Reforming long-term care (LTC) in Canada – at home and in institutions – is going to be a massive, multi-year effort.
The mental and physical toll of the past year and a half on Canadian seniors in long-term care, as well as on their families and friends, cannot be overstated. Accounts of major system failures reported as part of coroner’s inquests and commissions of inquiry in recent months have confirmed the need for fundamental reform — reform that is arguably decades overdue.
Adding to the pressure for change is Canada’s rapidly aging population. This major demographic transformation is accelerating. According to Statistics Canada, the number of Canadians aged 80 and up is projected to nearly triple in the next 25 years, and their share of the total population will more than double, from 4.5 per cent in 2021 to 9.5 per cent in 2046. This means that policy-makers must prepare for a major increase in the need for LTC services, at home and in institutions.
While there is a sense that the crisis and coming demographic wave are an impetus for reform, there is also a real risk that once the crisis has abated governments’ efforts could shift to other post-pandemic priorities. The list of priorities keeps growing; for example, governments need to tackle large delays in elected surgeries, learning delays among vulnerable student populations, urban core renewal and child care reform. Ongoing efforts are needed to keep LTC’s shortcomings in the public debate and to propose solutions to address these flaws.
Kick-starting reform in long-term care
Over the last 20 years, numerous commissioned reports have called for reform and improvements to long-term care. The IRPP recently led an initiative aiming to better understand the reasons for decades of inaction by governments at the federal and provincial/territorial levels, and to start a conversation on how to ensure officials tackle the systemic failures. This included a Policy Options feature series, a webinar series on long-term care reform, and new research publications by experts in the field.
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A range of leading experts noted the host of issues in LTC, calling attention to important challenges such as the following:
- The role of standards and of appropriate monitoring and auditing LTC homes: Experts note that standards are designed to apply to “organizations and providers, so they tend to be more technical and medical.” This means that they do not always speak to the quality-of-life issues that are important to residents. Would a set of values-based principles and a robust governance structure for individual homes be good solutions? The question of how best to reform institutional care should be the subject of informed public debate, including the physical design of institutions, the role of for-profit and not-for-profit providers, how to deliver care to culturally diverse populations, and the projected increase in the prevalence of dementia.
- The need for a human resources strategy to recruit, train and retain caregivers to better meet LTC needs, at home and in institutions: These jobs are hard to fill because they are physically demanding and require advanced social skills, yet they offer low pay, minimal job security and few benefits. As a result, they end up being filled by precarious workers who are mostly female and, increasingly, racialized. An entirely new model, consisting of rewarding work with good compensation, is needed. But how should the federal and provincial governments adopt this reform in face of a working-age population that is projected to grow much more slowly than in the past couple of decades? Is part of the solution to reorganize care delivery around naturally occurring retirement communities?
- The need for new ways to finance LTC: Germany, Japan and South Korea have been successful in providing universal LTC to their older populations, and they have maintained low death rates in care homes during the pandemic. All three countries have replaced their patchwork systems of LTC provided by local and regional governments with universal, public LTC insurance (LTCI). Germany introduced LTCI in 1995, Japan in 2000 and Korea in 2008, and they have been adjusting and enhancing their programs ever since. Although similar in name, these systems vary widely in how they were developed and implemented. Each country’s system reflects the unique realities facing policy-makers in terms of population coverage, public opinion, concerns about the effect on women in the labour force, financial sustainability and intergenerational equity. What should Canada’s federal and provincial governments do? And how can they overcome the major drawback of federal-provincial/territorial conditional transfers?
- The proper balance between care at home and in institutions: Although provincial governments have been moving more resources into home care in recent years, the pace of this shift has been slow. As a result, many Canadians have unmet home care needs, and there is still an emphasis on institutional rather than home care when it comes to how we finance and deliver long-term care. In British Columbia, two-thirds of new admissions in LTC homes were people who had received no home supports for 90 days prior to admission. This means they were not provided with the recommended incrementally increasing levels of support in the community over time. Policy-makers should look to European countries that provide a cash-for-care benefit option – a direct transfer paid to older citizens to support at-home care.
Keeping the pressure on policy-makers
There are some reasons to be optimistic that progress is possible. Governments are setting aside money for change. The federal government’s 2021 budget announced $3 billion over the next three years to “support provinces and territories in ensuring standards for long-term care are applied and permanent changes are made.” Ontario, which experienced one of the highest number of deaths in LTC facilities, is investing $4.9 billion over the next four years to increase the amount of daily care that recipients receive. Other provinces have announced billions more.
This funding is a good start. However, given the scope of the challenges, there are no quick fixes. Few of the major issues can be fully addressed in the next year, meaning that Canadians should expect to see multi-year plans for change. Multi-year policy challenges also mean that citizens must keep long-term care at the forefront of the political agenda via the ballot box. The next round of provincial budgets in 2022 should start to outline plans for change.
Follow the IRPP’s research on Canada’s “Faces of Aging” to keep informed of expert ideas on how to galvanize LTC reform.