Health Human Resources in Community-Based Health Care: A Review of the Literature

Compnent 1 of Building a Stronger Foundation: A Framework for Planning and Evaluating Community-Based Services in Canada

Raymond W. Pong, Ph.D.², Duncan Saunders, M.B., Ph.D.¹,
John Church, Ph.D. ¹, Margaret Wanke, M.H.S.A.¹ ,
Paul Cappon, M.D., Ph.D.²

Prepared for the Federal/Provincial/Territorial Conference of Deputy Ministers of Health through the Advisory Committee on Health Human Resources
1995

¹ Healthcare Quality and Outcomes Research Centre
Department of Public Health Sciences
University of Alberta
Edmonton, Alberta

² Northern Health Human Resources Research Unit
Laurentian University
Sudbury, Ontario

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Executive Summary

Introduction

Although Canada has a well developed health care system, it also has one of the highest rates of institutionalization in the world. But it has become evident that health care is more than institutional care. It encompasses a much wider range of services and activities, including self-care, disease prevention, health promotion, community support, ambulatory care, acute and specialized treatment, long-term care and rehabilitative services. In many western societies, including Canada, the determination to control health care costs, the need to be more accountable and the attempts to make services more accessible, along with the realization that medical care is just one of many factors that sustain population health, have coalesced to reshape the health care system in substantial ways. The closing and downsizing of some hospitals and psychiatric institutions, reform of the long-term care system and the emphasis on primary health care have meant a greater reliance on community-based health care. At the same time, technological advances, changes in practice organization and a better informed public have made it possible for many medical services traditionally provided in institutions to be delivered in community settings.

While there is no universally accepted definition of community-based health care, most would agree that it means bringing health services as close as possible to where people live and work and providing health services outside hospitals and other institutions. It emphasizes consumer participation, holistic and team approaches, a more rational use of health resources, greater responsibility by individuals for their well-being and a and health promotion orientation.

Health care is a labour-intensive industry and personnel account for 70 percent or more of health care cost. Human resources play an even more prominent role in and account for an even greater share of the cost of community-based health care as it relies less on facilities and advanced technologies. In developing a framework for evaluation and policy decisions in relation to community-based health care, it is, therefore, imperative to pay special attention to health human resources issues.

Literature Review Approach

The purpose of this literature review is to determine if there is documented evidence showing how health human resources are conceptualized, utilized, developed, regulated and managed affect the outcomes of community-based health care. To this end, an extensive literature review was conducted, involving on-line database keyword searches, additional searches for other studies, contacting knowledgeable individuals, screening of abstracts, assessing the methodological strength of the studies and integrating the findings. The findings of the literature review were organized and presented by means of a modality-outcome matrix. Modalities refer to the conceptual dimensions used in understanding or analyzing health workforce issues. Six modalities have been identified:

• Health human resources continuum;
• Roles of providers and role substitution, expansion and diversification;
• Education and skills acquisition;
• Models of personnel configuration and provider remuneration;
• Statutory regulation of health occupations and
• Management of the health work force.

As the six dimensions are much-discussed themes in the healthworkforce literature, they represent the major issues or concerns for policy-makers, planners and researchers. Outcomes, on the other hand, refer to results expected or achieved. In this case, they are the criterion dimensions according to which community-based health care is evaluated. The five outcomes are:

• Sense of control;
• Fairness;
• Value for money;
• Quality of care and
• Quality of work life.

Major Review Findings and Policy Issues

On the basis of the findings from the literature review, four major policy issues have been identified - health human resources continuum, human resources substitution, regulation of health occupations and human resources management and enhancement - and broad policy directions are suggested for consideration. While there is considerable empirical evidence to support the general thrust of these suggested policy directions, further policy developments around these four issues should be given top priority.

Health Human Resources Continuum

Literature Review Findings: Self-care and informal caregiving are widespread phenomena. As medical technologies become more sophisticated and as health care consumers become better informed, individuals can now perform many health care tasks that were at one time the exclusive responsibilities of formal caregivers in institutional settings. In most of the studies reviewed, self-care and informal care have been shown to be useful and effective in response to a variety of health problems. Studies have shown that as long as they receive appropriate training, supervision and monitoring, informal caregivers can provide counselling, health education and promotion, rehabilitation, long-term care, etc. as effectively as formal caregivers. Since self-care and informal care are, by definition, free (at least from the perspective of governments and other third-party payers), they are cost effective as long as the care does not aggravate or prolong the health problem of the care recipient. However, it would be an over-generalization to say that self care or informal care is effective. It is necessary to specify what kind of self-care provider or informal caregiver is capable of doing what under what conditions

Health human resources need to be reconceptualized if community-based health care is to become effective, holistic and client-focused. The traditional view of health human resources, which tends to focus almost exclusively on formal caregivers with extensive formal training, must be replaced by one that sees health human resources as a continuum, ranging from those who keep themselves healthy to those who look after their sick or disabled relatives and friends, and from indigenous health care workers with mostly on-the-job training to the highly qualified specialists.

The question is not whether self-care providers and informal caregivers form part of the health human resources continuum. The evidence that they play an important role in buttressing the health care system is substantial in certain areas and under certain conditions. Without them, the formal health care system would collapse because it is unlikely to have enough resources to meet all health care needs and demands of all citizens. As the focus of health care increasingly shifts to health promotion, disease prevention, rehabilitation, health maintenance, long-term care and psychosocial well-being, the role of self-care providers and informal caregivers become particularly important because they have been shown to be effective in many of these areas. A workforce policy framework to support community-based health care will not be effective without taking into consideration the whole spectrum of providers.

