This pandemic has revealed deep inequities. The socio-economic chasm that exists in Canada is bigger than many imagined, and fixes are necessary. Age inequities have also come to light as elderly Canadians suffered the highest rates of serious illness and death – outcomes that were exacerbated by decades of government decisions that have not valued the quality of life in our final years. It is clear we can no longer ignore calls for reforms that support our ability to age with dignity.
The problems that have come to the nation’s attention over the last year in long-term care (LTC) homes for seniors are not new. The issues related to staffing levels, aging facilities, and the lack of affordable, easy-to-manage alternatives to facility care for seniors who want to remain at home have been talked about for years.
The most basic right we have as Canadians is the freedom to decide where we want to live and with whom. We need to support this right with strong government action throughout a person’s lifespan. Quality of care needs to be there for those who can remain at home and equally for those who, for whatever reason, must live in LTC homes.
The challenge has always been to create enough public demand to force the government to deliver the funding and the sustained effort required to make real progress on both these issues.
I hope the volume and intensity of public outcry about the nursing home images splashed on screens across this country during the pandemic have finally caught the attention of the majority of Canadians, most of whom have never seen the inside of one of these homes, or personally faced declining health.
Better support for seniors and their caregivers at home
In seizing this momentum for change, policy-makers should first emphasize better support for seniors who want to remain at home. In B.C., the latest data show that two-thirds of new admissions to LTC homes were people who received no home supports for 90 days prior to admission. This speaks to a significant failure in our “continuum” of care. Admissions to LTC should generally follow a trajectory of incrementally increasing levels of support in the community, yet the evidence is telling us the majority of people admitted to LTC homes go from no formal care to full care overnight.
Lurking in the shadows are distressed family caregivers who are clearly exhausted caring for their loved ones with little or no relief from the public system (assessment for admission to LTC show 59 per cent of new residents have a distressed family member). This comes despite the fact the average LTC home resident in B.C. costs the health care system $60,000 per year – more than enough to pay for some significant help at home.
Individual and family financial pressures are one reason why seniors move to LTC. Subsidizing care in the community to the level an individual would receive in a facility seems a logical approach, yet our system provides significantly more subsidy to LTC facilities than home care – a disservice to both the individual needing care and to the taxpayer funding it. However, money is not the only reason a person moves to LTC. Our health-care system is risk-averse and continues to promote the idea that seniors are “safer” in a facility than at home. Perhaps more than anything, the pandemic has put this fallacy to rest.
The risk in LTC is not just COVID-19. Prior to the pandemic, residents risked falls, medication errors, infections, depression, weight loss and overall failing health. Perhaps most importantly, living in long- term care does not, and never will, confer immortality. Quality of life matters and our paternalistic approach to aging forgets that an individual’s right to determine their risk tolerance does not have an expiry date. A 30-year-old can engage in risky activities such as riding a motorcycle or climbing Mt. Everest, so why do we question the right of a 90-year-old man to decide he wants to live on his own?
Even if we get home care right, it will not eliminate the need for LTC, so we must reform the system to ensure frail and vulnerable seniors are offered a dignified life in their final years. This will require more money, financial incentives that compel quality, and a willingness to create and use robust oversight and enforcement tools.
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There has been much “buzz” about the need to include LTC in the Canada Health Act and/or eliminate all for-profit long-term care facilities. These may be ideas worthy of discussion, but most of us who have worked in the field know they are not the answer to all that is wrong. Further, they have potential unintended consequences and could delay the implementation of broadly accepted, necessary changes. If we want to see change in the foreseeable future, we need to focus on what can be achieved over the next five years.
Recognizing the link between quality staffing, funding, and wages
Better staffing will go a long way to improving care. We need more staff, appropriate staff and consistent staff – the evidence linking these inputs to quality is well-documented. However, there is no magical formula to achieve these metrics that does not include increased wages. The basic economic law of supply and demand applies to every labour market including long-term care. The default “we can’t find anyone to hire” can no longer be accepted as the reason for being short staffed. We talk about how rewarding work can be in long-term care and that is true. It can be rewarding. However, it also requires work on weekends, evenings and usually a healthy dose of overtime. We will not create a qualified, appropriate labour pool until we create stable full-time jobs with wages that reflect both the value and the difficulty of the work.
Fundamental to any reform is how LTC operators are funded. In Canada, many provinces contract with private operators to deliver the majority of their long-term care services. The virtues of competition and choice are used to support this model. In publicly funded but privately delivered LTC however, we have neither competition nor choice. There is no incentive to be better than anyone else because your funded bed will be filled regardless. Choice by the consumer is limited, in all practical terms, to whatever bed is available when you need it.
We need to employ the power of economic incentives to ensure that private operators deliver what we need to improve quality of life for residents. The current model financially rewards those who pay the lowest wages, spend the least amount on food, and source the cheapest supply of incontinence products and PPE. We have been seduced by the economic mantra that the private sector is more “efficient” than the public sector, without examining how these “efficiencies” are found and the resulting impact on residents.
It is the public’s money that is funding most private LTC operators in Canada. We should post on government websites the detailed revenue and expenditures for each publicly funded care home. Transparency in public sector spending could provide further momentum for reforms. Across Canada, there has been a general reluctance for government to hold publicly funded nursing homes to account. There are no fines issued for non-compliance with regulations and we talk of co-operation and partnerships with the care home operators. The role of government in LTC is oversight and regulation, not a partner to those who run a business. Our partner is the resident who has turned to us to provide them with the care and support they need and can no longer provide for themselves.
We need to shift our focus to the people who live in long-term-care, and the people who love them. Their voices should influence the funding and oversight of LTC homes, with somewhat less influence going to the people who own and operate publicly funded long-term care for frail seniors.
As policy-makers embark upon reforming long-term care, a central objective should be to expand decision-making autonomy to the majority of seniors so that they can choose to remain in their own homes if that’s what they want, or to support them when they decide to move to an LTC. That’s how we ensure aging with dignity.
This article is part of the Kick-starting Reform in Long-Term Care special feature.