Social marginalization and access to publicly funded home care in Ontario: a population-based retrospective cohort...

Older adults experiencing social marginalization may face inequitable access to publicly funded home care services. In Ontario, Canada, the Ontario Marginalization Index (ON-Marg) provides a multidimensional measure of area-level marginalization. This study examined whether ON-Marg dimensions were associated with access to publicly funded home care among community-dwelling adults aged 75 years and older.

We conducted a population-based retrospective cohort study using linked administrative health data from Ontario, Canada, for the year 2019. The cohort included individuals aged 75 + residing in the community (excluding those in long-term care). Home care access was stratified by ON-Marg dimensions: residential instability, material deprivation, dependency, and ethnic concentration. The primary outcomes were receipt of long-stay (≥ 90 days) and short-stay (< 90 days) home care aggregated at the community level (Aggregated Dissemination Areas -ADAs). Multivariable regression models adjusted for age, sex, hospitalization, and health complexity.

Among 1,071,899 older adults, 14% received long-stay home care and 9% received short-stay home care. Communities in the highest deprivation and ethnic concentration quintiles had a 1.60 and 2.77 percentage point greater probability, respectively, of receiving long-stay care compared to the least marginalized areas. In contrast, the most dependent communities had a 0.68 percentage point lower probability of long-stay access. For short-stay care, the highest instability quintile was associated with a 0.90 percentage point greater probability of access, while the highest ethnic concentration quintile was associated with a 2.26 percentage point lower probability. Regional analyses revealed considerable variation in these patterns across Ontario.

Access to home care in Ontario varies by dimension of marginalization. While some marginalized groups may have greater access-likely reflecting higher underlying need-populations with high dependency may face persistent barriers. Equity-focused reforms should consider how specific forms of marginalization affect not only need but also access and service delivery.