayat is a professor at the University of Toronto’s Rotman School of Management and a former health futurist at SE Health, a not-for-profit home care organization with operations in Alberta. She believes voucher systems are the future of home care, although she concedes there are drawbacks, such as the potential for quality hiccups.
But that, she noted, can also happen when government is running all forms of care.
“When your mom and dad are shopping around, they are going to get swindled sometimes,” Prof. Khayat said. “But, again, when it is publicly funded and publicly orchestrated, the way it is today, they don’t get swindled but they get terrible service.”
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She said the lack of standards, such as comprehensive audits for agencies and employee training requirements, is one of the strengths of Alberta’s client-directed model. The alternative, she said, is micromanaging, which can become a drag on the entire healthcare system.
“That’s what we do today – and it is getting us nowhere,” Prof. Khayat said.
David O’Brien, a retired AHS senior program officer for community, seniors, addictions and mental health, said the model’s lack of safeguards makes patients vulnerable.
“There can be all sorts of problems, including poor quality of care, abuse and myriad problems that you can only imagine,” he said.
Mr. O’Brien, who left AHS about two years ago, has family enrolled in the program. Ideally, a patient’s supporters help monitor the care provider.
“For people who don’t have family like ours, where we’re involved, that’s where the problems can occur,” he said.
To participate in Alberta’s client-directed model, private companies must sign an agreement with Alberta Blue Cross, meet insurance requirements and be bonded. If a recipient’s preferred provider is not on the Blue Cross’s list of agencies, the company can register if they meet the eligibility criteria.
The government did not respond to multiple requests to clarify whether the eligibility criteria extended beyond insurance requirements.
Alberta Health can inspect and monitor firms providing care under the client-directed model to make sure they are following the Continuing Care Act and relevant regulations, according to a government website. AHS, in its response to The Globe, said this could include unannounced visits. Furthermore, the AHS statement said the minister and department have the authority to inspect and take action in response to complaints.