5.8. Long term care

This section focuses on LTC provision for older adults with limitations in the activities of daily living arising from health conditions. LTC may be provided in facility-based settings, or in the community through home care and other support services. Publicly funded programmes are available in all provinces and territories for both sectors (facility-based care and home care). In most provinces, LTC has increasingly been integrated into geographically based delegated health authorities, and provincial ministries of health generally have division(s) responsible for LTC which provide overarching policy direction.

As LTC is not an insured service under the Canada Health Act, public policies, subsidies, programmes and regulatory regimes vary widely across the country. In both facility-based care and home care, access to publicly funded services is based on needs assessment. In home care, there may be an income-based co-payment for publicly funded services in some provinces and territories. There is also a significant market for privately procured home care services (Allin et al., 2020b). The cost of care in publicly funded LTC facilities does not generally entail OOP expenses to residents. Charges to residents for accommodation and meals are generally reduced or waived for those on low income.

Private facility-based LTC (i.e. paid for fully out of pocket) is a small segment of the sector. There are other privately paid residential options for seniors – variously referred to as seniors’ residences, or retirement residences – which are generally considered part of the housing (rather than LTC) sector. Core services generally include meal provision and housekeeping services. Residents may also be eligible for publicly funded home care, and/or choose to purchase care services privately. These residential options are not examined further in this section, where “LTC facilities” refers to publicly funded institutions to which admission is based on care need, and which provide 24/7 supervision and access to nursing services.

Estimates suggest that roughly 11% of public/government spending on health is directed to non-hospital institutions, most of which are LTC facilities, compared with about 5.5% on home and community care (CIHI, 2019a). In 2016, about 3% of Canadians aged 65 years and older, and 12% of Canadians 85 years and older, were living in an LTC institution (Statistics Canada, 2016). Factors predicting admission to a facility include age, diagnosis of dementia and other chronic conditions (such as diabetes, urinary incontinence and mood disorders) and losing a spouse (Garner et al., 2018). While facility-based care is generally targeted to high-needs individuals, there is some evidence of potentially inappropriate use of facility-based LTC: a study of six provinces and territories found that 22% of individuals aged 65 and older who entered an LTC facility had been assessed with low to moderate needs which may indicate that they could have been supported at home (CIHI, 2017a).

In 2020, 46% of LTC facilities were publicly owned, with 28% operated on a private for-profit basis, and 23% private not-for-profit, with variations across provinces (CIHI, 2020). For example, in Ontario, the majority of LTC facilities are private for-profit (57%) and private not-for-profit (27%), while in Quebec the majority are publicly owned (86%) (CIHI, 2020). Even after adjusting for case mix, there is evidence that not-for-profit facilities provide more direct care per client than for-profit facilities, and that chain-affiliated facilities, both for-profit (of which 83% are chain affiliated) and not-for-profit (of which 38.5% are chain affiliated), provided fewer direct hours of care than non-chain-affiliated facilities (Hsu et al., 2016). While there is some evidence that better patient outcomes are associated with not-for-profit LTC facilities compared with for-profit homes, more research is needed to test this association (McGrail et al., 2007; McGregor & Ronald, 2011). A recent study in British Columbia found that there was greater use of the ED and hospital beds by residents from private LTC facilities versus residents from publicly owned facilities (Office of the Seniors Advocate British Columbia, 2018).

Waiting times for publicly funded facility-based LTC across the country are common, although comprehensive data are limited. Estimates from Ontario suggest that the median waiting time for an LTC facility from hospital was 92 days in 2016/2017, up from 70 days in 2015/2016. The median waiting time for LTC home from community was 149 days in 2016/2017, up from 132 days in 2015/2016 (Health Quality Ontario, 2018). In 2018–2019, about 40% of LTC residents are admitted from hospital, 34% from home-based settings, and 25% from other residential settings (e.g. seniors’ residences) (CIHI, 2019c).

In 2014–2015, an estimated 3.3% of adult Canadians (not limited to seniors) received home care services, including publicly funded and privately procured services (Gilmour, 2018). About 60% of care recipients were seniors, who primarily receive long-term services (other target populations for home care services include those with short-term acute needs; for example, to avoid or following a hospital stay, or at end of life). Publicly funded home care is intended to support (rather than replace) informal care by family members or friends, and is mostly provided in-kind. It may be delivered by public employees or through contracted agencies which may be for-profit or not-for-profit. Most provinces and territories have programmes that offer the option of providing personal budgets for clients to purchase their own care for some selected groups that meet certain eligibility criteria.[19] These programmes have historically been oriented to younger adults with disabilities (Carbone & Allin, 2020).

Some of the characteristics of home care users (of long-term services) include cognitive impairment, mobility issues, chronic conditions, and associated with older age, urban location of residence and female clients (Johnson et al., 2018). In Ontario, while 39% of people receiving home care in 2011–2012 had cognitive impairment, this increased to 57.3% in 2016–2017. Similar increases were seen in the percentage reporting high care needs (37% to 48%), needing assistance with activities such as bathing and eating (17% to 24%) and with high to very high health instability (13% to 23%) (Health Quality Ontario, 2018).