How to Repair Long-Term Care in Canada

In the early months of the pandemic, Canadians were shocked by a cascade of deaths in long-term care homes. By mid-2020, 80% of COVID-19 deaths in Canada were in these facilities. That our vulnerable elderly died this way will remain our lasting shame and disgrace. A year later, Canada still had, at 62%, the highest proportion of deaths in long-term care (LTC) of any G20 country, Samir Sinha, director of health policy research at the National Institute on Ageing and director of geriatrics at Sinai Health in Toronto, told a federal committee. Sinha informed the politicians that Canada spends about 30% less on LTC than the average of other OECD countries. COVID-19 was “a shock wave that cracked wide all the pre-existing fractures in our nursing homes,” wrote the authors of Restoring Trust: COVID-19 and the Future of Long-Term Care, a June 2020 report from the Royal Society of Canada. By late 2020, a survey found that the vast majority of Canadians (86% overall and 97% of those over 65) were concerned about the state of LTC in Canada. The preventable tragedy that unfolded in LTC added urgency to longstanding calls for improvements, such as better staffing levels, and higher care standards, as well as new demands for transparency about how public money is spent. These have found their way into the current election campaign. Party leaders are making pronouncements about the role of the federal government in setting standards and that of for-profit companies operating in a sector that cares for our vulnerable citizens. Almost 30% of LTC in Canada is operated on a for-profit basis.

What has happened during the pandemic is a tragedy, but the real tragedy is how people have been living in long-term care, even before COVID-19. Isobel Mackenzie

“What has happened during the pandemic is certainly a tragedy, but the real tragedy is how people have been living in long-term care, even before COVID-19,” says BC Seniors Advocate Isobel Mackenzie. Her comprehensive and critical report, A Billion Reasons to Care, was published February 4, 2020, just as the pandemic began. (BC was the first province to appoint a seniors’ advocate, a position similar to that of an ombudsperson.) Still, Mackenzie wonders if, even now, there is enough political will to make significant improvements. As Colleen Flood, director of the University of Ottawa’s Centre for Health Law, Policy and Ethics, observes: “The frail elderly are particularly susceptible to being overlooked because of gender, age, mental and physical disability. They are just not a very interesting political constituency for the media, the general public or for politicians.” But this growing demographic is of significant interest to large corporations (and their shareholders) that operate LTC facilities across the country.

LTC in Canada: A snapshot

Some of the key proposals to improve conditions in Canadian LTC facilities are described below, but before considering them, it’s useful to keep in mind some of the sector’s basic features. Across Canada, LTC facilities, which fall under provincial jurisdiction, receive significant amounts of public money for care-related expenses. This funding is provided regardless of whether they are operated by public entities (for example, by municipalities in Ontario and health authorities in British Columbia), non-profit and charitable organizations, or for-profit companies. (Retirement homes, in contrast, receive no public funding for providing direct care, though some received extra support in the wake of the pandemic, for instance for personal protective equipment.) The healthcare needs of LTC residents have changed significantly over the past two decades. They have more complex care needs: about two-thirds of residents have some form of dementia, and many have multiple health conditions and cognitive impairment. Residents constitute a small but highly vulnerable proportion of the overall Canadian society: their average age is 85 and at least three-quarters are women. LTC is not covered under the Canada Health Act (CHA), which provides access to medically necessary hospital and physician services at no direct cost to patients. Sinha says that LTC represents “the largest form of hands-on care” that is excluded from the CHA. Home care is also excluded, and also in need of attention. Research by the National Institute on Ageing found that before the pandemic, 430,000 Canadians had unmet home-care needs, and 40,000 were on wait lists for LTC. Provincial and territorial governments license and regulate all LTC facilities. As a result, they have evolved differently across the country because of varying political landscapes, history, lobbying, advocates, and population density. For example, Manitoba and Quebec, because of particular political landscapes, have a greater proportion of non-profit and public LTC homes, while in Ontario the for-profit sector dominates. Where population is sparse, as in the territories, all LTC is publicly operated. The out-of-pocket cost to residents, criteria for admission, and even mandated daily hours of care differ significantly among the provinces, where the facilities are known variously as nursing homes, continuing care facilities, and residential care homes. What they have in common are long waitlists, often a year or more.

