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There is no avoiding the impact of population aging. As people grow older, they are at more risk of losing autonomy and developing disabilities. Therefore, they should rely on others for help with daily tasks. These needs will grow fast over the next few years with post-war Baby Boomers in their 60s, 70s and 80s.

All provincial governments in Canada are facing major challenges as the demand for home and long-term care services is set to expand rapidly.

New research shows this shift is already underway. It will transform our care systems. Provinces must act, yet we see little co-operation among them to find the best response.

When it comes to health care, narrow-sighted independent decisions have been the traditional approaches of the provinces, which tend to muddle along with major system inefficiencies only to go to the federal government – and ask for more money – when things inevitably go wrong.

A more collaborative approach is the answer. Canadians would be better off if provinces shared lessons learned from the different policy approaches they use to address the inevitable rise in future home and long-term care needs.

Future care needs in Quebec

Recently, a team of researchers at HEC Montreal worked with Quebec’s Commissaire à la santé et au bien-être and used data collected by the provincial government in the delivery of publicly financed care services in the province, as well as original surveys of Quebecers, to project future demand, supply and financing needs for home and long-term care support services.

The projected results over 17 years (2023-40) – assuming the current set of policies continues – are sobering.

Quebec will experience a massive increase in the need for autonomous care support and services. Compared to 324,400 people with such needs in 2023, the province should expect an increase of 223,400 by 2040 (69 per cent), including 33,700 additional people with severe disabilities usually requiring long-term care institution services.

The province’s residents will also need 236 million additional annual care hours by 2040 (an increase of 70 per cent), including 21 million additional hours of nursing care, 83 million hours of assistive care for daily living and 132 million hours of support services for domestic activities. These needs will also vary a lot across regions within the province, given the demography and the actual mix of services.

To maintain the current level of services, an additional 13,700 nurses and 45,600 personal support workers will need to be hired. If the current trajectory is maintained, 42,500 places in long-term care homes will need to be built – doubling the current capacity. That means building 2,500 new places in long-term care facilities each year, which is more than what was done over the last three years combined.

All this would mean an increase in the total public cost of autonomy support services to $16.5 billion (inflation-adjusted) in 2040 from $7.6 billion in 2023 – an increase of 120 per cent over 17 years.

Surveys show that when health needs are low or moderate, Quebecers show a strong preference for receiving care in their homes rather than in residential facilities or intermediate and long-term care institutions. When a person’s disabilities are severe, no clear preference emerges between staying at home or being admitted to a long-term care institution.

Finally, Quebecers attach little importance to the type of service provider – public or private. The level of services, the cost and wait times are the top determining factors behind their preferences.

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Not just a Quebec challenge, A pan-Canadian one

Compared to other OECD countries, Canada’s public home care and long-term care investment is low and the proportion of home care to long-term care is much lower. Residential care in long-term care homes across Canada is largely financed by provincial governments, with relatively small out-of-pocket contributions.

Home care services, although financed by a different mix of private and public funds in each province, will nonetheless face demographic pressures from aging Baby Boomers.

Although this study uses unique, rich data from Quebec, the pressures on capital development, human resources and public finances to care for an aging population are set to expand in all provinces, accounting for differences in age structure and population size.

Care needs are shifting rapidly as our populations are aging. In the coming two decades, the demands on physical infrastructure, workforces and provincial finances will be enormous.

Despite this major challenge, potential policy solutions exist. Shifting resources towards home care is promising but how it is done depends on the myriad of overlapping provincial programs, the cost of various services, and ways of distributing public funds.

As well, in many places, the support services that enable older adults to live autonomously in their homes may be provided by municipalities, further complicating the design of more effective care services.

Tailoring public care delivery toward certain services (i.e., nursing) while leaving other services (i.e., help with daily tasks such as dressing, cooking, etc.) to private and not-for-profit sectors could lead to cost efficiencies and diversify the human resources needed.

As a result, public providers could focus on areas where significant medical intervention is required and where there is a need for specialized knowledge in how to provide effective, high-quality care.

Regardless of the policy options pursued, the current lack of planning is perhaps the most dangerous issue. Other countries are being proactive and Canadian provinces must be as well.

The Canadian federation is at its best when provinces share their knowledge to address similar issues.

Quebec is just a few years ahead of the others in confronting the huge rising care needs associated with functional decline in older adults. It must act, as must other provinces.

Simply rearranging the deckchairs on the Titanic when it is about to hit the iceberg does not prevent the inevitable. Avoiding the iceberg by making a significant shift in policy should be a top priority in Canada.

Editor’s Note: For all home care and long-term care services, Quebec is using the SMAF (Système de mesure de l’autonomie fonctionnelle – Functional Autonomy Measuring System) scale for measuring disabilities and the case-mix Iso-SMAF Profiles for estimating the required hours of care and support services. Each of the 14 Iso-SMAF Profiles is associated with the required number of hours of nursing care, assistive care for daily living (help with dressing, eating, mobility, etc.) and support services for domestic activities (help with cooking, transportation, etc.). Other administrative data are collected to quantify the actual number of hours provided in home care and long-term care services.

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Pierre-Carl Michaud
Pierre-Carl Michaud holds the Jacques-Parizeau Research Chair in Economic Policy, is a professor in the department of applied economics at HEC Montréal, and a fellow at CIRANO.
Réjean Hébert
Réjean Hébert is an associate professor in the school of public health at Université de Montréal.

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