Understanding Health and Social Services for Seniors in Canada.

Understanding Health and Social Services for Seniors in Canada. REPORT APRIL 2015

Understanding Health and Social Services for Seniors in Canada David Verbeeten, Philip Astles, and Gabriela Prada Preface Canada s demographic trend presents key challenges for health and social services for seniors. Just as demand for services, especially in health care and related areas, is expected to grow, the revenues for their provision are expected to shrink. These trends should accelerate as the very large cohort of baby boomers moves into retirement. Although these challenges are not in themselves insurmountable, they will need to be addressed proactively in order to ensure system readiness and viability. This report establishes a clear snapshot of current government seniors health care programs and services that can inform the design of future programs, plans, and strategies to better address seniors, and their families, needs. Thus, it does not focus on private programs and services except where they rely on government support. The report first presents the social and economic context of seniors health in Canada, including projections of demographic trends and fiscal pressures. It notes measures for wellness and health promotion that are being or can be implemented to help individuals remain independent for as long as possible. It then looks at the basket of services currently available to seniors throughout the provinces and territories of Canada, including primary care, home care, long-term care, and palliative care. Challenges to seniors care programs, such as irregular or difficult access, a rising incidence of dementia, fiscal constraints, limited seniors-friendly redress mechanisms, and current federal legislation, which limits federal functions, are also explored. Finally, the report presents good practices and emerging approaches, from both Canada and other countries, that are improving the provision of and satisfaction with seniors care among clients and their families. To cite this report: Verbeeten, David, Philip Astles, and Gabriela Prada. Understanding Health and Social Services for Seniors in Canada. Ottawa: The Conference Board of Canada, 2015. 2015 The Conference Board of Canada* Published in Canada All rights reserved Agreement No. 40063028 *Incorporated as AERIC Inc. An accessible version of this document for the visually impaired is available upon request. Accessibility Officer, The Conference Board of Canada Tel.: 613-526-3280 or 1-866-711-2262 E-mail: accessibility@conferenceboard.ca The Conference Board of Canada and the torch logo are registered trademarks of The Conference Board, Inc. Forecasts and research often involve numerous assumptions and data sources, and are subject to inherent risks and uncertainties. This information is not intended as specific investment, accounting, legal, or tax advice.

CONTENTS i EXECUTIVE SUMMARY Chapter 1 1 Introduction 3 Characteristics and Consequences of Population Aging 8 Importance of Wellness and Health Promotion for Seniors Chapter 2 11 Seniors Health Care Services Across the Continuum of Care 14 Primary Care 21 Home Care 28 Long-Term Care 39 Palliative Care 43 Federal Government Provisions to Special Seniors Groups: Veterans, First Nations, and RCMP Chapter 3 47 Key Challenges Affecting Seniors Health and Health Care Services 48 Lack of Timely and Equitable Access 54 The Growing Dementia Challenge 60 Restricted Funding to Support Seniors Growing Health Needs 67 Limited Senior-Friendly Mechanisms for Redress 70 The Current Federal Role in Key Health and Social Services for Seniors Chapter 4 74 Emerging Approaches in Canada and Beyond Chapter 5 80 Conclusion Appendix A 83 Bibliography

Acknowledgements This report was written by David Verbeeten and Philip Astles under the direction of Gabriela Prada. We would like to thank Louis Thériault and Dan Munro for internal review and John Abbott and Canadian Medical Association staff for external review. We would also like to thank the individuals from provincial governments and other organizations who kindly agreed to participate in the interviews for this project and provided their thoughts about seniors care in Canada, as well as relevant documents that informed this report. This report was made possible by the generous contribution of the Canadian Medical Association. The findings and conclusions of this report are entirely those of The Conference Board of Canada and do not necessarily reflect the views of the Canadian Medical Association. Any errors or omissions in fact or interpretation remain the sole responsibility of The Conference Board of Canada.

EXECUTIVE SUMMARY Understanding Health and Social Services for Seniors in Canada At a Glance Health care services in Canada will come under strain as the population continues to age and chronic and degenerative diseases become more common. Although there is a relatively comprehensive range of health services for seniors, there are many weaknesses in these services, including large discrepancies across the country, lack of coordination, restricted access to or narrow eligibility for programs or facilities, and lack of funding for prioritized services. All of these are resulting in unmet needs, stressed caregivers, and social inequities. Issues around seniors health and health care services are complex; successfully addressing these issues requires coordinated effort between federal, provincial, and territorial governments, as well as other key health care stakeholders and communities. Find this and other Conference Board research at www.e-library.ca

Understanding Health and Social Services for Seniors in Canada Population aging, in Canada and throughout the developed world, will affect economic growth and welfare-state sustainability. Health care services in particular will come under strain as the percentage of the population over the age of 65 grows. In 2015, only the first of the large cohort of baby boomers has passed this important threshold, and the movement of this demographic bulge through the system over the next few years will accentuate and accelerate many contemporary trends. These include increased frequency and intensity of use of hospitals, home care, long-term care, and palliative care facilities, along with decreased sources of revenue to fund this infrastructure. These trends are not in themselves insurmountable, but they will need to be addressed proactively to ensure that Canada can meet the needs of its oldest citizens while being fair to younger generations. Effective, well-designed services and programs are essential for Canada s future. The report presents the social and economic context of seniors health in Canada, including fiscal and demographic projections, as well as a discussion of the measures that exist to help seniors maintain good health on their own. Average per capita health care expenditure in Canada increases with every year of life after 65. Although increased health care spending is more closely correlated with the prevalence of chronic conditions than age, older people suffer from more chronic conditions than younger people and these ailments require treatment and ongoing management. More than three-quarters of seniors have at least one chronic condition. Find this and other Conference Board research at www.e-library.ca ii

Executive Summary The Conference Board of Canada Twenty per cent of seniors reported that no health care professionals had reviewed their medications in the last 12 months. As well, seniors suffer from a larger number of chronic diseases especially cardiovascular disease, cancer, diabetes, and respiratory disease than any other age group. Seniors also take more prescription drugs and over-the-counter medications than any other age group, with elevated risks of adverse side effects due to mixing of drug classes. Yet 20 per cent reported that no health care professional had reviewed their medications in the last 12 months. A lack of medication review can place seniors at risk of negative side effects from adverse interaction, jeopardizing their health and engendering downstream costs for other parts of health care systems. Addressing social determinants, such as adequate income and affordable housing, is fundamental to keeping seniors healthy and independent, and more resilient when facing illness and disability. Healthy diets, physical activity, and other healthpromoting choices are profoundly affected by the social determinants of health. Health promotion and education programs, as well as screening programs for cancer and chronic diseases, should be encouraged and well supported. Such programs must be designed to be accessible and inclusive of those most at risk of health and social issues. Appetite for and access to services in all these areas are discussed in this report. Among the many chronic conditions affecting seniors, the prevalence of dementia stands out as a particularly important issue. In 2011, almost 750,000 Canadians were living with dementia, and this is set to double by 2031 if nothing changes. The complexity of care required by dementia sufferers is already putting a strain on many areas of the care continuum, with increased demand for specialized care facilities and specialized training for staff. Many countries around the world experiencing similar trends have taken the significant action of producing a national dementia strategy in order to coordinate a response to this challenge. Canada has been slow in taking such a step. All jurisdictions in Canada purport to fund broad services along the continuum of care for elderly residents and all provide a broadly comparable set of core benefits to patients. Alberta stands out among its peers for its coverage of seniors care, which includes dental and vision Find this and other Conference Board research at www.e-library.ca iii

Understanding Health and Social Services for Seniors in Canada In 2012, it was reported that as many as 461,000 Canadian were not getting the home care they thought they required, while a further 331,000 reported receiving less home care than they needed. care. 1 However, in all jurisdictions, including Alberta, these services are typically uncoordinated and seniors usually have to pay user fees or have their incomes tested to qualify for some or most services. Contributions may differ from person to person, depending on capacity to pay, and they can be waived entirely where individuals demonstrate need or low-income status. But despite this, a recent survey found that cost of services is a barrier to accessing services for seniors. Variations in financial support across Canada represent a significant inequity in access to care. Apart from these cost considerations, other barriers to access also exist. Even when clients qualify for a program, access may be restricted by obstacles such as wait times and the administrative complexity involved in enrolment. For example, in 2012 it was reported that as many as 461,000 Canadians were not getting the home care they thought they required, while a further 331,000 reported receiving less home care than they needed. Meanwhile, those wishing to access a long-term care (LTC) facility face a waiting period that could range anywhere from 27 to over 230 days, depending on the province. These and other gaps are identified throughout this report. With the expected growth in demand in all areas of seniors care, appropriate funding to match capacity with demand is essential. Notably, we observed that even though experts were unanimous in their support for expanding home care, which is a less expensive setting for nursing and convalescence than hospitals, there has not been an increased allocation of funds to this sector over the last decade (as a proportion of overall health care expenditures). Assisted or supportive living arrangements may constitute a more appropriate option for many individuals, but most provinces are only now beginning to focus on building them out. Another area of care seeing a deficit in availability is palliative care delivered in either the patient s home or in a hospice environment. It has been reported that as few as 16 per cent of 1 This statement holds true at the time of publication. Structural reform and curtailment of the continuum of care in Alberta cannot be ruled out as a result of economic change. Find this and other Conference Board research at www.e-library.ca iv

Executive Summary The Conference Board of Canada Canadians requiring palliative care actually receive it, many of them seniors. These imbalances in supply and demand between areas along the care continuum need to be addressed properly. Seniors care in Canada has room for improvement. Some other developed countries, including Sweden, Denmark, and the United Kingdom, which act as comparators throughout this report, do at times organize their provision in different ways and can point in some instances to better performance and coverage. Canada can learn from these and other countries, even as we can acknowledge that it has faced and will continue to face some unique complexity in serving a diverse population over an immense geography. The complex and interconnected challenges facing seniors and seniors care in Canada will require national action from federal, provincial, and territorial governments, as well as other key stakeholders and communities. Only by working together and in sync, will Canada be able to improve health care services for seniors, enhance the quality of life of seniors and their families, and reduce the unfair health disparities that exist among seniors across Canada. Find this and other Conference Board research at www.e-library.ca v

CHAPTER 1 Introduction Chapter Summary Canada s aging population is placing increased demands on health care and related social services just as revenues to fund them are set to shrink. Many seniors live with one or more chronic diseases. To reduce the burden of these on individuals and health services, programs that promote wellness and effective disease management should be encouraged and sustained. Such programs should recognize the importance of disease prevention and health promotion, health and social services, and the social determinants of health in ultimately determining health outcomes. Find this and other Conference Board research at www.e-library.ca

Understanding Health and Social Services for Seniors in Canada Canada is aging. The ongoing demographic transition toward an older population characterizes all developed countries to one degree or another. It presents them with a common set of challenges in relation to economic growth and welfare-state sustainability. Just as demand for services is expected to grow, especially in health care and related areas, the revenues for their provision are expected to shrink as slower labour force growth reduces Canada s economic potential. These trends will likely accelerate as the very large cohort of baby boomers moves into retirement. Although the challenges are not insurmountable, steps must be taken to ensure system readiness and viability. Canada can mitigate some of the expected costs and pressures of population aging through effective, well-designed programs that meet the evolving needs of its oldest citizens. 1 By providing readers with a better understanding of the current state of seniors health and the various arrangements for seniors care in Canada in early 2015, this report is a step on the path toward better preparedness. It will inform the work of the Canadian Medical Association on development of a national seniors strategy. Findings are based on research conducted by The Conference Board of Canada in the autumn of 2014, including government reports, peer-reviewed literature, customized data from Statistics Canada, and over a dozen interviews with heads of government departments and health care associations in eight provinces from every region of the country. 1 Chappell and Hollander, An Evidence-Based Policy Prescription, 8 15. Find this and other Conference Board research at www.e-library.ca 2

