Nevertheless, the results reveal that home care is significantly less costly than residential care even when informal caregiver time is valued at replacement wage.

C anadians provide significant amounts of unpaid care to elderly family members and friends with long-term health problems. While some information is available on the nature of the tasks unpaid caregivers perform, and the amounts of time they spend on these tasks, the contribution of unpaid caregivers is often hidden. (It is recognized that some caregiving may be for short periods of time or may entail matters better described as "help" or "assistance," such as providing transportation. However, we use caregiving to cover the full range of unpaid care provided from some basic help to personal care.) Aggregate estimates of the market costs to replace the unpaid care provided are important to governments for policy development as they provide a means to situate the contributions of unpaid caregivers within Canada's healthcare system. The purpose of this study was to obtain an assessment of the imputed costs of replacing the unpaid care provided by Canadians to the elderly. (Imputed costs is used to refer to costs that would be incurred if the care provided by an unpaid caregiver was, instead, provided by a paid caregiver, on a direct hour-for-hour substitution basis.) The economic value of unpaid care as understood in this study is defined as the cost to replace the services provided by unpaid caregivers at rates for paid care providers. Methods and Data Sources

Integrated care delivery can be achieved in various ways. Irrespective of which model is adopted, some of the key factors to be considered are how care can be coordinated effectively across different types of services, and how all the care provider organizations can be coordinated to ensure continuity of care for frail elderly persons.

This article presents a major new finding in regard to the value for money of primary care services. It was found that the more higher-care-needs patients were attached to a primary care practice, the lower the costs were for the overall healthcare system (for the total of medical services, hospital services and drugs). The majority of the cost reductions stemmed from decreases in the costs of hospital services. Thus, for highercare-needs patients, it appears that the nature of the physician-patient relationship is related to reductions in hospital costs. For example, for very-high-care-needs diabetic patients, the average annual hospital cost in fiscal 2007-2008 for those in the lowest attachment group was $16,988, whereas the hospital costs for those in the highest attachment group was $5,909. The results obtained were even more striking for patients with congestive heart failure. A series of multiple regression analyses were conducted, and the results were very consistent: attachment to practice was the best predictor in regard to cost and was a more significant predictor than other variables that were related to healthcare costs, such as age. These findings support the general literature on the benefits of primary care and the continuity of care.

In this paper, the authors provide a policy prescription for Canada's aging population. They question the appropriateness of predictions about the lack of sustainability of our healthcare system. The authors note that aging per se will only have a modest impact on future healthcare costs, and that other factors such as increased medical interventions, changes in technology and increases in overall service use will be the main cost drivers. They argue that, to increase value for money, government should validate, as a priority, integrated systems of care delivery for older adults and recognize such systems as a major component of Canada's healthcare system, along with hospitals, primary care and public/population health. They also note a range of mechanisms to enhance such systems going forward. The authors present data and policy commentary on the following topics: ageism, healthy communities, prevention, unpaid caregivers and integrated systems of care delivery.

This paper reports on the results of analyses using administrative data from British Columbia for 10 years from fiscal 1987/1988 to 1996/1997, inclusive, to examine the comparative costs to government of long-term home care and residential care services. The analyses used administrative data for hospital care, physician care, drugs, and home care and residential long-term care. Direct comparisons for cost and utilization data were possible, as the same care-level classification system is used in BC for home care and residential care clients. Given significant changes in the type and/or level of care of clients over time, a full-time equivalent client strategy was used to maximize the accuracy of comparisons. The findings suggest that, in general, home care can be a lower-cost alternative to residential care for clients with similar care needs. The difference in costs between home care and residential care services narrows considerably for those who change their type and/or level of care, and home care was found to be more costly than long-term institutional care for home care clients who died. The findings from this study indicate that with the appropriate substitution for residential care services, in a planned and targeted manner, home care services can be a lower-cost alternative to residential long-term care in integrated systems of care delivery that include both sets of services.

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