People don’t have a choice. If you are lucky enough to get [an LTC] spot, because they are rare as hens’ teeth, then you stay with it. Colleen Flood

The imbalance between demand and supply means “people don’t have a choice. If you are lucky enough to get a spot, because they are rare as hens’ teeth, then you stay with it,” Flood observes. “The idea of any kind of competitive rigour from having the private sector involved is just a joke, because there are no real market forces at play.” Individuals who need 24-hour care, but are waitlisted for LTC, are sometimes forced to turn to private facilities – known as retirement homes or assisted living facilities – that have emerged to meet demand. Individuals pay for room and board and are charged for additional services, such as having their medication dispensed or even being helped up if they have fallen down. Some, who need and can afford it, pay for extra nursing care from an outside agency. However, if their health deteriorates, they are often transferred to hospital to await LTC accommodation. Studies show that prospective residents and family members have a clear preference for accommodation in not-for-profit LTC compared to for-profit facilities, because the former have higher standards of care. And of the non-profits, publicly run facilities and those established through community efforts to cater to specific ethnic groups are deemed most desirable by would-be residents.

Levelling the playing field: How non-profit LTC is disadvantaged

In Ontario, especially, higher resident death rates in for-profit LTC facilities, compared to non-profit homes, led to public alarm and persistent questions about why the private sector, with its requirement for extracting profit, should be allowed to operate in such a vital area of care. There were also more COVID-19 outbreaks and deaths in BC for-profit LTC homes, but the contrast was not as marked in that province, which was more successful overall in limiting harm to residents. An academic report for Canadian Public Policy found that while the design of some for-profit LTC facilities was a factor in higher death rates (older for-profit homes have more multi-bed/ward accommodation), for-profit ownership alone led to worse outcomes. Ontario’s Science Table, the province’s COVID-19 advisory board, concluded that chain ownership, as well as crowding and older design, led to more deaths. These and other concerns prompted Ontario to appoint an independent Commission of Inquiry, convened in July 29, 2020, to report on how to better protect LTC residents and staff from future outbreaks. “Care should be the sole focus of the entities responsible for long-term care homes,” the commission recommended. Some of the large for-profit LTC companies are owned by investment vehicles, such as real estate investment trusts (REITs). “While the REIT holds the licence and, therefore, the legal responsibility for the residents’ care, it hires a separate company to run its long-term care home and provide that care,” the commission report stated. “This may be an excellent financial arrangement for the investors, but it is more difficult to understand why it is a suitable arrangement for resident care.” The commission recommended that the province adopt an approach in which almost all for-profit enterprises should not be allowed to operate LTC facilities. Instead, the commission said such enterprises have a role to build the homes and receive payment from the government “for an agreed upon number of years” so the companies “recover their investment and an agreed-upon rate of return,” with ownership subsequently reverting to the province. Non-profit nursing home providers, some run by charities, are at a very real disadvantage compared to large for-profit corporations when it comes to their ability to access financing for construction and to operate with economies of scale. This disparity is not just the case in Ontario, but the issue has been studied more in that province than in other parts of Canada. As Sinha observes, when politicians want to increase LTC accommodation – and non-profits and municipalities “don’t raise their hands to run more homes” – governments turn to the for-profit companies. The major for-profit providers of LTC in Canada are Extendicare Inc., Sienna Senior Living Inc., Chartwell Retirement Residencies REIT, and Revera Inc. They all benefit from efficiencies because of the scale of their operations. Because of their size, the large for-profits have access to debt financing and can standardize designs and centralize back-office operations. All operate LTC facilities in Ontario and British Columbia, while Extendicare and Revera are also in Alberta and Manitoba. (The companies also own and operate retirement homes, while Extendicare also has a contract services business, Extendicare Assist Management and Consulting Services, which manages other LTC homes, including some non-profits.) All except Revera are publicly traded on the stock market and hence responsible – and attractive – to shareholder/investors. “Why it’s time to bet on geezers” was the headline on a May 2019 article in the Globe and Mail, extolling a “bounce” in LTC stocks. In Quebec, the government leases rooms in private nursing homes, which receive permits from the province, to alleviate pressure on public LTC facilities. One such private nursing home was CHSLD Herron, an LTC facility in the Montreal suburb of Dorval, where at least 38 residents died in March and April 2020. The owners closed the home shortly afterward. This spring, survivors and relatives of the deceased reached a $5.5-million settlement in a class action suit against the facility’s management. Several class action suits have been launched in Ontario, but that province’s Progressive Conservative government passed legislation, retroactive to the beginning of the pandemic, to make it significantly harder to sue LTC companies. Ontario’s Progressive Conservative Party has many links with for-profit LTC companies; former premier Mike Harris, under whose tenure for-profit LTC expanded significantly in the province, is the chair of the board of Chartwell. AdvantAge Ontario, a not-for-profit organization, represents 70% of the province’s non-profit and 93% of public homes run by municipalities. (Under provincial legislation, each municipality must operate at least one LTC home.) In its pre-budget submission, the organization asked that all new allocations in the future go to not-for-profit or municipal homes only. “But to make that possible,” says CEO Lisa Levin, “we need to change the rules of the game.” Compared to for-profit operators, non-profits have difficulty gaining access to land and financing, may not qualify for mortgages, and lack expertise in development and redevelopment. Levin proposed that her organization be supported to set up a Centre for Excellence for not-for-profit LTC facilities to increase capacity of the sector along with seed funding and loan guarantees from the province to mainstream lenders, changes to facilitate Infrastructure Ontario loans for non-profit LTC, and access through hospitals to sub-prime interest rates from the Ontario Financing Authority. She agreed that the obstacles to the growth in the non-profit sector can seem overwhelming, “but you know when there is a will, there is a way.” In the 1980s, she points out, the provinces and the federal government helped community groups to get funding and loan guarantees to allow them to build social housing. A group of prominent researchers and policy-makers take things a step further in the May 2021 report Investing in Care, Not Profit: Recommendations to Transform Long-Term Care in Ontario. They argued that, in for-profit LTC, “the investors’ gain is the residents’ loss.” The authors recommended that all new licences go to non-profit LTC providers and that federal and provincial governments fund capital costs for new LTC facilities – “as they have done in the past for public hospitals” – instead of looking to private capital for construction. Like AdvantAge Ontario, the authors think there should be a centre to provide capacity building for non-profits, but they want Ontario to create a public agency to help not-for-profit LTCs “plan, finance and operate LTC to best-standard practice.”

Neither left- nor right-leaning governments have shown much interest in taking deeper ownership of the system since it is both capital- and cost-intensive. Tal Woolley

Some onlookers remain skeptical that provinces will be motivated to take a larger role in the LTC sector. On May 29, 2020, Bloomberg reported a drop in for-profit LTC stocks after Ontario took over management of five hard-hit LTC homes. But Tal Woolley, an analyst at National Bank Financial, doubted that this move was a preview of future government action. “Neither left-leaning nor right-leaning governments in the past have shown much interest in taking deeper ownership of the system since it is both capital- and cost-intensive.” “The reality,” says BC Seniors Advocate Mackenzie, “is that even if we decided the best model would be 100% public ownership and operation, it would not be a panacea.” She adds that the sheer number of for-profit LTC homes makes such a wholesale shift improbable. In any event, improving all LTC should be the goal, and it seems obvious that the quality of care residents receive depends on the people providing that care.

Staffing: “The conditions of work are the conditions of care”

Professor Pat Armstrong was finishing up a 10-year international study of promising practices in LTC when COVID-19 emerged to hammer the sector in Canada. “I was getting two or three phone calls a day from media frantically doing stories,” she says. But instead of enthusing to reporters about excellent LTC models, Armstrong, a distinguished research professor of sociology at York University, found herself describing the persistent inadequacies with the sector in this country. She patiently explained how jobs in LTC facilities are often precarious (most are part-time, without benefits) and how that affects the continuity and quality of care of residents. “The conditions of work are the conditions of care” is a statement she often repeats, and it rings true. Barebones staffing levels lead to “a primary orientation to tasks, not to care,” she says.