Chapter 1 The Conference Board of Canada In absolute terms, the number of seniors will double between 2009 and 2036, from around 5 million to over 10 million, much faster than the projected rate of overall population growth. This report first establishes the social and economic context of seniors health in Canada, including projections of demographic trends and fiscal pressures. It identifies measures for wellness and health promotion that are or can be implemented to help individuals remain independent for as long as possible. It then looks at the basket of services presently available to seniors throughout the provinces and territories of Canada, including wellness and disease prevention, primary care, home care, long-term care, and palliative care. Challenges to seniors care programs, such as irregular or difficult access, a rising incidence of dementia, fiscal constraints, limited seniors-friendly redress mechanisms, and current federal capacity or functions, are also explored. Finally, the report presents good practices and emerging approaches, from both Canada and other countries, that are improving the provision of and satisfaction with seniors care among clients and their families. Characteristics and Consequences of Population Aging The first members of the baby-boom generation turned 65 in 2011. In that year, nearly 15 per cent of Canadians were 65 years and over. Under a medium-growth scenario, seniors are projected to make up around a quarter of all Canadians by the middle of the century, with most of the increase occurring by the early 2030s. By contrast, only 8 per cent of Canadians were 65 years and older in 1971. 2 In absolute terms, the number of seniors will double between 2009 and 2036, from around 5 million to over 10 million, much faster than the projected rate of overall population growth, which is from around 34 million to 44 million. 3 Atlantic Canada is now, and will most likely remain, the greyest part of the country over the next several decades. 4 (See Chart 1.) Smaller cities and rural areas are experiencing faster demographic change than major urban centres. 2 Employment and Social Development Canada, Canadians in Context. 3 Statistics Canada, Population Projections for Canada, 46, 55. 4 The out-migration of younger residents to other provinces is compounding the demographic trend in Atlantic Canada. Find this and other Conference Board research at www.e-library.ca 3

Understanding Health and Social Services for Seniors in Canada Chart 1 Population 65 Years and Over, Percentage by Region, 2011 and Projected for 2036 (per cent) Nun. N.W.T. Y.T. B.C. Alta. Sask. Man. Ont. Que. N.B. N.S. P.E.I. N.L. Canada Proportion in 2011 Increase by 2036 0 5 10 15 20 25 30 35 Source: HRSDC, www4.hrsdc.gc.ca/.3ndic.1t.4r@-eng.jsp?iid=33. Canada has yet to experience the impact of the bulge of baby boomers as it passes 65. As such, even though population aging until now has been only a small part of average annual growth in public health care spending, 5 and even though many seniors are living longer and more engaged lives than ever before, the baby boomers will accentuate and accelerate the pressures on the health care and other services. Seniors already account for around 45 per cent of provincial and territorial health care payments. 6 They are also the most frequent and intense users of many parts of the health care system. Seniors accounted for 40 per cent of acute hospital stays in 2009 10, where they tended to stay longer, to consume more resources for the same procedures, and to rely on more services (inpatient mental health, inpatient complex continuing care, inpatient rehabilitation, outpatient, and emergency). 7 5 Canadian Institute for Health Information (CIHI), Health Care Cost Drivers, 12 13. 6 CIHI, National Health Expenditure Trends, 77. 7 CIHI, Health Care in Canada, 2011, 28. Find this and other Conference Board research at www.e-library.ca 4

Chapter 1 The Conference Board of Canada Because the working-age population will shrink in the coming years, Canada will face a declining tax base by 2030, and thus less revenue to fund the staterun services and programs on which seniors rely. Average per capita health care expenditure in Canada increases every year of life after 65. (See Chart 2.) Although increased health care spending is more closely correlated with the prevalence of chronic conditions than with age, older people suffer from more chronic conditions than younger people, and these ailments require treatment and ongoing management. 8 And, seniors suffer from a greater number of chronic diseases especially cardiovascular disease, cancer, diabetes, and respiratory disease than any other age group. Over three-quarters of seniors have at least one chronic condition. 9 Seniors also take more prescription drugs and over-the-counter medications than any other age group, with elevated risks of adverse side effects due to the mixing of drug classes. In 2009, more than half of seniors on public drug programs in six provinces were using five or more drug classes. 10 Indirectly, aging also affects the health care system. The proportion of those who are working age (15 to 64) in the total population will shrink in the coming years. But, the tax base from which health care and other services receive funding will also shrink. With the labour force contracting and the employment rate falling, by 2030 the number of working-age Canadians for every senior is projected to drop to 2.7 from about 5 in 2010. While immigration and increased fertility could slow this trajectory, and improvements in technology and productivity could mitigate some of the consequences, Canada will nevertheless face a declining tax base and thus less revenue to fund the state-run services and programs on which seniors so heavily rely. 11 In addition to health care services, seniors are entitled to federal Old Age Security (OAS) and the Guaranteed Income Supplement (GIS), and most provinces offer a top-up to these forms of assistance. 12 All provinces provide some kind of aid to seniors for their housing needs, whether 8 CIHI, Seniors and the Health Care System, 5. 9 Smith, Chronic Diseases Related, 2. 10 CIHI, Seniors and Prescription Drug Use. 11 Department of Finance Canada, Economic and Fiscal Implications. 12 Quebec and P.E.I. do not seem to offer any top-up. Nova Scotia offers a tax refund for seniors who receive GIS yet pay provincial income tax. Find this and other Conference Board research at www.e-library.ca 5

Understanding Health and Social Services for Seniors in Canada Chart 2 Estimate of Annual Total Government Health Expenditure Per Capita, by Age, Canada, 2012 (current dollars) <1 1 4 5 9 10 14 15 19 20 24 25 29 30 34 35 39 40 44 45 49 50 54 55 59 60 64 65 69 70 74 75 79 80 84 85 89 90+ Total 0 5,000 10,000 15,000 20,000 25,000 30,000 Source: Canadian Institute for Health Information, National Health Expenditure Trends, 1975 to 2014, 171. public accommodation, rent subsidy, property tax deferral, or grants to retrofit homes for aging and disability. Notably, British Columbia has Shelter Aid for Elderly Renters (SAFER), which provides a rent subsidy of $900 per month, with eligibility differing slightly between Vancouver and other, less expensive parts of the province. Quebec has the Home Adaptation for Senior Citizens program, which offers up to $16,000 for disabled people or those coping with a loss of independence. Find this and other Conference Board research at www.e-library.ca 6

Chapter 1 The Conference Board of Canada All Canadians are entitled to a variety of health-related services when they turn 65, but coverage varies by province and may involve modest fees or incometesting. In 2010, the median benefit amount that the federal and provincial governments gave to non-senior families was $4,000, compared with $25,300 for senior families. 13 In 2011, over 40 per cent of the total income of the senior population came from government sources. 14 In part, because of these transfers, fewer seniors than children or workingage people are low-income or fall below low-income cut-offs, and they tend to be wealthier on average in assets. The Canadian poverty rate among seniors is lower than in most OECD countries, but it has risen somewhat in the last few years, reaching 6.7 per cent in the late 2000s. 15 Generally, studies show that socio-economically disadvantaged seniors have poorer health status than their wealthier and more educated counterparts, although this effect lessens with increasing age. 16 All Canadians are entitled to a broad basket of health-related services when they turn 65, but coverage varies by province and may involve modest fees or income-testing. Some of the services are available to residents of all age groups as a matter of course, although they are all utilized most extensively, and sometimes almost exclusively, by seniors. In 2009 10, seniors accounted for 95 per cent of people in residential or long-term care (LTC), 85 per cent of those in hospitalbased continuing care, and 82 per cent of clients of home care services. In 2009, provincial and territorial governments spent, on prescription drugs, an average of $170 per adult aged 24 to 64, yet $1,311 per senior. In the same year, the share of seniors who visited a family physician 10 times a year or more was almost double that of working-age adults (9.7 versus 5.5 per cent). 17 13 Statistics Canada, Income in Canada. 14 Statistics Canada, Income Composition in Canada, 11. 15 The Conference Board of Canada, How Canada Performs: Elderly Poverty. 16 CIHI, Health Care in Canada, 2011, 16. 17 Ibid., 34. Find this and other Conference Board research at www.e-library.ca 7

Understanding Health and Social Services for Seniors in Canada Identifying and implementing measures for wellness and health promotion is an essential component of an approach to help individuals remain healthy and independent for as long as possible. As the foregoing strongly suggests, the accelerated pace of aging in Canada will likely strain the country s health care systems as well as its related social services. Seniors tend to require, and to be eligible for, more help from the state than most other population groups. As the gap in income and earning power between generations widens and sovereign debts continue to mount both to the detriment of the young policy-makers will need to strike a fine balance to ensure that efficient and cost-effective programs are in place to address the demands of its aging population without jeopardizing the livelihoods and contributions of younger generations. 18 Importance of Wellness and Health Promotion for Seniors Identifying and implementing measures for wellness and health promotion is an essential component of an approach to help individuals remain healthy and independent for as long as possible. Investment in such measures throughout the lifespan is essential to maintain and improve quality of life and reduce demands on the health care system. Addressing the social determinants of health, such as adequate income and affordable housing, is fundamental to keeping seniors healthy and independent, and more resilient when facing illness and disability. The main causes of death for seniors are circulatory and respiratory diseases and cancers. Most seniors live with at least one chronic condition. 19 Healthy diets, physical activity, and other health-promoting choices are profoundly affected by the social determinants of health. Programs that encourage exercise and provide education about nutrition can boost well-being among elderly citizens, and must be designed to be accessible and inclusive of those most at risk of health and social issues. Such programs are often available through municipal recreational centres across Canada. Team-based models of primary care across the 18 Gill, Knowles, and Stewart-Patterson, The Bucks Stop Here. 19 Public Health Agency of Canada (PHAC), The Chief Public Health, 28 29. Find this and other Conference Board research at www.e-library.ca 8

Chapter 1 The Conference Board of Canada Keeping seniors socially connected is an integral part of healthy aging. Social support helps to slow cognitive decline, the onset of dementia, and the progression of physical disabilities. country, including community health centres, offer similar programs. In Ontario, for example, many family health teams offer programs to keep seniors well, including aging at home, falls prevention, and meditation. Falls among seniors are the leading cause of injury hospitalization across Canada. 20 Prevention of falls can be achieved through initiatives that focus on addressing risk factors, such as exercise programs to improve balance and strength, appropriate use of assistive devices, and drug management practices. Given the economic importance of keeping seniors well and healthy, these health promotion programs, as well as screening programs for cancer and chronic diseases, should be encouraged and well supported. Informing seniors of these options should improve rates of engagement. Keeping seniors socially connected is an integral part of healthy aging. Social support helps to slow cognitive decline, the onset of dementia, and the progression of physical disabilities. It has a positive effect on longevity. But social interaction among seniors requires public and private spaces that facilitate engagement. The World Health Organization s initiative for age-friendly communities recommends that policy-makers and urban planners consider the needs of an aging population when designing neighbourhoods. 21 (See Facets of an Age-Friendly Community. ) The recommended features of such a community all help seniors come together and make the most of their surroundings. Seniors with physical or mental health issues particularly need supportive housing, accessible transportation, and programs and services that promote the sense of community. 20 CIHI, Seniors and Falls. 21 World Health Organization, Global Age-Friendly Cities. Find this and other Conference Board research at www.e-library.ca 9

