Pursuing Equity to Combat Fragmentation in the Home Care Sector: A Study of Using Integrated Care Programs to Deliver Health and Social Care to Elderly Persons Living at Home

Integrated care programs (ICPs) deliver care that is coordinated across carers, care sites, and support systems; continuous over time and between visits; tailored to clients' expressed needs and preferences; and based on shared responsibility for optimizing health among clients, carers, and the state. This research asks how ICPs combat issues of fragmentation in a home care sector fundamentally reshaped by neoliberalism. Using a post-positivist epistemological approach, I collect and analyze data from government documents, NGO reports, scholarly literature, and 117 interviews with program administrators, paid and unpaid carers, and elderly clients in five Canadian ICPs working in the home care sector. These include Aging in Place in Ottawa, Ontario; SMILE in South Eastern Ontario; Carefirst in Scarborough, Ontario; CHOICE in Edmonton, Alberta; and Hope Home Health in Hope, British Columbia. My central argument is that ICPs are most useful as a policy solution to fragmented home care when they use policy techniques that promote equitable processes and outcomes as opposed to focusing on enhancing cost-efficiencies for the state. To understand the interrelations among fragmentation, efficiency, equality, and equity, I use a Feminist Political Economy theoretical framework to assess the gendered, classed and racialized impacts of the policy techniques used by ICPs. By looking at which groups are affected through their involvement in ICPs, in what ways, and under what conditions, I find that policy techniques aimed at achieving cost savings for the state often increase inequality/inequity between, and among, clients and carers. Increasing inequality/inequity increases fragmentation. In contrast, ICPs that use policy techniques that challenge neoliberal ways of working often promote equality/equity as their primary policy goal. These techniques help mitigate fragmentation. Understanding if, how and why ICPs meet the expressed needs of clients and carers in different contexts is essential for program administrators looking to improve their programs, as well as for the clients and carers involved in the daily relations of home care. Knowing that ICPs are most useful as a policy solution to fragmented home care when they promote equitable processes and outcomes gives a clear direction for future reforms that can benefit clients and carers alike.