INTRODUCTION:

Most industrialized countries have initiated health care system reforms that are aiming to in-crease the number and scope of health services delivered on an ambulatory basis and at the pa-tient's home. In Québec, this shift is called the "virage ambulatoire". Traditional home health-care services include case management, nursing, personal care, home support (or homemaking), occupational and physical therapies, social work counseling, nutrition counseling, and respiratory therapy. More complex forms of clinical treatments at home are emerging, such as IV therapy, life support/ventilator assistance systems, cancer therapy, palliative care, and ser-vices for persons with AIDS or Alzheimer's dis-ease [CIHI, 2003a]. This report is mainly con-cerned with these latter forms of interventions, i.e. high-tech home care. Technology, we argue, cannot simply be seen as one of several factors driving change in home care, but should be viewed as a pervasive component of a new model of care. The aim of this report is to iden-tify the organizational issues associated with an increased use of health care technology at home and provide recommendations regarding the de-velopment of such services in Québec. This report is organized in six parts. First, we present the rationale for this investigation and describe the methods and data sources. Second, we summarize the features of home health care service developments in Canada and present four problems raised by the increased use of technol-ogy at home. Third, we describe in greater detail the prevalence and patterns of the use of tech-nology in home care services as provided by Québec local community health centres (CLSCs), and highlight potential barriers and opportunities in the expansion of such services. Fourth, we synthesize the organizational, social, ethical, and legal dimensions of technology-enhanced home care from a review of the inter-national literature. Fifth, we analyze how such dimensions could be addressed in the delivery and evaluation of home care services, referring specifically to the Québec health care reform. Finally, in conclusion, we formulate recommen-dations and identify the actors whose decisions and actions might be influenced by this report. TECHNOLOGY AT HOME IN QUÉBEC A study was conducted in 1999-2001 by the first author of this report (PL) and her colleagues at Université de Montréal. The aim of the research was to identify the organizational, technical, and human factors influencing the use of certain technologies at home by CLSCs. A mail-back survey was sent to CLSCs; the response rate was close to 70%. Almost all responding CLSCs had been involved in the provision of home IV ther-apy. The two most common modes of IV deliv-ery were gravity (81.3% of CLSCs) and pro-grammable pumps (97.9%), whereas the mechanical delivery system was used less fre-quently (58.9%). Oxygen therapy was the second most frequent home care service provided by CLSCs (with fixed concentrators 83.5% of CLSCs). The provision of services related to parenteral nutrition was limited but still signifi-cant (26.6%). A large proportion of CLSCs (78.1%) indicated that they had been involved in the delivery of peritoneal dialysis care. A major-ity of CLSCs had been involved in the provision of anticoagulant therapy services (87.9%), while a third (35.6%) had been involved in the delivery of IV chemotherapy. Despite the abundant litera-ture underscoring the rapid growth of home telecare, the use of various information technology -based home monitoring services was infrequent. ISSUES IN ORGANIZATION AND DELIVERY Introducing sophisticated technologies into the home setting has created new types of patients, new treatment possibilities, new roles and re-sponsibilities for providers and caregivers, new ethical dilemmas, and new areas of accountabil-ity. Part 4 of the report is an attempt to clarify and summarize issues that are often entangled both in the literature and in practice. Organiza-tional dimensions of technology-enhanced home care are intimately linked to the characteristics of the home care delivery model, and to the par-ticular needs of patients in terms of care, tech-nology, and support. Social dimensions of the use of technology at home refer to the capacity of the patients and their relatives to maintain sat-isfying relationships, to engage in leisure activi-ties, to raise a family, to carry out social roles, to be employed and earn an income, and to live without discrimination. Several factors suggest that issues of legal liability in home care will in-crease [Kapp, 1995a] home care is becoming increasingly high-tech; patients are being dis-charged "quicker and sicker"; and the coordina-tion of care provided by various professionals is becoming more complex (making it increasingly difficult to control legal risks).

CONCLUSION:

Current challenges in the organization and deliv-ery of home care call for immediate policy ac-tions. Sophisticated technology is changing the nature of health systems across industrialized countries, and one of its most significant devel-opments is the use of complex equipment in the patient's home. The use of such equipment often requires the clinical and technical expertise of secondary and tertiary level care providers, as well as a keen understanding of home care pa-tients' needs­an expertise that CLSC home care program staff have developed for particular clientele over the last two decades in Québec. One critical challenge, for the next decade, will be to bring these two types of expertise together in or-der to provide specialized home care that re-mains meaningful for the patients and their rela-tives, while being effective from clinical and organizational perspectives. In this endeavour, coordination among individual care providers and among health organizations is key, as is building the technical and clinical competence of providers, patients, and caregivers. Each of our four recommendations addresses a particular facet of the 'home care problem'. While a global vision of home care should help structure the fu-ture of this service in Québec, regional leader-ship is required to support and implement organ-izational incentives that will enable effective coordination between hospitals and CLSCs or the réseaux locaux de services in which they are now integrated.