Understanding Health and Social Services for Seniors in Canada Facets of an Age-Friendly Community green spaces resting spots age-friendly pavements safe pedestrian crossings walkways cycle paths adequate public washrooms wide doors accessibility ramps As seniors become more dependent or deal with illness and disabilities, Canada s provinces and territories offer a range of products and services that can help seniors cope. Public subsidy of long-term care, home care, palliative care, and pharmacare exists in all jurisdictions, albeit in different combinations, and under different rules. Find this and other Conference Board research at www.e-library.ca 10

CHAPTER 2 Seniors Health Care Services Across the Continuum of Care Chapter Summary Beyond primary and acute care, other health care services such as pharmacare, home care, long-term care, and palliative care are fully or partially covered through provincial health insurance, although discrepancies in these services are wide across Canada and the services are patchy and uncoordinated. Coverage for dental and vision care is generally less available. Access to primary health care has improved, but access issues in home care leave many seniors without the care they feel they require. This adds to the enormous strain on informal caregivers, who require extra support. Coverage and eligibility for long-term care is varied and complex. Capacity issues in the sector are reflected in wait times for placement and contribute to inappropriate use of acute care beds. Few of those seniors who require palliative care actually receive it, and those who do often experience a patchwork of uncoordinated services. Find this and other Conference Board research at www.e-library.ca

Understanding Health and Social Services for Seniors in Canada This section presents an overview of the health care services across the continuum of care available to seniors in all provinces and territories. Long-term care (LTC), home care, palliative care, and pharmacare are available to all seniors without cost or for a co-payment fee that is calculated in several ways. Dental and vision care are less likely to be available within provincial and territorial programs. (See Table 1.) Among provinces, Alberta stands out for its more comprehensive coverage of dental and vision care. It is one of only four jurisdictions and the only province in Canada that have public oral health care services for seniors (the others being Yukon, Northwest Territories, and Nunavut). This may explain why, in 2014, 15 per cent of Canadian seniors did not receive the dental care they needed because of cost. 1 Low- to moderate-income seniors in Alberta can qualify for a maximum of $5,000 for eligible dental procedures every five years, including examinations and X-rays, polishing and scaling, fillings and pain control, extractions, root canals, and dentures. Seniors in the province can qualify for optometric visits and up to $230 every three years for prescription eyeglasses. 2 Alberta also covers some clinical psychology ($60 per visit up to $300 per family per year), private home care (up to $200 per family per year), and chiropractics ($25 per visit up to $200 per patient per year). 3 By contrast, Newfoundland helps those on assistance receive dental examinations and routine fillings and extractions every three years and helps them pay for dentures every eight years. 4 A few provinces cover one eye examination and follow-up every year or two. 1 CIHI, How Canada Compares. 2 Alberta Seniors, Dental and Optical Assistance. 3 Alberta Health, Coverage for Seniors Benefit. 4 Department of Health and Community Services, Dental Services. Find this and other Conference Board research at www.e-library.ca 12

Chapter 2 The Conference Board of Canada Table 1 Coverage of Health Care Services for Seniors in Canada, by Province, 2014 LTC 1 Home 1 Palliative 2 Pharma Dental 3 Vision B.C. Income Income Yes 4 Income None Partial Alta. Fee Yes Yes 5 Fee Income 6 Income 6 Sask. Income Fee Yes Income None Limited Man. Income Yes 7 Yes Income None Partial Ont. Fee Yes Yes Income None None Que. Fee Fee Yes Income None Partial N.B. Fee Income Yes Income None None P.E.I. Fee Yes Yes Fee None None N.S. Fee Fee Yes Income None 8 Partial N.L. Fee 9 Yes Yes Income Limited None Nun. Yes Yes Yes Yes Partial Partial N.W.T. Fee Yes Yes Yes Yes Partial Y.T. Fee Yes Yes Yes Partial Partial Definitions Income: Income-tested. Fee: Set charges for service with reduction on request and by assessment of need. Income supports are often available to assist with these fees. Yes: Coverage for those who qualify, even as eligibility may be narrow and provision restricted. None: No coverage by public health insurance. Limited: Minor coverage for individuals on social benefits only. Partial: Universal yet partial coverage for seniors, typically one eye examination every 12 24 months. 1 LTC costs include those for accommodation, and home care is defined here to include basic housekeeping. Seniors enrolled in home care can also receive extended therapies such as physiotherapy and occupational therapy. Coverage is based on a client s assessed needs and availability of services, which vary by province. 2 For the last month of life. The caveat about home care applies to palliative care. 3 For procedures, products, or services outside of hospitals. 4 Fees may apply if residential hospice care is required as part of end-of-life treatment. 5 Exceptions include infusion supplies and equipment. 6 Provided through Alberta Blue Cross on behalf of the province. 7 In rural areas outside Winnipeg, there may be charges for basic housekeeping. 8 Some coverage is available through the Department of Community Services for individuals receiving employment support and/or income assistance. 9 Liquid, but not illiquid, assets may be taken into consideration when assessing capacity to pay. Source: The Conference Board of Canada. Find this and other Conference Board research at www.e-library.ca 13

Understanding Health and Social Services for Seniors in Canada Primary care is an integrated and comprehensive system of care that includes health promotion; illness and injury prevention; first contact and triage services; and the diagnosis and management of emergency, acute, and chronic health concerns. A common refrain in our interviews with stakeholders was that the basket of services for seniors was only as good as the ability of individuals to access them. Lack of knowledge about programs or complexity of administration can be serious impediments. As behavioural economists have observed, even very minor frictions can stop people from doing what they want or what is best for them. 5 In the case of seniors care, the frictions are hardly minor, especially for elderly adults facing challenges such as dementia or computer illiteracy. As an example, Nova Scotia s Supportive Care Program will provide $500 per month to eligible seniors with cognitive impairments, through direct deposit, for home support services such as personal care, respite, meal preparation, and domestic chores. The program will also reimburse snow removal up to $495 per year. 6 Eligibility for the program is based on income. Nonetheless, there are fewer than 300 people enrolled in this program, in part due to lack of awareness or perceived complexity in registration. The clients substitute decision-makers may also be dissuaded by the high level of responsibility and accountability to which they are held for management of funds. The following sections provide an overview of the services available for seniors across key health care system areas: primary care, home care, long-term care, and palliative care. Primary Care Primary care is not a defined program, but rather an integrated and comprehensive system of care that includes health promotion; illness and injury prevention; first contact and triage services; and the diagnosis and management of emergency, acute, and chronic health concerns. 7 Primary care providers can help seniors navigate the continuum of care and overcome some of the bureaucratic hurdles. Family physicians are the most common point of first contact for seniors with health care 5 Thaler and Sunstein, Nudge, 6 14. 6 Nova Scotia, Continuing Care. 7 The Conference Board of Canada, Final Report: An External Evaluation of FHTs, 1. Find this and other Conference Board research at www.e-library.ca 14

Chapter 2 The Conference Board of Canada and related needs, and often act as gatekeepers to more specialized services, including home care and long-term care. What is more, primary care providers can make sure that seniors are not just receiving treatment for what ails them, but are aware of and follow wellness and health promotion practices that enhance their independence. An effective primary care system is crucial for keeping seniors out of hospitals. 8 Seniors are more likely than other Canadians to have a family physician. In 2013, 95 per cent of seniors reported having a regular medical doctor, compared with only 82 per cent (on average) of non-senior adults. 9 As noted above, seniors are also almost twice as likely as others to visit their medical doctor more than 10 times in a year. However, having a family physician does not guarantee timely access to primary care services. According to The Commonwealth Fund, Canada ranks last or near-to-last on most measures of timeliness of care and this performance has not improved since 2010. Fewer than half of Canadians reported same- or next-day access to a doctor or nurse; or evening, weekend, or holiday access. Over one-third of Canadian seniors (37 per cent) reported that they had been to an emergency department for a condition that could have been treated by their doctor. Of all emergency department visits, it is estimated that 20 per cent could be handled elsewhere. 10 In the past two years, 11 almost a third of seniors had to wait two months or more to see a specialist. Ontario has seen some successes in improving wait times through its family health team initiative. However, challenges still persist across the country, particularly in some areas where critical shortages of health care providers exist. For example, a shortage of geriatricians has been reported in Canada. 12 8 Drummond, Therapy or Surgery? 10. 9 Statistics Canada, CANSIM table 105-0501. 10 CIHI, How Canada Compares. 11 Davis and others, 2014 Update, 20 21. See also CIHI, How Canada Compares. 12 Heckman, Molnar, and Lee, Geriatric Medicine Leadership. Find this and other Conference Board research at www.e-library.ca 15

Understanding Health and Social Services for Seniors in Canada Chronic diseases, rather than age, are the main socio-economic burden on health care systems; therefore, gaps in assessment and care represent a considerable oversight. In relation to disease management, which is essential to avoid costly complications, there is also room for improvement. For example, in 2009, one-third of seniors failed to get their influenza vaccination or have an eye exam, and half of those with diabetes failed to receive a foot examination. Many seniors also feel that they do not get sufficient advice on body weight maintenance. 13 As chronic diseases, rather than age per se, are the main socio-economic burden on health care systems, such gaps in assessment and care represent a considerable oversight. Indeed, almost a quarter of Canadian seniors in 2014 with at least one chronic condition did not have a daily treatment plan. Although this rate is fairly good by international standards ranking better than most European countries, but trailing the U.S. and Australia it could be boosted through primary care intervention. 14 Given the presence of chronic conditions, seniors are more likely to take more prescription and over-the-counter drugs than younger people, and the management of these medications typically occurs at the primary care level. More than half of seniors claim to take five or more drugs from different drug classes, and 20 per cent reported that no health care professional had reviewed their medications in the last 12 months. 15 A lack of medication review can place seniors at risk of negative side effects from adverse interaction, which can jeopardize seniors health and engender downstream costs for other parts of health care systems. Indeed, between 2006 07 and 2010 11 there were almost 140,000 hospitalizations for adverse drug reactions among seniors in Canada. 16 Some integrated models enhance the quality of primary health care services for seniors, improve health outcomes, and lower costs. Winnipeg s geriatric program assessment teams (GPATs) are a good example. Implemented in 1999, this program has specially trained staff 13 CIHI, Seniors and the Health Care System, 2, 11. 14 The Commonwealth Fund, 2014 Commonwealth Fund International Health Policy Survey of Older Adults in Eleven Countries. 15 CIHI, How Canada Compares. 16 Ibid. Find this and other Conference Board research at www.e-library.ca 16

