Watching scenes of overcrowding, neglect, suffering and untimely death in LTC homes in the early days of the pandemic was agonizing, and has no doubt reinforced the desire of many Canadians to age in their homes for as long as possible. But the home-care needs of many older adults across Canada are unmet.

Those who do receive publicly funded home-care services report having little control over how their care is provided, a lack of continuity in care, and having to deal with multiple caregivers and a complicated bureaucracy. Whatā€™s more, many activities such as food preparation and other daily chores donā€™t qualify for public funding. Family members and other informal caregivers are left to fill the gaps. These are often women who report high levels of distress and burnout. To provide better support to Canadians who wish to age at home, policy-makers should look at successful examples in European countries that provide a cash-for-care benefit option ā€“ a direct public transfer paid to older citizens (or their caregivers) to support at-home care.

One in five seniors have care needs that could be met at home

According to the Canadian Institute for Health Information, the problems that plague the home-care system ā€“ including financial constraints, limited availability of services, confusion on how to access services and lack of responsivenessā€ˆā€“ drive older Canadians toward institutional care. Between 2012-13 and 2014-15, about one in five seniors who entered LTC institutions had care needs that likely could have been met at home. In Canada about 80 per cent of spending on LTC goes to institutions while 20 per cent is spent on home care, a disparity that may drive some people to opt for institutional care prematurely.

Canada must do better. In a report published by the Institute for Research on Public Policy, my colleagues and I argue that part of the solution is to provide cash-for-care benefits. More than half of OECD countries offer cash benefits to care recipients. These benefits can be used to purchase formal home-care services, to compensate family and friends who provide informal care, and/or to pay for equipment and home renovations.

Empowering care recipients, maintaining autonomy

The experiences of Germany and the Netherlands, where cash-benefit programs are widely used, demonstrate that they can be a practical solution to improving LTC services for those with low or moderate care needs, and can offer many advantages. Better access to home-care services can reduce unnecessary and unwanted admissions to LTC homes. It can also empower recipients to manage their own care, maintain their autonomy and customize the kinds of supports they receive to their individual circumstances, rather than be squeezed into a cookie-cutter definition of service provision.

But there must be restrictions on how cash-for-care benefits are spent as well as policies that counteract the risks. Both Germany and the Netherlands have introduced restrictions to curb growing program costs and to combat fraud. For instance, in the Netherlands, cash benefits can be invoiced to a centralized personal health budget for each individual, up to an annual maximum, or to pay caregivers based on formal contracts, even if the caregiver is a family member.

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Protecting informal caregivers

Thereā€™s also a concern that offering cash payments for informal care would encourage more working-age women, who already provide the bulk of home-care services, to reduce their participation in the workforce. In Canada, women account for 54 per cent of informal caregivers. According to the most recent estimates, the wages forgone by caregivers due to missing work or working reduced hours totaled $221 million a year for Canadian women between 2003 and 2008, compared to $116 million for men.

Policy-makers should consider providing additional supports for informal caregivers, such as strengthening job-leave provisions, bolstering respite support and supplementing Canada Pension Plan contributions.

The pandemic has demonstrated that new investments are sorely needed to improve the quality and safety of long-term care institutions. We recommend that cash benefits be part of a suite of initiatives that cover the full spectrum of Canadiansā€™ care needs, including significantly more investment in LTC homes, better access to formal home care and greater support for informal care. We recommend that provincial and territorial policy-makers target cash benefits to those with low and moderate health-care needs, and that they work with the federal government to implement additional measures to ensure that informal caregivers do not suffer financial setbacks.

Over the next 20 years, both the overall number of older adults and their share of the overall population are expected to rise considerably, putting further pressure on an already strained system. Other countries are much further ahead than Canada in designing policies to help older adults age at home. Canada must catch up quickly.

As attention begins to shift to life beyond the pandemic, we canā€™t lose this window of opportunity to reform long-term care. Policy-makers should move quickly to introduce a new cash-benefit program, with appropriate regulations, to help older adults age at home.

This article is part of theĀ Kick-starting Reform in Long-Term CareĀ special feature.Ā 

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Colleen M. Flood
Colleen M. Flood, FRCSC, FCAHS, is a University Research Chair in Health Law & Policy and the inaugural Director of the Centre for Health Law, Policy & Ethics, University of Ottawa.

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