Barebones staffing levels lead to a primary orientation to tasks, not to care. Pat Armstrong

Many LTC facilities were short-staffed during the worst of the pandemic – a Statistics Canada report found that 85% of LTC facilities in Canada experienced serious staffing challenges and that workers who stayed on the job faced risks. By mid-February 2021, close to 30 staff members and more than 14,000 LTC residents had died from COVID-19 in Canada, Sinha told the federal standing committee. Because of what happened during the pandemic, most people would agree that LTC workers should have sick pay. And Ontario Premier Doug Ford concedes that LTC residents need more than the daily hours of care now funded by the province. The regional discrepancies are striking. British Columbia, for example, mandates three hours and 36 minutes of care a day for each resident, while Ontario requires only two hours and 45 minutes – a 24% difference. Publicly run LTC facilities in Canada typically boost care hours with additional taxpayer dollars, and non-profits often provide more care time thanks to fundraising and charitable donations. As well, most LTC facilities rely on family members to supplement hands-on care for their relatives, and some families who can afford it pay for outside help. (The prohibition on these helpers entering LTC homes during the pandemic contributed significantly to resident isolation and suffering.) During the second wave of the pandemic in Ontario, more LTC residents died than in the first wave, and in November Ford pronounced that four hours a day is “the gold standard” and pledged $1.9 billion to increase direct care to that level – but not until 2024/2025. “By then, most current residents of long-term care will be dead,” Sinha wryly observed. To provide four hours of care for existing LTC residents/beds, the province would have to hire 29,200 full-time equivalent positions over the next four years – 17,000 personal support workers and 12,200 nurses, according to estimates from the Financial Accountability Office of Ontario. Early in the pandemic, Prime Minister Justin Trudeau announced that the federal government would work with premiers to ensure LTC “is properly supported.” The result was an initiative to improve national standards for care (but not, as some had hoped, federal legislation).

The national standards/accreditation route

“A massacre” is what took place in LTC facilities during the COVID-19 pandemic, says Sinha. “This is a pan-Canadian issue, so I’m glad the federal government started taking an interest in providing leadership in this space, even though this is not traditionally an area of federal jurisdiction.” In its 2021 budget, the Liberal government pledged $3 billion over four to five years to improve LTC and later committed that money to improving standards of care. During the election campaign, the Liberals promised an additional $6 billion to help provinces implement them. Sinha is heading up the HSO National Long-Term Care Services Standard Technical Committee, which is charged with developing new care standards that will be applied to LTC through an accreditation process. He has insisted on widespread public engagement to develop them. (In the past, the public was invited to review draft standards after they were drawn up by the Standards Council of Canada.) By mid-summer, 15,000 Canadians had filled out a national survey on the changes they would like to see. Sinha is holding town halls across the country and expects to have a new set of standards by 2022. Standards for LTC already exist and are applied by Accreditation Canada, a non-profit organization. They set out principles and provide detailed guidelines in areas such as “safe and reliable care” (referencing, for example, wound care and prevention of pressure ulcers) and “access to psychosocial and supportive care services” for residents and families. While Accreditation Canada can, and sometimes does, cancel a facility’s accreditation, the organization can’t impose fines against facilities that don’t meet standards to which they agreed. Still, only about 58% of LTC homes in the country now seek accreditation through Accreditation Canada. In Quebec, accreditation and certification is mandatory for all LTC homes, while requirements vary in the rest of the country. In some provinces, for example Ontario and BC, accreditation is voluntary and some LTC facilities opt instead for the Canadian division of CARF (Commission on Accreditation of Rehabilitation Facilities), a US organization. “The for-profit homes generally tend to go with a US accreditation process, which is cheaper and easier,” Sinha says. Questions remain about how new standards will be used. Sinha hopes that provinces and territories will receive new federal funding only as a condition of implementing new standards. (Money that is not “tied” tends to be spent in other areas, he notes.) But beyond that, “do we mandate accreditation? More importantly, what about enforcement, regulation, and compliance?” he asks. “Will the federal government support implementation of standards through legislation?”