Chapter 2 The Conference Board of Canada visit seniors in their homes to check on their health and well-being. Following an assessment, a clinician can file a report recommending support from groups such as home care, day hospital or Meals on Wheels. 17 The program has saved on costs and improved quality of care, including by lowering rates of medication overuse, according to Accreditation Canada. 18 Winnipeg also implemented PRIME in 2009, whereby seniors deemed in need receive a case manager for weekly health monitoring at home, with after-hours support, education, exercise and therapy, counselling, and personal care also provided. Some of PRIME s extended services are subject to income-testing. 19 PRIME is meant to keep seniors out of hospitals and other expensive facilities. Referrals to the program are accepted from family physicians, the home care program, hospitals, or other health care professionals involved with the participant. Pharmacare Benefits Residents of every province and territory in Canada become eligible for pharmacare when they turn 65. Most seniors qualify for at least some assistance to cover the costs of pharmaceuticals, even when their incomes are quite high. (See Pharmacare for Seniors, by Province, 2014. ) Despite this, 7 per cent of Canadian seniors reported skipping medication or not filling a prescription because of the cost. This leaves Canada ranking 10th out of 11 countries surveyed on this measure by The Commonwealth Fund. 20 17 Winnipeg Health Region, What Is GPAT? 18 Accreditation Canada, Geriatric Program Assessment Teams. 19 Winnipeg Health Region, Is PRIME Right for You? 20 Ibid. Find this and other Conference Board research at www.e-library.ca 17

Understanding Health and Social Services for Seniors in Canada Pharmacare for Seniors, by Province, 2014 British Columbia Fair PharmaCare is open to all residents, and enhanced assistance is available for those born before 1939. PharmaCare pays 70 per cent of prescription costs after deductible. If you make less than $15,000, there is no deductible; less than $30,000, the deductible is equal to 2 per cent of income; and over $30,000, 3 per cent of income. For those born before 1939, PharmaCare pays 75 per cent of prescription costs after deductible, with no deductible for those earning less than $33,000, and a deductible equal to 2 per cent of income for those earning less than $50,000 and of 3 per cent of income for those earning more than $50,000. Alberta Alberta Blue Cross Coverage for Seniors is provided premium free by the government. Seniors pay 30 per cent of listed drugs up to $25, and Alberta Blue Cross pays the rest. Saskatchewan The Seniors Drug Plan covers prescription costs above $20 for all seniors with net incomes of less than $75,480 in 2010. Manitoba Pharmacare pays 100 per cent of prescription costs for all residents once a deductible is met. The deductible rate is progressive, ranging from 2.91 per cent of family income for those making less than $15,000 to 6.6 per cent for those making more than $100,000, with intermediate rates in between. Ontario The Ontario Drug Benefit (ODB) Program charges $2 for each prescription for individual seniors making less than $16,018 or couples making less than $24,175. For those making more than these amounts, a yearly deductible of $100 is charged, plus up to $6.11 each time a prescription is filled. Find this and other Conference Board research at www.e-library.ca 18

Chapter 2 The Conference Board of Canada Quebec All citizens must have prescription drug insurance. At 65, all citizens are automatically registered for the Public Prescription Drug Insurance Plan, but can choose to opt out for private coverage. In the public plan, seniors who receive between 93 and 100 per cent of the GIS get drugs free of charge. For those who receive no GIS, a monthly deductible is set at $16.65 and co-insurance at 32.5 per cent, with total monthly contributions capped at $83.83. For those who receive between 1 and 93 per cent of GIS, the monthly deductible and co-insurance are the same as for no GIS, but the maximum monthly contribution is set at $51.16. (Co-insurance is calculated as a percentage of the prescription cost minus the deductible.) New Brunswick The New Brunswick Prescription Drug Program (NBPDP) is available to low-income seniors, administered by Medavie Blue Cross. Under this plan, individuals on GIS pay $9.05 for each prescription up to a maximum of $500 in one calendar year. Other beneficiaries pay $15 per prescription, with no yearly maximum, if they are a single person making $17,198 or less; a seniors couple making $26,955 or less; or a couple with one non-senior making $32,390 or less. Prince Edward Island All seniors pay only the first $8.25 of each prescription as well as the professional fee. Nova Scotia The Seniors Pharmacare Program is open to all seniors without other sources of coverage. All seniors pay co-payments of 30 per cent of the total cost of each prescription, up to an annual maximum of $382. Premiums may be waived for single seniors making less than $18,000 annual income or married seniors at less than $21,000. They may be reduced for single seniors making less than $24,000 and married seniors at less than $28,000. Seniors who receive the GIS do not pay a premium. The maximum annual premium seniors would pay is $424. Seniors can claim these expenses on their income tax. Find this and other Conference Board research at www.e-library.ca 19

Understanding Health and Social Services for Seniors in Canada Newfoundland and Labrador The Newfoundland and Labrador Prescription Drug Program (NLPDP) offers the 65 Plus Plan, which covers all seniors who receive OAS and GIS. These seniors pay only the dispensing fee up to $6. The NLPDP also offers the Access Plan, which covers all low-income individuals and families as follows: single individuals making less than $27,151; couples making less than $30,009; and families making less than $42,870. Qualifying applicants to the Access Plan pay a co-payment of between 20 and 70 per cent of each prescription cost. Nunavut The Extended Health Benefits (EHB) program covers the full cost of prescription drugs for residents 65 and over who have no other insurance. The Drug Benefit List is defined by Health Canada s Non-Insured Health Benefits Program (NIHB), which is set up for First Nations and Métis. Northwest Territories The Extended Health Benefits program provides non-native and Métis residents over 60 with full coverage for prescription drugs on the Drug Benefit List of the NIHB Program. Yukon Pharmacare and Extended Benefits are available to residents who are 65 and older and to their spouses if they are 60 and over. Pharmacare pays the total cost of the lowest-priced generic prescription drugs listed in the Yukon Formulary. Source: The Conference Board of Canada, drawing upon government websites and interviews. Despite the differences across Canada, provincial and territorial practices in this area are in line with those of developed countries. However, drugs prescribed at hospitals in some leading countries are free of charge, while drugs outside of hospital are subject to co-payments (often waived for seniors), or there are caps in the annual fees that seniors pay. In the U.K., outpatient drugs are usually subject to a co-payment of Find this and other Conference Board research at www.e-library.ca 20

Chapter 2 The Conference Board of Canada Keeping seniors, who are not demented or critically ill, in the community is one of the most costeffective ways for health care systems to deal with the needs of elderly patients. US$12.62 per prescription, but people over 60 years old are exempted. 21 In Sweden, reimbursement of drug costs begins when costs exceed US$169, with a gradual increase to 100 per cent as costs rise. There is a cap of US$339 on the amount that an individual pays annually, although co-payments on some drugs are not capped. 22 Denmark s system is similar, with reimbursement starting when costs exceed US$135 and increasing up to 85 per cent for payments over US$475. Chronically ill patients with very high drug use can apply for a full reimbursement for any costs over US$554. Pensioners can apply to their municipalities for further financial assistance. 23 Home Care Keeping seniors in the community is one of the most cost-effective ways for health care systems to deal with the needs of elderly patients who are not fully demented or critically ill. The relatively high cost of care in acute settings has made it a policy priority to expand the use of other care settings and cut down on inappropriate use of acute care. Beds in LTC facilities are also more expensive than home care. In 2011, Home Care Ontario estimated the per diem cost of care at home in Ontario at $42, of a long-term care bed at $126, and of a hospital bed at $842. 24 The difference in care costs has prompted a shift from acute to home care to reduce health care expenditures in recent years. In addition to the potential savings from home care, the vast majority of seniors around 9 out of 10 do live in a home setting and want to live there for as long as possible. Provincial representatives interviewed for this study emphasized the importance that their respective governments, departments, or associations place on the function of home care within the context of population aging. 21 Jones, Continuing Healthcare. 22 The Commonwealth Fund, International Profiles of Health Care Systems, 2013. 23 Olejaz and others, Denmark. 24 These prices are likely higher now, given inflation. Find this and other Conference Board research at www.e-library.ca 21

Understanding Health and Social Services for Seniors in Canada Even when fees for home care are not a barrier, the hours that are available to clients tend to be restricted and may be reduced upon reassessment. Home care is divided between nursing services and personal care services. Nursing services, which can include convalescence, rehabilitation, physiotherapy, occupational therapy, and speech therapy, are typically provided free of charge. Some provinces require incometesting or levy a fee for the use of personal care services such as meal preparation, bathing, and laundry. Charges for personal care services are subsidized, typically ranging from $2 to $12 per hour, often depending on income, and many seniors do not have to pay the full amount of such charges or anything at all. 25 Some clients may also be enrolled in self-management programs, whereby they receive direct state funding to purchase private services. These programs tend to involve small numbers of consumers, not least because access to information about them is difficult. 26 Even when fees for home care are not a barrier, the hours that are available to clients tend to be restricted and to be subject to reduction upon reassessment. A recent EKOS survey on home and residential care, carried out for The Conference Board of Canada, indicated that the majority of those who could recall the number of home care hours in a typical week for themselves or their dependents had received less than five hours of each kind of service available. (See Chart 3.) The same survey revealed that almost half of respondents felt that there had been times in the last 12 months when they could have used additional help, and almost one-tenth of respondents were unable to receive any public home care services when they felt that they required them. 27 Home care costs in Denmark, Sweden, and the U.K. are covered in very different ways. The Swedish system is the most similar to Canada in that personal care is arranged for the senior and is subject to a co-payment. This is up to a maximum of US$274 per month in Sweden. 28 In Denmark permanent home care is completely paid for by municipalities. It is 25 Sun Life Financial, What Does Long-Term Care. 26 Spalding, Watkins, and Williams, Self Managed Care Programs in Canada, 26. 27 Dowdall, Feeling at Home? A Survey of Canadians on Home and Community Care. 28 The Commonwealth Fund, International Profiles of Health Care Systems, 2013. Find this and other Conference Board research at www.e-library.ca 22

Chapter 2 The Conference Board of Canada Chart 3 Service Received, Hours per Week, 2014 (share of responsdents, per cent) None 1 5 6 > Don t Know/No Response Pharmacy counselling (n = 96) Nutritional counselling (n = 78) Respiratory care (n = 75) Medical supplies and equipment (n = 247) Transportation (n = 150) Rehabilitation care (n = 223) Community supports (n = 115) Home care nursing (n = 251) Homemaking (n = 274) Personal care (n = 324) 0 10 20 30 40 50 60 70 80 90 100 Sources: Dowdall, Feeling at Home? needs-based and the services offered are dependent on assessment of the needs. 29 In the U.K., seniors can receive an attendance allowance for personal care. This is tax-free and not means-tested. How it is spent is at the complete discretion of the senior. 30 Support for Informal Caregivers The majority of home care in Canada is actually provided informally by unpaid family, friends, and neighbours. The Conference Board of Canada estimates that unpaid caregivers provided 10 times the number of paid hours in home care in 2007 around 1.5 billion hours from nearly 3.1 million people. Given that the same source estimates total public spending on home and community care in 2010 to have been between $8.9 billion and $10.5 billion, and private spending between $1.87 billion and $1.89 billion, the hidden economic value of informal caregivers is 29 The Commonwealth Fund, International Profiles of Health Care Systems, 2013. 30 Age UK, Attendance Allowance. Find this and other Conference Board research at www.e-library.ca 23

