出版社：Utrecht University, Maastricht University, Groningen University
摘要：Introduction : In this article we consider Ontario policy responses to an aging population and highlight lessons learned about the challenges of sustaining policy change in unstable sub-sectors. We consider the case of community based long-term care (LTC) policy in Ontario over the past decade analyzing the trajectory and legacy of what has been referred to as “Aging at Home” strategy. Description of the innovation or study : Aging at Home policies aim to maintain persons as independently as possible, for as long as possible, in their own homes through coordinated access to home and community care (H&CC). This research analyzed the legacy of policy decisions around the care of older persons and considered the implications of historical policy trajectories for this population in Ontario. To inform the discussion, we share results from qualitative interviews conducted with policy experts from across Ontario. Discussion of its impact : In 2007, the Ontario Government announced the implementation of the Aging at Home Strategy with the intention to enable "people to continue leading healthy and independent lives in their own homes". In year two of the Strategy there was a shift away from preventative measures and community capacity building to high needs seniors, targeting reductions in acute utilization. In year three, the shift went further from building capacity in supportive housing and caregiver supports towards specialized geriatric emergency teams and post-acute supports/rehabilitation. Analysis of why the innovation or study ended and assessment of its legacy : Existing theoretical frameworks suggest that historical legacies have led to a great deal of policy stasis. This seems to be the case in the Mainstream sectors where Canadian Medicare still largely includes public funding for hospital and physician services. However, when juxtaposed against the trajectories in marginal subsectors, existing theoretical frameworks seem to lose their explanatory power. Why is it we see such stability in the Mainstream sectors, but such volatility in the Marginal sectors in Ontario? After analyzing 18 semi-structured interviews (conducted as part of a larger CIHR funded iCOACH project) conducted with policy experts, two important lessons emerge about the nature of policy change in these sectors. Firstly, health systems are not monolithic; and secondly, health policy change can be contingent on competing policy agendas in other sub-sectors of health systems. Key Lessons : Sub-sectors within healthcare systems will have divergent political dynamics, institutional arrangements and policy histories. We suggest that existing theoretical frameworks for policy change can be too general to account for important differences. Competing policy agendas in marginalized sectors can be appropriated by competing policy agendas in other prevailing sectors. In the case of Aging at Home, findings suggest it was largely appropriated by the interests of more dominant actors in the Mainstream sector. Conclusion : Ontario's experience with the Strategy has been quintessential, rather than novel; it shifted to expand capacity of institutional care. In redefining the role of the H&CC sector moving forward – as informed by the participants – we need to leverage interests of dominant players, ‘share risk’, and structurally reform funding and delivery of H&CC services.