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Lisa Levin, CEO of the group representing most of Ontario’s non-profit LTC homes, notes that a new set of national standards will address both care as well as the design and operation of LTC buildings. (A separate group is drawing up standards for safe operating practices and infection control, including HVAC and plumbing.) “Implementing all this will cost a lot of money,” she says. “I’m concerned that it will be a frustrating process if the public’s expectations are raised and then if there is no money, or not enough money.” For her part, BC Seniors Advocate Mackenzie says that while accreditation standards are a good thing, they are difficult to measure. “They don’t really have the teeth that we need; they are not traditionally designed as a framework for annual reporting on specific metrics. I’m not sure they will be sufficient to get at the meat of what we have to get at because they are voluntary … and facilities are not compelled to allow the public to see accreditation reports.”

Transparency and the importance of audits when public money is spent

Billions of dollars of public money are spent on LTC in Canada every year. But when it comes to reporting where the money goes, it’s often difficult to find answers. Mackenzie took a close look at this issue in A Billion Reasons to Care, which audited public money spent in private or non-profit LTC. (In BC, 37% of LTC facilities are operated by for-profit companies, 35% by local health authorities, and 28% by private non-profits.) “All things being equal,” she explains, “the not-for-profits will apply more money to direct care of residents, and the for-profits will apply more money to their profits and to the assets that they own.” Both types of facilities receive the same amount of public funding on a per-diem basis. “But there is no line where we say, ‘This is your profit,’” Mackenzie says. Consequently, for-profit operators will set out to find the profit. “It gives them the incentive to get labour at the cheapest cost, to get food at the cheapest cost, because every time it can get something for less than we funded them to do it for, that’s their profit, and it’s the only way we let them get profit.” Mackenzie argues it would be more transparent if the government spelled out the funding agreement and audited it and added a specified return (as is done with regulated utilities) for its profit: “We will pay you 5% as your management fee to operate this on our behalf. That is your profit, period.” Mackenzie is adamant about the importance of audits. Private companies can keep details of their operations private, but because LTC receives substantial public funding, for-profit LTC facilities “aren’t private businesses,” she says. Unlike private businesses, they don’t operate in a competitive market. Because for-profit LTC operators have such a large presence in BC, Mackenzie doesn’t think it is practical to convert them to non-profit or public ownership. But she thinks the public could drive change about the quality of care delivered if it had access to detailed information about the operations of all LTC homes. The concerned public, she says, includes both LTC residents and their families and advocates, as well as taxpayer watchdog groups. Mackenzie also sees some merit in the Ontario Commission of Inquiry’s suggestion that for-profit companies be restricted to building LTC facilities, but not operating them, and then transferring ownership back to the public after an agreed-upon payment over a specified number of years. It would make even more sense, she argues, to see governments pay rent on a square-foot basis to for-profit LTC companies based on the quality of their facility – the way governments pay rent to private companies for office space – instead of subsidizing their debt. “What they do for mortgages is their business.”

Conclusion

Professor Armstrong, who has researched and written about the sector for decades, is concerned the window of opportunity for making substantial improvements to LTC may be closing. Most observers agree that any push to open up the Canada Health Act to include LTC is a non-starter, in part because of the risks involved, primarily a well-financed lobby that would push to expand private delivery of healthcare in Canada. But Carolyn Tuohy, professor emeritus at the Munk School of Global Affairs and Public Policy in Toronto, is not alone in arguing that a stronger federal presence in LTC could have considerable advantages because of “the need for equity in matters so closely connected to human dignity,” as she wrote in a recent paper.