Understanding Health and Social Services for Seniors in Canada enormous. 31 As we heard from several interviewees, governments fear breaking the bank by monetizing these relationships. Some research ominously suggests that volunteer relationships, once monetized, cannot be easily de-monetized. 32 It may not be surprising then that most provinces offer fairly limited supports for caregivers. (See Table 2.) Only Manitoba has caregiverspecific legislation; and only Nova Scotia gives direct grants of $400 per month to eligible caregivers (but only 1,700 people are presently receiving this support). Tax credits are offered by all provinces as well as the federal government for caregivers. Further, all provinces mandate compassionate care leave of between 8 and 12 weeks, whereby employees are entitled to unpaid time off without risk of termination. (Alberta implemented such a policy only in February 2014.) Caregivers can apply to Service Canada for up to six weeks of compassionate care benefits (a form of employment insurance) during this time. 33 In recognition of the burden that caregivers must often bear, and that up to a third of Canadian caregivers report distress in their role, provincial health care systems provide respite services. 34 In this way, caregivers can place dependents in short-term beds within established public care facilities. This temporary relief from their duties allows caregivers to maintain peace of mind and to avoid recourse to permanent institutionalization for their dependents. Nonetheless, The Conference Board of Canada heard from several interviewees that administrative inconvenience in conjunction with inflexible schedules at long-term care facilities can mean that many caregivers do not always avail themselves of respite services. 35 Many experts feel that more services of this nature are needed. 31 Hermus and others, Home and Community Care in Canada, 17, 20 21. 32 Gneezy and Rustichini, A Fine Is a Price. 33 Service Canada, Employment Insurance Compassionate Care Benefits. 34 CIHI, Health Care in Canada, 2011, 77. 35 Inflexibility refers to the need to book beds well in advance, even though long-term determination of need is often not easily planned, and to book spots in week-long blocks rather than for a given day. Find this and other Conference Board research at www.e-library.ca 24

Chapter 2 The Conference Board of Canada Table 2 Supports for Caregivers, by Province, 2014 Compassionate care leave (weeks) Respite Grant for family caregiver Caregiver-specific legislation Tax credit 1 B.C. 8 $4,530 at net income threshold of $14,717 Alta. 8 2 $10,544 at net income threshold of $16,763 Sask. 12 $9,214 at net income threshold of $15,736 Man. 8 Bill 42 The Caregiver Recognition Act (June 2011) $3,605 at net income threshold of $12,312. Also available is the Manitoba Primary Caregiver Tax Credit. This is a refundable credit of up to $1,275 to those who are the primary caregiver for a spouse, neighbour, or friend who lives at home. This can be claimed for up to three care recipients who require a minimum threshold of care assessed against Manitoba Home Care Program Guidelines. Ont. 8 $4,648 at net income threshold of $15,905 Que. 12 $775 $1,131 (no net income threshold defined) 3 N.B. 8 $4,550 at net income threshold of $15,536 N.S. 8 $400 per month $4,898 at net income threshold of $13,677 P.E.I. 8 $2,446 at net income threshold of $11,953 N.L. 8 $2,783 at net income threshold of $13,606 Nun. 8 $4,608 4 at net income threshold of $15,735 N.W.T. 8 $4,608 at net income threshold of $15,735 Y.T. 8 $4,608 at net income threshold of $15,735 Canada $4,530 at net income threshold of $15,472 1 Net income threshold refers to the income of the dependent, not the caregiver. 2 as of February 1, 2014 3 refers to 2014 4 The Family Caregiver Amount (FCA) of $2,093 is added to these amounts in certain circumstances, for federal and Yukon tax credits. Sources: Conference Board of Canada, drawing upon government websites, interviews, and TaxTips.ca. Find this and other Conference Board research at www.e-library.ca 25

Understanding Health and Social Services for Seniors in Canada Adult day care programs provide seniors with mental and social stimulation to avoid isolation and loneliness and promote well-being. For caregivers, adult day care programs, offered in many municipalities, can also afford temporary relief. These programs provide seniors with mental and social stimulation to avoid isolation and loneliness and promote well-being. Activities are held in a safe environment and meals and snacks are typically included. Adult day care programs can be public or private, non-profit or for profit. They are often subsidized, with daily rates as low as $6 to $8 in many provinces. Assessment for access to public adult day care programs is conducted by provincial and regional health authorities or professional associations, such as Ontario s Community Care Access Centres. Many provinces are piloting with the rapidly evolving field of programs in telemedicine to help caregivers manage dependents in their own homes. In New Brunswick, a home monitoring system known as Care Link Advantage, developed and based in Sudbury, Ontario, is fully funded. It costs between $130 and $150 a month. 36 Care Link Advantage uses a series of cameras and motion sensors around the home that notify the caregiver by text if anything out of the ordinary is detected. Professionally trained bilingual staff are also on hand in dispatch stations to field calls and coordinate with paramedics, fire departments, family, and friends. Care Link Advantage can help monitor whether seniors are eating and sleeping properly, falling down, wandering aimlessly outside, and taking their medications. 37 For seniors who dislike the idea of cameras, more discrete remote technologies can be installed. Lifeline buttons for falls and other emergencies are especially popular, not least because falls are the leading cause of injury hospitalization in Canada, often involving hip fracture. 38 Notably, Nova Scotia will reimburse approved seniors up to $480 per year for purchasing a lifeline button for falls. 39 It will also provide up to $499 per year for approved seniors to buy an automated 36 Stunt, Use of Surveillance Tech. 37 Care Link Advantage, Care Link Advantage. 38 CIHI, Seniors and Falls. 39 Nova Scotia, Personal Alert Assistive Program. Find this and other Conference Board research at www.e-library.ca 26

Chapter 2 The Conference Board of Canada medication dispenser. 40 Lifeline buttons can be connected to sensors that are placed throughout the home on fridges, pill-boxes, and showers to monitor daily activities. The information can be digitally collected, analyzed into patterns, and transmitted to family members through e-mail, text, or mobile app. 41 At the international level, there is some form of government support available to caregivers in each of the three international comparators considered. In Denmark, informal caregivers can receive a care allowance that compensates them for lost wages incurred due to their care responsibilities. The amount is determined by the municipality. 42 If appropriate, a person giving informal care to a loved one can even be employed directly by the municipality for up to six months. 43 In Sweden, parliament passed a law in 2009 stating that municipalities are obliged to offer support to people caring for people with chronic illness, the elderly, and those with disabilities. This takes three forms: respite care; individual or group counselling; and, less commonly, an attendance allowance paid directly to the caregiver. 44 In the U.K. meanwhile, people providing 35+ hours of care per week for a loved one may be eligible for a carer s allowance of around US$110 per week. This allowance is not meanstested but is available only to people earning less than US$182 per week (after deductions). 45 In addition a local council is obliged to provide an assessment of the help a carer requires either directly to them or to the person being cared for (Carer s Assessment). This can lead to help with travel costs, respite, a computer, driving lessons, massages, and leisure classes for stress, among others. 46 40 Nova Scotia, Medication Dispenser Assistive Technology. 41 See, for example, Lively, Personal Emergency Response. 42 OECD, Denmark: Long-Term Care. 43 Olejaz and others, Denmark. 44 Johansson, Long, and Parker, Informal Caregiving for Elders in Sweden. 45 CarersUK, Factsheet: Carer s Allowance. 46 CarersUK, Factsheet England & Wales: Assessments. Find this and other Conference Board research at www.e-library.ca 27

Understanding Health and Social Services for Seniors in Canada Long-term or residential care clients tend to be the oldest seniors, unmarried, and more frail than counterparts who receive care at home or in the community. Long-Term Care Long-term care (LTC) goes by many different names in Canada s provinces and territories. Residential care, nursing homes, continuing care, and personal care homes are some of the terms used to refer to facilities that provide individuals with around-the-clock, on-site nursing attention. There is no national consensus on the parameters of what constitutes long-term or residential care, but clients across the country do present a common profile. They tend to be the oldest seniors (above 85), unmarried, and more frail than counterparts who receive care at home or in the community. Their cognitive capabilities and physical health status are usually moderately or severely impaired. They experience difficulty in performing basic or instrumental activities of daily living. They either have little informal support or they have needs that cannot be looked after by informal caregivers. 47 LTC, as defined here, should not be confused with retirement residences. The latter are privately run facilities that cater to seniors in different stages of life. The clients are tenants who rent a room or suite in the residence and pay for assistive services as required or desired. Retirement residences must meet provincial licensing standards and undergo occasional reviews, but they are otherwise independent in ownership and operation, funding, and admissions criteria. By contrast, LTC may be publicly or privately run, but is otherwise regulated in the same way with regard to costs, funding, and admissions criteria. There is also a handful of LTC facilities across Canada for younger adults with physical or mental conditions. The approach to determining the eligibility and costs borne by individuals for LTC varies considerably across provinces and territories. The procedures and formulas are complex and sometimes opaque. (See Long-Term Care Coverage, by Province, 2013 or 2014. ) Income is often taken into consideration, and some provinces guarantee a disposable income for residents and any spouses or dependents in the community. 47 CIHI, Health Care in Canada 2011, 89 93. Find this and other Conference Board research at www.e-library.ca 28

Chapter 2 The Conference Board of Canada When calculating charges, Quebec and Newfoundland and Labrador will factor in liquid assets (cash or cash equivalent) and not just income. Alberta, Ontario, Quebec, P.E.I., and Nova Scotia technically ask LTC residents to co-pay for accommodation only. Long-Term Care Coverage, by Province, 2013 or 2014 British Columbia The minimum monthly rate is $991.20 for a single and $736.00 for each spouse in a married couple. The maximum monthly rate is $3,157.50. For those with after-tax income of less than $19,500, $3,900 is reserved for the patient to keep and the remainder is divided by 12 to determine the monthly rate. For those with after-tax income of more than $19,500, 20 per cent is reserved for the patient to keep and the remainder is divided by 12 to determine the monthly rate (up to the maximum). Alberta Accommodation charges are levied. The rate for a private room is $60.45 per day, or $1,839 per month; for semi-private $52.30 per day, or $1,591 per month; and for standard $49.60 per day, or $1,509 per month. The charges are set to increase by 3 per cent in 2015. To help ensure affordability for low- and moderate-income residents, income support is available through the Alberta Seniors Benefit (ASB) or the Assured Income for the Severely Handicapped (AISH) programs. Saskatchewan Resident charges are based on tax returns, with additional charges for prescriptions, medications, and incontinence supplies and a $20 monthly supply charge for personal hygiene items such as shampoo. As of October 1, 2014, resident charges range from $1,049 to $1,995 per month. The resident pays the minimum amount of $1,049 plus 50 per cent of the portion of their income between $1,341 and $3,234. Find this and other Conference Board research at www.e-library.ca 29