Instead, the question is how self-care, informal care and formal care should be integrated and how they can be made to complement each other. A related question is how providers of self-care and informal care can be supported. A comprehensive and integrated health workforce policy or planning framework that takes into account the entire human resources continuum does not exist in Canada. The development and implementation of such a framework must become one of the top priorities in community-based health care planning and implementation.

Human Resources Substitution

Literature Review Findings: There is ample and strong evidence to support the use of mid-level providers, such as nurse practitioners and midwives, especially in primary care. It has been shown over and over again in many jurisdictions that the care provided by these practitioners, working under the supervision of or in cooperation with physicians, is safe and of high quality.

Literature Review Findings: Research has generally shown that it is cost effective to use mid-level providers such as nurse practitioners and midwives. But it should be noted that, with the exception of some studies of nurse practitioners in the 1970s, most of the research in this area has been conducted in other countries whose systems or approaches of health care financing and practitioner remuneration are quite different from those in Canada. Caution is needed in extrapolating the research evidence to the Canadian context.

Literature Review Findings: Role substitution is not restricted to mid-level providers. Although the amount of evidence available and the strength of the evidence vary from one occupational group to another, it is safe to say that considerable role substitution is feasible and effective when it is done properly.

Compared to many other countries, Canada lags behind in using health human resources substitution as a policy tool in health care reform. Use of nurse practitioners in Canada is relatively rare except in isolated communities and in the far north. The official recognition of midwifery has occurred very recently and only in a few provinces. In fact, "reverse substitution" is often practised in this country. Highly qualified or extensively trained practitioners are taking over functions that have been adequately performed by lower-level personnel.

Much of the empirical evidence on role substitution pertains to mid-level providers. Evidence concerning role substitution in other areas or disciplines is less systematic and abundant. While more research and evaluation should be encouraged, the relative paucity of empirical evidence must not be used as an excuse to prevent experimentation on more innovative ways of using health human resources.

Human resources substitution is a policy instrument that can be used to achieve some of the goals of community-based health care like cost effectiveness, service accessibility and equitable distribution of resources. But it is important to ensure that substitution is adopted not just to save money. Substitution is done because it has been shown or can be demonstrated that the same function can be performed just as competently and efficiently by a provider with less extensive training or without formal credentials. If cost savings can be achieved at the same time, so much the better.

Regulation of Health Occupations

Literature Review Findings: Although very little research on the statutory regulation of health occupations is directly related to community-based health care, the importance of occupational regulation must not be overlooked. If one of the hallmarks of community-based health care is a more flexible use of health human resources, related research findings suggest that this may be difficult to accomplish unless there are major changes in the way health occupations are regulated. A number of studies have found that rigid regulation inhibits the use of mid-level providers. The same could be true for other forms of role substitution and the use of multiskilled workers. There is also evidence that excessive regulation raises service costs and reduces service access. Where occupations are allowed to set restrictive entry-into-practice criteria and other practice conditions, costs of service tend to increase and service utilization tends to decrease.

Reform of the existing system of occupational regulation is a sine qua non for developing and implementing a health human resources policy that supports community-based health care. This is particularly important because statutory regulation of health occupations is usually taken for granted and is seldom seen as an important policy tool for health system reform. Without changes to the way health occupations are regulated, it would be difficult to practise human resources substitution or use multiskilled workers. If community-based health care means becoming more responsive to the needs of the consumers, it is necessary to have a more flexible workforce. This, in turn, requires an occupational regulatory system that allows experimentation and innovative approaches in human resources utilization, development and management.

However, it must be noted that occupational regulation is just one aspect within a complex regulatory system that encompasses, among other things, program or facility accreditation, government policies and malpractice insurance. It would be quite futile to make changes to occupational regulation without at the same time adjusting the other aspects of this complex regulatory mechanism. Also, it is important to emphasize that reform of occupational regulation does not mean doing away with standards and safeguards. The challenge is to find alternatives to the present system, which enhance flexibility, appropriate use of human resources, consumer choice and quality assurance.

Health Workforce Management and Enhancement

Literature Review Findings: If self-care providers and informal caregivers are seen as an integral part of the health human resources continuum, they must be given the opportunity to learn how to take care of themselves and others and to enhance their caring capability. Studies and demonstration projects have shown that some types of training are effective. But given divergent objectives, the wide range of training approaches used and the diversity of caregivers, it is understandably difficult to produce a consistent body of research evidence on this topic.

Literature Review Findings: With respect to the training of formal caregivers, the focus of this literature search and review is on preparing or reorienting formal caregivers to work in community settings. This includes redesigning educational programs or curricula, moving classrooms and practicum sites from institutional to community settings, providing opportunities to learn in a multidisciplinary environment and helping providers cope with job transfers from institutions to community agencies. Generally speaking, the studies show positive results.

Literature Review Findings: In relation to workforce management, one research finding that has special significance for community-based health care is the characteristics of work in community settings which are conducive to positive quality of worklife. Many studies have found that practitioners working in home care and community health like their work and they regard autonomy, flexibility, freedom to manage work and direct contacts with patients/clients as the most rewarding aspects of their job.

The effectiveness of practitioners providing community-based health care and their quality of worklife could be improved by various management and educational measures. Similarly, the ways providers are organized, deployed and remunerated could affect the quality and cost effectiveness of their services. However, there is neither a magic formula nor a one-size-fits-all solution. The stu dies reviewed show that some measures are effective in one program or one health service centre or one community, but not necessarily in others. Likewise, the review of studies of education and skills acquisition suggests that while experts generally agree on a number of things that need to be done, there is not a consensus on how they should be done. As community-based health care encompasses a wide array of services, providers, agencies and organizational forms, it must experiment with different strategies, using experiences gained in other programs and jurisdictions as a guide and a source of inspiration. A trial-and-error approach and incremental improvements seem to be a prudent way to introduce appropriate educational models and management practices, at least until more definitive