We need a new vision so people are not terrified of going into LTC homes at the end of their life. Colleen Flood

For her part, Flood is adamant that the current system must operate to higher standards, which means considerably more funding. In her opinion, however, tweaking the current system is not enough. “I’m suggesting we need to step back and reconceptualize the whole thing, create some new arrangements between federal and provincial governments,” she says. “We need a new vision so people are not terrified of going into LTC homes at the end of their life.” As COVID-19 spread in our communities, it drew stark attention to the health, social, and economic inequities that exist throughout Canadian society. But the earliest victims of the pandemic were residents of LTC, our most fragile and vulnerable elders. Surely one key lesson from the pandemic is the urgent task to improve LTC so residents can live, and die, with dignity. Over the next 30 years, the number of Canadians over 85 will triple, and costs for those who need care will rise in lockstep. Perhaps it is time for more radical change.

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Foundations, long-term care research, and “venture philanthropy”

In early 2020, as the death toll in long-term care (LTC) homes was mounting, some foundations and individual donors came to the National Institute on Ageing (NIA) with questions: “‘What can we do? Where can we make an impact?’” recalls Samir Sinha, the NIA’s director of health policy research. The NIA knew that no one was tracking COVID-19 infections and deaths in LTC facilities across Canada, so individual donors and two foundations pitched in to support the work, says Sinha, who is also director of geriatrics at Mount Sinai and the University Health Network hospitals in Toronto. That funding helped to support research that documented the alarming incidence of COVID-19 deaths among LTC residents. The NIA also determined that Canada’s older seniors were 75 times more likely to die from COVID-19 if they lived in LTC facilities rather than in the community. Those findings compelled the federal government to begin looking to find ways to support improvements in the LTC sector, Sinha says. He is leading a technical group seeking to develop new national standards for the sector by 2022; the Liberal government pledged $3 billion to support the implementation of those standards. Can philanthropy assist the LTC world in other ways? In Sinha’s view, foundation funding is best directed at supporting knowledge and advocacy rather than subsidizing the operation of LTC homes, a government responsibility. In the health sector, foundations and non-profits are more likely to support initiatives concerning children and youth, as well as capital campaigns. But as donors and foundation directors age, seniors’ care issues will begin to have “more of a resonance,” says James Booty, executive director of La Fondation Emmanuelle Gattuso, a private foundation based in Toronto.

The pandemic spotlighted LTC issues that have been known about for a long time but that people might not want to see. James Booty

Also, the pandemic spotlighted LTC issues, such as problems in facilities, that have been known about for a long time “but that people might not want to see,” he added. La Fondation Emmanuelle Gattuso supported the NIA’s work; another contributor, the Slaight Family Foundation, declined an interview request. Trying to “shore up” public funding of LTC homes would be an enormous and never-ending task, says Booty, who agrees with Sinha that support for research and advocacy would be a more effective avenue for foundations to support. AdvantAge Ontario is a charitable organization representing non-profit LTC homes. CEO Lisa Levin says her members would welcome foundation support for her plans to establish a Centre of Excellence with the aim of increasing the capacity of non-profit LTC facilities so they could better compete with for-profit LTC chains. She says she would welcome funding to allow her members to introduce therapy dogs into facilities or provide better food for residents. Sinha thinks another possible role for Canadian charities is “venture philanthropy” – specifically to demonstrate and evaluate new models of LTC care. This kind of impact investing is already happening in the US, where the Robert Wood Johnson Foundation has backed the Green House model of small home-like settings, originally developed in the early 2000s in Mississippi by a US physician.

The Liberal election platform includes a promise to “develop a safe long-term care act collaboratively to ensure that seniors are guaranteed the care they deserve, no matter where they live.” Conservative leader Erin O’Toole has opposed national standards and federal legislation on LTC as intrusions on provincial jurisdiction. The party’s platform promises to improve LTC and provide funding for renovation of LTC homes, and it highlights financial support to allow older Canadians to live at home, or live with their children. The NDP election platform includes a pledge to end private, for-profit LTC, bring LTC homes under the public umbrella, and work with others to develop national LTC care standards “regulated by the same principles as the Canada Health Act.”