Understanding Health and Social Services for Seniors in Canada Manitoba Residents are guaranteed disposable income of $3,600 per year. If a spouse is still living in the community, he or she is guaranteed $32,772 annually for living expenses. How much a client pays for residential care is calculated to ensure that these basic amounts remain as disposable income for the client and spouse. As of August 1, 2014, the minimum daily rate is $33.90 and the maximum $79.20. Ontario An accommodation co-payment is levied for places in LTC homes. The rates, as of September 1, 2014, are as follows: $56.93 per day, or $1,731 per month, for basic or standard accommodation; $67.93 per day, or $2,066.21 per month, for semi-private; and $80.18 per day, or $2,438.81 per month, for private. The rates for semi-private or private beds are somewhat lower if the beds are considered old, according to ministry design standards. Those in standard accommodation can apply for a rate reduction. If granted, the province pays the facility the value of the reduction so that the facility still receives an overall payment of $56.93 per day. Those in semi-private or private accommodation are not eligible for reduced co-payments. Quebec Maximum client contributions vary by type of room: $1,758.30 per month for a private room; $1,470 per month for a semi-private room; and $1,092.60 per month for a ward (three or more beds). Deductions apply for personal expenses ($203 per month); a spouse in the community ($1,132.48 per month); each dependent child 18 or over ($568.54 per month); and each dependent child 17 or under ($453.45 per month). Residents pay for their own hair care, personal care products, personal telephone or TV, and personal care of clothing (dry cleaning, mending, etc.). A reduction can apply upon request, and financial assessment will take into account liquid assets (cash and cash equivalents), property, monthly income, and family situation. New Brunswick Effective April 1, 2013, the maximum amount to be paid by nursing home residents was $107 per day, which increased to $113 in April 2014. A government subsidy can be applied after financial assessment upon request. Clients are assessed on a gradual scale in relation to how much above OAS/GIS their Find this and other Conference Board research at www.e-library.ca 30

Chapter 2 The Conference Board of Canada families earn. (Those who do not earn more than OAS/GIS pay 0 per cent of income.) Clients without a spouse or dependent at home are assessed on 100 per cent of their net income. The scale is set higher if they have a spouse at home, and higher still if they have one or more dependents at home. Prince Edward Island Residents pay for accommodation. The cost is $77.60 per day. Those with a net annual income of less than $30,000 may qualify for a subsidy. If the client has a spouse in the community, the total assessed income is split on a 50/50 basis. Clients are required to contribute all of their income toward accommodation costs, but not their assets. The 2011 12 annual Health PEI report Administration of the Long-Term Care Subsidization Act indicates that the average client received a subsidy of 31 per cent and that 75.1 per cent were receiving a subsidy of some kind. Nova Scotia Clients pay $107.75 per day for standard nursing home accommodation; $64.25 per day for residential care (a lower level of care than nursing homes); $52.00 per day for housing units serving up to three people (the lowest level of care); and $34.75 per day for respite care beds. Clients able to pay the full amount do not get financially assessed, but the vast majority (more than 90 per cent) do not pay in full. Clients will not be left with incomes lower than $3,126 per year, and they are not expected to pay more than 85 per cent of their assessed income toward accommodation charges. Spouses in the community will not be left with incomes lower than $20,500 per year; they retain control over 60 per cent of the joint family income and maintain control over all assets. Newfoundland and Labrador The maximum an individual will be charged in LTC is $2,800 per month. A financial assessment can be requested to receive subsidy. A single individual can keep $10,000 in liquid assets (cash or cash equivalent) and a couple, $20,000. Nunavut Full coverage is provided by the territory. Find this and other Conference Board research at www.e-library.ca 31

Understanding Health and Social Services for Seniors in Canada Northwest Territories Residents pay a monthly co-payment of $761. The amount is not income-tested. Residents can apply to their local income assistance office for an exemption. Yukon Clients pay $35 a day in the four continuing care facilities. This is estimated to be around 10 per cent of the actual cost. 48 The amount paid by the client is not dependent on income. Source: The Conference Board of Canada, drawing upon government websites, interviews, and Sun Life Financial. Those who cannot afford the minimum rates as identified by their provincial governments can apply for exemptions. Most of the overall LTC funding does come from public sources. (See Table 3.) As the following table summarizes, in no province in 2012 did the average resident pay more than a quarter of average LTC operational costs. For example, the maximum monthly rate that British Columbia s LTC facilities can charge residents is over $3,000. But the average resident in 2012 only paid around $1,200, which represented 23 per cent of the actual total monthly costs per resident in the province s residential care system in that year. As in Canada, none of the comparator countries download the full costs of LTC on the seniors who require this level of care. In Denmark, institutional care, such as nursing homes, is subject to co-payments at a rate of 10 per cent of income up to US$26,000 (US$2,167 per month) and 20 per cent of income over that threshold. 49 In Sweden, institutional care commissioned by the municipalities is subject to a maximum co-payment by individuals at the same level as home care, US$274 per month. The absolute level of co-payment is capped and based on income. 50 LTC in the U.K. is free for those with less than US$37,000 in assets. 51 Some people are exempted from this test based on a care 48 CBC News, Yukon Long-Term Care Fees to Rise. 49 The Commonwealth Fund, International Profiles of Health Care Systems, 2013. 50 Ibid. 51 Jones, Continuing Healthcare. Find this and other Conference Board research at www.e-library.ca 32

Chapter 2 The Conference Board of Canada Table 3 LTC Cost Structure and Percentage Covered by Resident, Averages, by Province, 2012 Annual cost to resident ($) Monthly cost to resident ($) Actual total annual cost per resident ($) Actual total monthly cost per resident ($) Cost covered by resident (%) B.C. 15,337 1,278 66,531 5,544 23 Alta. 11,552 963 60,791 5,066 19 Sask. 13,965 1,164 97,543 8,129 14 Man. 13,138 1,095 69,634 5,803 19 Ont. 16,002 1,334 66,022 5,502 24 Que. N.B. 11,598 967 76,713 6,393 15 P.E.I. 14,497 1,208 72,590 6,049 20 N.S. 15,766 1,314 72,703 6,059 22 N.L. 11,635 970 70,832 5,903 16 TE 1 8,254 688 116,822 9,735 7 1 TE = Territories. Information from Statistics Canada was not available for individual territories. Sources: The Conference Board of Canada; Statistics Canada. assessment via the NHS continuing healthcare scheme. Those qualifying for the scheme have nursing, personal care, and care home fees, including accommodation, paid for in full. For those who do not qualify, the NHS funds nursing care in care homes up to US$160 per week. 52 In theory, admissions criteria to enter an LTC in Canada are fairly broad, typically covering publicly insured adults over 18 who need 24-hour medical attention. In practice, the pressures of an aging population and a rise in dementia mean that increasingly only the most critically ill and cognitively impaired seniors will likely be placed in a bed. Several interviewees informed The Conference Board of Canada that LTC has gone from a custodial model of care in the 1980s to an end-of-life model 52 Jones, Continuing Healthcare. Find this and other Conference Board research at www.e-library.ca 33

Understanding Health and Social Services for Seniors in Canada Median and average provincial wait times hide the range that may exist between regions or different facilities. of care today, with the average time spent in LTC declining as clients tend to die sooner after entry. Wait times need to be assessed with these trends in mind. Much effort has been made to keep down wait times to access LTC to avoid an undue alternate level of care (ALC) in acute care settings. (For more discussion of ALC days, see the section Lack of Timely and Equitable Access. ) The areas in Quebec for which data were obtained have the longest wait times in the country and the Western provinces the shortest. (See Table 4.) Saskatchewan, with the best average wait time of 27 days from either the community or a hospital, is actually fairly unusual in having over-capacity in its rural LTC. It hopes to shut down some beds and reallocate resources to more cost-effective home and community care services. Some representatives from Central and Eastern Canada expressed less optimism about their province s likely ability to deal with the demands of an aging population in the next 20 years. Median and average provincial wait times hide the range that may exist between regions or different facilities. In the Erie St. Clair Local Health Integration Network (LHIN) in southwestern Ontario, for example, wait times for LTC beds can range from under a week to several years, depending on the centre. 53 For certain very highly regarded LTC facilities, like Baycrest in Toronto, wait times are effectively so long that many clients who want to be placed there could pass away before they get a bed. No incentives are offered in Canada for reducing delays in transfer from hospital to LTC. Incentives are present in Denmark, Sweden, and the United Kingdom. As a result of discrepancies between organizations and regions, as well as concerns about ALC in hospitals, most provinces enforce firstavailable-bed policies for LTC. (See LTC Level of Choice, by Province, 2014. ) Ontario alone does not have a first-bed policy, and Alberta s policy was put under review in June 2013. In the other provinces, various penalties may attend refusal to accept the first available bed. Individuals 53 Community Care Access Centres, Erie St. Clair CCAC LTC Wait Times. Find this and other Conference Board research at www.e-library.ca 34

Chapter 2 The Conference Board of Canada Table 4 LTC Wait Times, by Province, 2012, 2013, or 2014 Wait period Notes Dates covered B.C. 45 days Median 2013 14 Alta. 31 days Average for all facility-based continuing care Sask. 27 days Average from community or hospital April 1, 2013 March 31, 2014 Q1 2014 Man. 77 days Median 2012 13 Ont. 60 90 days Average for crisis admission 2013 14 108 days Average for less priority Que. 396 days Average Québec City 2012 213 days Average Montréal N.B. 134 days Average As of March 10, 2014 63 days Median P.E.I. 91 days Average 2012 N.S. 230 days Median from community 2013 14 136 days Median from hospital N.L. Sources: The Conference Board of Canada, drawing upon government websites, interviews, and reports. See also Health Quality Ontario, Long-Term Care; Manitoba Health, Annual Statistics, 70; Vérificateur général du Québec, Vérification de l optimisation, 18; Prince Edward Island, Backgrounder: Long-Term Care. risk being placed at the bottom of the wait list or being removed from the wait list entirely. Most provinces do allow for transfer after the fact and do encourage case managers to keep issues of distance, culture, and family unification in mind when selecting LTC beds. Find this and other Conference Board research at www.e-library.ca 35

Understanding Health and Social Services for Seniors in Canada LTC Level of Choice, by Province, 2014 British Columbia A first-bed policy is in place. Seniors must accept within 48 hours. Refusal results in removal from the residential access program. A waiting list for transfer exists. Case managers are encouraged to take family, travel, and clinical considerations into account when making decisions about appropriate placements. Alberta Regional policies have been criticized as inconsistent and opaque. The province s first-bed policy was put under review in June 2013 for quality and safety implications. Health Quality Council of Alberta s review recommends eliminating the $100 penalty for refusing the first bed and doing more to take into consideration family and distance concerns. Saskatchewan Most regions impose a first-bed policy. Saskatoon has a 75-kilometre limit, and Regina Qu Appelle is considering a 150-kilometre limit. The option of a waiting list transfer is available. Saskatchewan often has LTC overcapacity in rural areas. Shortages are most likely in the cities and in the far north. Manitoba Seniors may be required to move to take a temporary placement before they can move into their preferred home. Ontario Patients are allowed to remain in hospital while waiting for their preferred option. Patients cannot be required to choose a specific number of LTC choices, and cannot be required to accept a first available bed that is not their preferred choice. Find this and other Conference Board research at www.e-library.ca 36

