Why Canada Needs to Improve Residential Care for Ageing Populations (and why we aren’t doing it)

Susan Braedley, MSW PhD

Older people and their families often view long-term residential care as the last and worst resort for care, while policy makers see it as an expensive problem with a propensity for scandal. Provincial governments have been strategizing how to keep frail older persons out of residential care via a suite of programs such as home care, day care and respite beds. While these policies provide much needed services and reduce hospitalizations, they are based on the questionable assumption that frail older people have families with the capacity and finances to provide the majority of their often complex and challenging care. The reality remains that there is and will continue to be a small percentage of elderly people who require intensive 24/7 care and housing. The ageing of the population is already putting pressure on the long-term residential sector and scandals about quality of care continue to erupt, with scandals about violence and neglect emerging regularly, yet it remains a neglected policy arena.

Canada could do much better. An international research team led by Dr. Pat Armstrong of York University has been conducting comparative research in four Canadian provinces and  five other OECD member countries.  Findings to date demonstrate that staffing level is the most critical issue in providing quality care[1]. In Canada, long-term care residences are often operating below recommended minimum staffing levels, with little consistency across jurisdictions in what constitutes adequate staffing. For example, in  B.C, the recommended level is 3.36 hours of direct care per resident per day – a recommendation most B.C. homes do not achieve. In Ontario, there is no standard at all, despite persistent policy recommendations and pressure for a 4 hour per day per resident standard.

Some countries provide higher quality care without recommended or legislated staffing levels. However, these are countries, such as Norway, have high levels of public provision. In Canada, most provinces have re-oriented policy to support for-profit service delivery, hoping for private sector investment and much-touted innovation and efficiencies. This dramatic expansion of for-profit delivery has had serious perverse effects. There is compelling Canadian evidence that for-profit providers as a group provide lower quality care than do municipal and non-profit residences[2], and that this poor quality is likely due to low staffing levels.  For example, recent studies have shown that residents in for-profit homes have much higher rates of death and hospitalizations.[3][4] In other jurisdictions that have taken the same route, such as Germany, legislated minimum staffing ratios have gone some way to ensure quality with for-profit providers. But questions about whether this is sufficient to address the profit versus more care dilemma in for-profit provision remain. For example, regulations in the sector have already produced an expensive morass of reporting mechanisms that take workers away from resident care in order to produce the masses of documentation on the very care that they now have even less time to provide.

[1]Harrington, C., Choiniere, J., Goldmann, M., Jacobsen, F. F., Lloyd, L., McGregor, M., & … Szebehely, M. (2012). Nursing Home Staffing Standards and Staffing Levels in Six Countries. Journal Of Nursing Scholarship, 44(1), 88-98 11p. doi:10.1111/j.1547-5069.2011.01430.x

[2] , McGregor, M. and L. Ronald (2011). Residential Long-Term Care for Canadian Seniors. Nonprofit, For-profit or  Does It Matter? Toronto, Institute for Research on Public Policy.

[3] Tanuseputro, P., et al. (2015). “Hospitalization and Mortality Rates in Long-Term Care Facilities: Does For-Profit Status Matter?” Journal of the American Medical Directors Association 16(10): 874-883.

[4] Ronald, L. A., et al. (2016). “Observational evidence of for-profit delivery and inferior nursing home care: when is there enough evidence for policy change?” PLoS Med 13(4): e1001995.