Canada recognized the right to housing in 2019 through the passing of the National Housing Strategy Act, which commits our government to the progressive realization of the right to housing. This means that housing should meet certain conditions to be adequate such as being affordable, habitable and accessible. For Canada’s aging population living in long-term care (LTC) homes*, the right to housing means that their homes are safe, adequate and accessible. However, the COVID-19 pandemic has intensified the substandard conditions experienced by residents of many LTC homes, many of which sadly became sites of viral transmission that resulted in a high number of preventable deaths. It is important that our governments adopt policies that will prevent such a tragic outcome in the future.
LTC homes are different than assisted living facilities or retirement homes as these are designed to house residents who are more independent and require less assistance with activities of daily living (ADL). Individuals who suffer from chronic conditions, trauma or illness that limit their ability to carry out basic self-care tasks live in LTC homes, which support them with the provision of care.
As such, LTC are homes to their residents and their right housing, including adequate facilities, should be protected. This includes proper infection control, clinical management and the maintenance of a basic standard of living, and ensuring that residents live in safety and dignity with essential health services provided.
Long-term care homes in Canada
In Canada, LTC homes are funded by the federal government through the Canada Health Transfer to the provinces and are a provincial responsibility governed by the Federal-Provincial Fiscal Arrangements Act. However, LTC is not included in the Canada Health Act as an insured health service, so the provinces and territories are not required to fund LTC homes in order to receive federal funding. This has led to the uneven allocation of funds which has in turn resulted in the delivery of varying standards of care across the provinces
According to the Canadian Institute for Health Information (CIHI), there are 198,220 LTC beds across 2,076 homes in Canada. Of those homes, 46% are publicly owned and operated and 54% are privately owned and operated. This means that with a population of 6,835,866 people aged 65 and older, there are 29 LTC beds per 1,000 older persons.
While not every older person in the country will rely on a LTC home, the limited availability of these homes means limited housing options for residents who need them. But older persons are not the only people who rely on LTC homes. In Ontario, while older persons represent the majority of LTC residents, 6.6% are younger than 64 years old, and the limited number of LTC options impact them as well.
The pandemic and LTC homes in Canada
There are several systemic issues that serve as barriers to adequate housing in LTC homes, which were exacerbated by the COVID-19 pandemic. Understaffing, overworked staff, lack of inspections and accountability mechanisms, poor design and age of the homes, the presence of mould, bug infestations, overcrowding and neglect are just some examples. The pandemic has brought these systemic issues to the surface, forcing our society to reflect on ways our aging population is treated and initiating a renewed call to make LTC homes safe and adequate for their residents.
People over the age of 70 are twenty times more likely to require hospitalization from COVID-19 and are at even greater risk of death, as indicated by the rates of infection and death across geographies. LTC facilities in Ontario and Quebec represented 82% of all COVID-19 cases and 88% of all deaths. Many of the residents of LTC homes were reported to live in conditions that were undignified and unsafe. For many of the residents who were forced to physically remain in their rooms and unable to leave, isolation also became a major concern.
Additionally, many of these homes are experiencing staff shortages, which has led to an overworked staff who experience physical and psychological stress. LTC staff are also increasingly vulnerable to infection, representing 10% of infection cases across the country. In larger LTC homes with shared rooms, the likelihood of an outbreak was much higher, which led to increased absenteeism, increased workloads for already overworked staff, and ultimately, reduced the ability of these homes to provide an adequate standard of care.
Comparing Canada’s LTC homes to other countries
The pandemic not only showcased the living conditions of our LTC residents in Canada, but it also illuminated the challenges associated with providing adequate housing for older populations living in LTC homes globally. However, some countries have fared better than others, as their LTC homes are able to meet standards of care and housing adequacy.
So, what makes some countries more successful at providing adequate LTC homes to their residents?
The approach to managing and funding LTC homes that a country takes will depend greatly on several factors including a country’s history, political landscape, available resources, culture, community standards, the role of government in social welfare and the varying emphasis on personal/familial responsibilities. Despite differences in funding mechanisms and qualifications, there is very little difference between public expenditures dedicated to LTC homes, taken as a percentage of GDP, but the standard of care varies greatly.