Chapter 2 The Conference Board of Canada Quebec Residents have the right to choose their hébergement, but they may be admitted temporarily to another facility if their first choice is not available. Generally, beds must be accepted within 48 hours. New Brunswick If their first preference is not available, patients may have to accept the first bed available within a 100-kilometre radius, at least temporarily. Patients have the right of refusal on the basis of language. Nova Scotia First-available-bed within 100 kilometres is enforced for medically stable hospital patients waiting for a nursing home. The provision does not apply to individuals in community care, seeking transfer from an existing placement, requiring a different level of care from an existing placement, requiring peritoneal dialysis, or seeking unification with a family member already in a home. Prince Edward Island A medically discharged person may not remain in hospital when an LTC bed is offered, regardless of where the bed is located. Patients have the option to transfer back to their home region when a bed becomes available. Newfoundland and Labrador The first-available-bed policy is enforced within each health region. A waiting list exists for transfer. Nunavut Only one facility is listed in Nunavut. Northwest Territories After being approved for an LTC placement, clients are put on a waiting list. They are then assigned the first available appropriate bed in one of the nine facilities in the territory. If clients are placed in another community, transportation costs of the patient and their family are borne by the client and family. If they cannot pay these costs, requests for support can be made to the government Health and Social Services department. Find this and other Conference Board research at www.e-library.ca 37

Understanding Health and Social Services for Seniors in Canada Yukon All LTC facilities in Yukon are in the same city. The waiting list for placement is managed based on level of need and urgency. If an offered placement is refused, there is no penalty in terms of waiting-list priority. Sources: The Conference Board of Canada, drawing on government websites, interviews, and reports. See also British Columbia, Office of the Ombudsperson, The Best of Care, 3, 16, 31 32; Health Quality Council of Alberta, Review of Alberta s Health; Saskatchewan Ministry of Health, Housing Options for Saskatchewan, 5; Manitoba Health, Healthy Living and Seniors, What Health Services; Vérificateur général du Québec, Vérification de l optimisation, 18; Nova Scotia Department of Health and Wellness, Facility Placement Policy. In general, LTC is a highly regulated sector. All provinces require that privately run LTC facilities be inspected and licensed by one or more agencies, and standards or guidelines are typically in place for the performance of publicly run LTC facilities. Inspection reports are produced, and may include recommendations, but these reports are not always made public unless by express request. More than one piece of legislation and more than one agency are often involved in LTC regulation, which can engender confusion as to lines of oversight among laypersons and even experts with long experience. In Alberta, for instance, the Ministry of Health audits accommodation standards, while Alberta Health Services audits health standards. Some of those interviewed by The Conference Board of Canada also feel that regulation of the LTC sectors tends to be too punitive. Pass/fail criteria encourage efforts to meet minimum requirements, yet not to improve the quality of care or engage in self-evaluation. Accreditation standards, such as those established by Accreditation Canada and the Commission on Accreditation of Rehabilitation Facilities (CARF) Canada, provide opportunities to engage service providers and health care administrators in quality improvement beyond minimum standards. However, these accreditation programs are not mandatory for all health care programs across the country. Most provinces are seeking to cut back on LTC beds as a result of their costs and the preference of seniors to be accommodated elsewhere. The most common initiatives presently being tried in several provinces have to do with finding a middle ground between home care and LTC. Find this and other Conference Board research at www.e-library.ca 38

Chapter 2 The Conference Board of Canada Canadian patients with terminal diseases are entitled to some form of palliative care. However, it has been estimated that only 16 to 30 per cent of these patients receive it. Governments are seeking to build out their assisted or supportive living arrangements. Whereby seniors, including those who may have mild dementia, receive 24-hour attention, but at a lower level than that expected in a nursing home and by staff who may not be as highly trained as a nurse or a doctor. Notably, Newfoundland began Protective Community Residences in 2009 10. These dementia bungalows, as they are sometimes called, involve 10 to 12 beds with mildly demented patients who can still take part in helping to run the household with chores such as dishes, laundry, and bed-making. The program has been praised positively by families. Palliative Care Canadian patients with terminal diseases are entitled to some form of palliative care. However, it has been estimated that only 16 to 30 per cent of Canadians needing palliative care actually receive it. 54 Most provinces have specific palliative care pharmacare programs that provide extended coverage for patients who are diagnosed as terminal. But only British Columbia, Alberta, Prince Edward Island, and Yukon have coordinated palliative care programs whose specialized teams assess, treat, and follow patients across the health care system. The programs also provide these patients with fully covered or heavily subsidized medications as well as supplies. The other provinces and territories offer palliative care in a more patchwork fashion, with the extent of coverage often differing between hospitals, long-term care facilities, home care, and hospices. (See Palliative Care, by Province, 2014. ) In Ontario, palliative care has evolved piecemeal since the 1970s. The auditor general noted in her 2014 annual report that limited information and data on palliative care are available to the public and the government. She identified several problem areas for the province, including few performance measures; inequitable geographic distribution of services, especially in rural areas; too many expensive hospital beds and too few cost-effective hospice beds; poor dissemination 54 Parliamentary Committee on Palliative and Compassionate Care, Not to Be Forgotten. Find this and other Conference Board research at www.e-library.ca 39

Understanding Health and Social Services for Seniors in Canada of knowledge; lack of educational standards for physicians and nurses; and undue concentration on cancer and not enough on other chronic illnesses. 55 According to the Canadian Hospice Palliative Care Association, a similar situation prevails across much of the country. 56 There is a need to improve access to coordinated palliative care at home or in hospices, which are the preferred settings of end-of-life patients. In these settings, supply is not sufficient to meet demand. Improvements have been made since the 1980s, but palliative care still remained one of the 10 reasons for which seniors were hospitalized in Canada in 2009 10. 57 Palliative Care, by Province, 2014 British Columbia The Palliative Care Benefits Program is available to all those of any age in need of palliative care as certified by a physician. The program covers the full cost of listed drugs as well as medical supplies and equipment. (Home oxygen is not covered, but may be subsidized by the local health authority.) Home is defined as anywhere the person is living in the personal home, with family or friends, in a hospice, or at an assisted living residence. Palliative care in licensed LTC facilities or hospitals is provided separately by those bodies. Alberta The Palliative Care Program is available to patients diagnosed as end-of-life by a physician or nurse practitioner. Coverage includes listed prescription drugs, with a co-payment per fill of 30 per cent up to $25, and a maximum lifetime co-payment amount of $1,000; diabetic supplies, up to $600 per benefit year; and ambulance services. Infusion equipment and supplies are not covered. Patients in LTC facilities or hospitals are covered separately by those institutions. 55 Office of the Auditor General of Ontario, Annual Report 2014, 261 62. 56 Canadian Hospice Palliative Care Association, Fact Sheet. 57 CIHI, Health Care in Canada, 2011, 118. Find this and other Conference Board research at www.e-library.ca 40

Chapter 2 The Conference Board of Canada Saskatchewan The Palliative Care Drug Plan Program covers the full costs of listed prescription drugs, whether in the Saskatchewan Formulary or by the Saskatchewan Cancer Agency. A physician must sign the drug plan request. Coverage for dietary supplements and other basic supplies varies by health district. Manitoba The Palliative Care Drug Access Program provides deductible-free access to the formulary through Manitoba Health, Healthy Living and Seniors. All prescribed drugs are fully covered once an end-of-life application, approved by a physician, has been processed. Nutritional supplements are not covered. Medical supplies are provided by the regional health authority s home care office; wheelchairs may be requested from the Society for Manitobans with Disabilities (SMD). Palliative care products and services in hospitals or LTC facilities are covered by those institutions. Ontario The Ministry of Health and Long-Term Care (MOHLTC) funds palliative care through hospitals, home care via Community Care Access Centres (CCACs), LTC facilities, recognized hospices, and Cancer Care Ontario. Services are covered by the Ontario Health Insurance Plan (OHIP). A referral from a physician is required to receive extended coverage for drugs and supplies through home care. End-of-life cases are eligible for the Ontario Drug Benefit (ODB) plan. There is no single coordinated palliative care program. Quebec Publicly funded palliative care is offered at home through a Centre local de services communautaires (CLSC), in a hospital, or at a Centre d hébergement de soin de longue durée (CHSLD). Hospices may receive funds from regional authorities, but they do not have official status and often rely upon donations. Drugs are covered by other existing drug plans. There is no single coordinated palliative care program. New Brunswick There is no single coordinated palliative care program. Palliative care service differs by region, whether in hospitals, long-term care facilities, the home, or hospices. Find this and other Conference Board research at www.e-library.ca 41

Understanding Health and Social Services for Seniors in Canada Prince Edward Island The Palliative Care Program coordinates palliative care for all end-of-life patients of any age, whether at home or in hospitals or nursing homes. Patients enter the program by way of a physician referral, and it includes its own fully covered medical supplies and formulary. Nova Scotia The Palliative Home Care Drug Coverage Program covers the full cost of listed pharmaceuticals. Diagnosis by a physician or nurse practitioner is required to enter the program. Each regional health authority has teams that can support health care providers in providing end-of-life care. Nova Scotia has a provincial palliative care strategy that is aiming to improve palliative care service consistency, but services currently vary across the province. Newfoundland and Labrador There is no single coordinated palliative care program. Depending on health region, home care agencies will treat individuals at home or in a community clinical setting. Coverage includes equipment and supplies, household management needs, respite for the main caregiver, and medications. Nunavut There is no single coordinated palliative care program. Drugs and supplies are covered under existing pharmacare and home care arrangements. Northwest Territories There is no single coordinated palliative care program. Drugs and supplies are covered under existing pharmacare and home care arrangements. Yukon The Palliative Care Program coordinates end-of-life care for residents. Coverage for drugs and supplies is provided by other agencies. Source: The Conference Board of Canada, drawing upon government websites and interviews. People at the end of life require holistic, patient-centred care that recognizes individual needs and takes into consideration family and community capacity. The lack of integration and coordination across Find this and other Conference Board research at www.e-library.ca 42

Chapter 2 The Conference Board of Canada The federal government has direct responsibility for the funding and provision of health care services for several special groups of seniors, including First Nations, veterans, and the RCMP. palliative care services and programs seen in the majority of the provinces and territories across Canada is a serious concern that received the attention of a parliamentary committee in 2011. The Parliamentary Committee on Palliative and Compassionate Care called for a National Palliative Care Strategy and made 11 recommendations to strengthen the capacity of our health care system to enhance the quality and comprehensiveness of the services needed by end-of-life patients and their families. Little progress has been achieved since then. Federal Government Provisions to Special Seniors Groups: Veterans, First Nations, and RCMP The federal government has direct responsibility for the funding and provision of health care services for several special groups of seniors. (See Table 5.) The basket of services provided by the federal government to the population 65 and over, eligible for these benefits is comparable with the services available for other senior Canadians. However, a few issues exist in relation to LTC services for First Nations that deserve immediate attention. Through Veterans Affairs Canada (VAC), the federal government funds LTC for veterans. However, this is based not only on need, but also on income. 58 Home care services for veterans are provided through VAC s Veterans Independence Program (VIP). This program assists veterans to live in a healthy and independent way in their primary residence. Eligibility for the program can be a complex determination, the explanation of which runs to over 2,700 words in the 2013 Veterans Ombudsman review. 59 Criteria considered are service details, age, disability, income, and residence. The program includes health and support services, personal care services, housekeeping, access to 58 Veterans Affairs Canada, Long Term Care. 59 Veterans Ombudsman, A Review of the Support Provided by Veterans Affairs Canada. Find this and other Conference Board research at www.e-library.ca 43

