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

BACKGROUND: 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. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.