According to the Global AgeWatch Index, Norway is a leader in the delivery of LTC homes. It offers universal coverage as part of a tax-funded social care system, though care is municipally implemented and there are strong federal regulations. There is also an emphasis on the adoption of technology to account for staffing issues and as a means of prolonging the transition from in-home care to a LTC home. Generally, Scandinavian countries take great efforts to enable older persons to stay in their own home with the necessary accommodations to ensure a standard of care and quality of life is provided. Denmark and Sweden both offer the option of home or institutionalized care. In Denmark, private care providers are subject to quality and price standards. The government will reimburse family members for lost wages when informal care is provided to loved ones in their own homes. Three-quarters of municipalities sponsor integrated home care systems which has helped to reduce the number of people who rely on nursing home care. In Sweden, individuals can opt for private home care. In 1992, reforms decentralized care which resulted in a 50% decrease in the ratio of beds to clients. There are also separate facilities for individuals living with dementia.
Just as the delivery of LTC in Norway, Denmark and Sweden is distinctly Scandinavian, in the United States the approach is distinctly American. In the United States there is stark political opposition to tax-funded LTC homes through universal healthcare coverage and instead they rely on safety net or means-tested programming. The country relies on insurance-based care and private care models, and an LTC home is offered through Medicare and Medicaid. The federal government sets the standards, individual states are responsible for inspection of the facilities.
Australia has proven to be a leader in the delivery and monitoring of LTC homes. There are strict accreditation and inspection processes in place, and strong oversight which enabled it to fare well during the COVID pandemic. All homes are expected to provide equal care and funding is allocated based on overall resident dependency.
While LTC homes exist in other countries that are not included in this article, it is important for policy-makers to look at ways other countries protect their older persons and provide a LTC home that is adequate for their residents, allowing them to live with dignity.
Lessons learned
Looking both inward, and at other examples globally, there are several ways our governments can ensure adequate housing for older persons living in LTC homes.
One way to do so would be to institute better standards and oversight in our LTC homes. Some advocates have pointed to the need to set national standards as a condition of federal funding to provinces in order to improve the provision, oversight and accountability of care delivery that may include infection prevention practices. If this is the direction the federal government takes to improve our LTC homes, it’s vital that the federal and provincial governments better coordinate and adopt an emergency response plan to proactively address systemic barriers to adequate LTC homes.
Another important move that can increase adequate LTC homes is to make home care an option, enabling older persons to stay in the comfort of their home. This move would improve a person’s dignity while relieving the strain on LTC homes to care for the most vulnerable. To make home care a viable option, it’s important to ensure that resources are made available to caregivers to provide the necessary standard of care.
Staffing and resources for LTC homes also needs to be improved in order to lift the strain on this system as a whole. Governments can ensure there are enough trained staff and make available the necessary resources to run these homes adequately, improving the minimum standard of care. Likewise, infrastructure improvements such as the age and design of LTC facilities could also enhance the delivery of care.
Lastly, LTC homes that are culturally adequate should be increased to help residents who suffer from cognitive decline and regression as their sense of security, fulfillment and dignity of personhood would improve greatly. This could include something as simple as having a staff member who speaks the same language or grouping together people with similar cultures and beliefs. Cultural adequacy also means providing spaces for traditional practices and healing approaches.
Rethinking the care model
While many conversations around the inadequacy of LTC homes and their inability to protect their residents during the pandemic have revolved around the private vs. public debate, what we can conclude is there is a defined need to rethink the care model altogether. Solutions may lie in increasing resources to enable home care or adopting transformative resident approaches like a compassionate dementia care model.
Rethinking the care model also means listening to the needs of the residents of LTC homes and finding ways to engage them in identifying solutions that will meet their needs. It means listening to the families of residents, who care about their loved ones and often shoulder the burden of LTC unaffordability and inadequacy. Family members have been calling for improvements to LTC homes’ living conditions from a place of compassion so their loved ones can live dignified lives. It also means listening to policy makers and advocates who are equipped with the knowledge and evidence-based research pertaining to this complex issue and the approaches that can be leveraged to enhance LTC homes and the standard of care being delivered.
When we rethink the care model, we ensure that our older persons are not only able to live in safe, adequate and affordable homes, but it also reflects who we are as a society when we take care of our aging population and ensure their fundamental human rights.
*An LTC home is defined by Health Canada as a “living accommodation for people who require onsite delivery of twenty-four hour, seven days a week supervised care, including professional health services, personal care and service such as meals, laundry and housekeeping.” In the province of Ontario, the Long-Term Care Homes Act states that, “a long-term care home is primarily the home of its residents and is to be operated so that it is a place where they may live with dignity and in security, safety and comfort and have their physical, psychological, social, spiritual and cultural needs adequately met.