Understanding Health and Social Services for Seniors in Canada Table 5 Coverage of Health Care Services for Seniors From First Nations (FN), Royal Canadian Mounted Police (RCMP), and Veterans (VET) LTC 1 Home 1 Palliative 2 Pharma Dental 3 Vision FN 4 Partial Yes Provincial Yes Yes Yes RCMP 5 Provincial Provincial Provincial Fee Fee Fee VET Income Income Provincial 6 Yes Yes Yes Definitions Income: Income-tested. Fee: Set charges for service with reduction on request and by assessment of need. Income supports are often available to assist with these fees. Yes: Coverage for those who qualify, even as eligibility may be narrow and provision restricted. Partial: Universal yet partial coverage for seniors. Provincial: No federal funding 1 LTC costs include those for accommodation, and home care is defined here to include basic housekeeping. Seniors enrolled in home care can also receive extended therapies such as physiotherapy and occupational therapy. Coverage is based on a client s assessed needs and availability of services, which vary by province. 2 For the last month of life. The caveat about home care applies to palliative care. 3 For procedures, products, or services outside of hospitals. 4 The Non-Insured Health Benefits Program (NIHB) provides coverage for some services not provided by provincial plans. 5 Coverage under the PSHCP for RCMP will be subject to co-payment as of April 2015. 6 Palliative care is provided by VAC to the extent that it provides assistance with LTC and home care. (See text.) Source: The Conference Board of Canada. nutrition, respite care, 60 and grounds maintenance. These services can be accessed even if they are not offered by the provincial system. Dental, drug, and vision coverage is provided through Programs of Choice (POCs), which includes some services not included in or only partially covered by provincial insurance. 61 Palliative care is provided by VAC through support to access LTC or home care. 62 While the federal government provides most health care services for First Nations and Inuit, it does not provide access to LTC facilities that cater to clients with the most intensive care needs. Provinces also do 60 This service will pay for the delivery of meals to a client, up to a maximum rate per meal, or pay for transportation of the client to a local restaurant or other facility. It does not pay for the cost of the actual food. 61 Veterans Affairs Canada, Benefits and Services Programs of Choice (Poc). 62 Veterans Affairs Canada, Palliative Care. Find this and other Conference Board research at www.e-library.ca 44

Chapter 2 The Conference Board of Canada First Nations people need to move off reserve to access palliative services. They can then be faced with a wait of six months to a year before they have fulfilled the residency requirement for service, which effectively bars on-reserve seniors from accessing the services. not fund LTC facilities unless they are licensed, which is often not the case for the less intensive level of institutional care that is available on reserves. This is compounded by a federal restriction on funding any additional LTC facilities on reserves. 63 For people who need to go to LTC facilities, often the only options are provincial facilities away from the home communities. 64 Although institutional care and nursing support is funded, the available resources may not be sufficient to allow complete access by all those who require it. Home and community care services that are provided by the First Nations and Inuit Home and Community Care Program include nursing care, personal care, home support (for example, meal preparation), and respite care. 65 However, both a Health Council of Canada report and an evaluation by Health Canada found that, in at least some places, there was a need for increased capacity in the program. 66 The Health Council of Canada report notes that this can tend to drive a requirement for LTC at a younger age than other Canadian seniors. There is no specific funding for palliative care by the First Nations and Inuit Health Branch. The Health Council of Canada noted a situation arising from this in which First Nations people need to move off-reserve to access palliative services. They can then be faced with a wait of six months to a year before they have fulfilled the residency requirement for service, which effectively bars on-reserve seniors from accessing the services. Health care for retired members of the RCMP is generally provided by provincial insurance. However, those who have served for six years or more are covered by the Public Service Health Care Plan (PSHCP). Under this supplementary scheme, expenses for prescription drugs, 63 Health Council of Canada, Canada s Most Vulnerable. 64 Silversides, Long-Term Care in Canada. 65 Health Canada, First Nations & Inuit Health. 66 Health Canada and PHAC, Evaluation of the First Nations and Inuit Home and Community Care Program; Health Council of Canada, Canada s Most Vulnerable. Find this and other Conference Board research at www.e-library.ca 45

Understanding Health and Social Services for Seniors in Canada private nursing, and eyeglasses are generally covered up to 80 per cent. The cost of the plan is covered by the federal government and the retiree (75 per cent by the government, 25 per cent by the retiree). 67 In addition to the major groups outlined above, the federal government is also responsible for services to refugees and inmates in federal prisons. In the fiscal year 2011 12, the Interim Federal Health Program covered 128,000 refugees, 68 while in 2012 13 there were around 14,470 federal prisoners, 69 all of whom qualify for federal health care. 67 Treasury Board of Canada, Public Service Health Care Plan. 68 Canada Gazette, vol. 146, no. 9. 69 Statistics Canada, Adult Correctional Services, Average Counts of Offenders. Find this and other Conference Board research at www.e-library.ca 46

CHAPTER 3 Key Challenges Affecting Seniors Health and Health Care Services Chapter Summary Drivers of the access challenges present in the home care and long-term care sectors include mismatch between supply and demand, cost or perceived cost, and the complexity of entry processes and information. Dementia is a large and growing issue that exacerbates other challenges in seniors care. Lack of a coordinated dementia strategy and research undermines Canada s ability to achieve a successful approach in this area. Individuals and governments are underprepared for future long-term care requirements. Although strategies are being discussed, nothing is currently in place. The current limited role of the federal government in many areas critical to seniors care, which results from current legislation, has led to inconsistency and inequalities across the country. This may be exacerbating regional health disparities that already exist. Find this and other Conference Board research at www.e-library.ca

Understanding Health and Social Services for Seniors in Canada This report has already outlined some of the pressures affecting health and social care programs for seniors in Canada. There are, however, five key challenges that deserve careful consideration within a framework of health and social service improvement for seniors and their families. They are: lack of timely and equitable access the growing dementia challenge restricted funding to support seniors growing health needs limited senior-friendly mechanisms for redress the current federal role in key health and social services for seniors Failure to address these issues would compromise Canada s ability to meet the future health needs of seniors and will erode public confidence. Each of these is explained next. Lack of Timely and Equitable Access In general, seniors have access to a broad basket of services covered under the Canada Health Act (CHA) and, as noted previously in this report, seniors are more likely than younger Canadians to have a family physician. In 2013, 95 per cent of seniors (65+) had a regular family physician compared with 82 per cent of non-seniors. 1 Older but more detailed Canadian figures show that access to a doctor is not uniform across provinces. Of note is that the proportion of people reporting access in Quebec was around 10 per cent lower than the Canadian average between 2003 and 2011. 2 1 Statistics Canada, CANSIM table 105-0501. 2 Astles and others, Paving the Road to Higher Performance. Find this and other Conference Board research at www.e-library.ca 48

Chapter 3 The Conference Board of Canada Issues related to timely access to care are present across the continuum of care. Although some improvements have been made in the last few years, wait times to see physicians are still long by international standards. This is also true for emergency department care and acute care, such as surgery. 3 Provinces have implemented various measures to improve timely access to primary health care services. The availability of health care teams across Canada has helped improve access to clinical pharmacists, dieticians, and other health care providers, as well as some specialized services like mental health programs. Ontario has seen successes with its family health teams (FHTs), which through advanced access, have often been able to offer same-day appointments for minor health problems such that the median wait is less than a day. 4 FHTs have also seen success in extending access on weekends (42 per cent of patients reported this was probably or definitely available) and after hours (64 per cent). 5 Telehealth schemes, and in some cases e-mail communication with providers in some FHTs, have made available other channels through which care can be accessed as alternatives to waiting for a provider appointment. In addition FHTs reported many successful group programs aimed at promoting self-management of chronic diseases. (See Group Programs for Management of Chronic Diseases Free Up Physician Time for Others on the Waiting List. ) These often involved patients in the program, which many found to be of great value. 6 3 CIHI, Health Care in Canada, 2012. 4 The Conference Board of Canada, Final Report: An External Evaluation. 5 Ibid. 6 Ibid. Find this and other Conference Board research at www.e-library.ca 49

Understanding Health and Social Services for Seniors in Canada Group Programs for Management of Chronic Diseases Free Up Physician Time for Others on the Waiting List A successfully applied model that can significantly reduce wait times to see a doctor are group programs aimed at helping patients, often elderly patients, manage chronic diseases and other issues. These can have many advantages, such as social contact and peer-to-peer exchange of information. Examples include fall prevention classes, diabetes education, and information sessions on osteoporosis. All of these services can be delivered by health care professionals other than doctors, thus freeing up physician time to see other patients and reduce wait times. In an innovative extension of this concept, one family health team in Ontario delivers a seniors-focused exercise program through a public webcast. 7 This has an added benefit for seniors who have transportation or mobility issues. Regarding access to acute care services, there is no indication that wait times for procedures in acute care are longer for seniors than for younger Canadians. Indeed, the 2004 Health Canada 10-Year Plan to Strengthen Health Care focused on reducing wait times for a select group of priority procedures. 8 The Plan addressed seniors to the extent that the selected procedures tend to involve older Canadians above all. In 2013, almost all (97 per cent) of patients needing radiation therapy for cancer had treatment within the benchmark. Similarly, 82 per cent of patients requiring knee replacement and 83 per cent of patients needing hip fracture repair were also within target, 9 although timely access varies widely across provinces, regions, and communities. The percentage of patients within target requiring hip replacement and cataract surgery was a little lower at 76 per cent and 81 per cent respectively. 7 Lalonde, Family Health Team Participation Day. 8 Health Canada, First Minister s Meeting. 9 CIHI, Benchmarks for Treatment and Wait Time. Find this and other Conference Board research at www.e-library.ca 50

Chapter 3 The Conference Board of Canada Access to home care and LTC, on the other hand, present significant challenges. Given the increases in demand for these services it is perhaps unsurprising that many Canadians, including seniors, have unmet home care needs 10 or experience long wait times for placement to a suitable LTC facility. There are a few reasons for lack of timely access to home care and LTC services. These include the following: 1. Imbalance between supply and demand: As demographic trends continue, a greater proportion of Canadians require home care and long-term care services. Provinces and territories have been trying to cope with the increased demand and increased complexities of the clients needs. But despite their efforts, challenges still exist. An obvious barometer of stresses within the home care and LTC sectors is alternate level of care (ALC) hospitalization. ALC measures the level to which patients who no longer need to be in hospital wait to be discharged. As most hospital discharges are to the patient s home or to an LTC facility, delays in discharge are influenced by the availability/readiness of those settings to receive the patient. 11 (See Table 6.) Inappropriate waits in hospitals often lead to complications, such as hospital-acquired infections, which bring suffering to patients and more stress to a system that is already constrained and add to the already increasing health care costs. The Canadian Institute for Health Information (CIHI) has reported that the percentage of ALC-related hospitalizations in Canada has remained steady over recent years, at around 5 per cent of total hospitalizations from 2007 through to 2011. 12 However, this does not reflect the tremendous variability seen across the country, with some areas of very high ALC rates (discussed below). CIHI also noted that ALC days were more common in transitions to residential care than home care. Only one in six seniors discharged to home care with home care support services 10 Turcotte, Canadians With Unmet. 11 Wait Time Alliance, Timely Access to Care for All Canadians. 12 CIHI, Health Care in Canada, 2012, xiii, 33. Find this and other Conference Board research at www.e-library.ca 51

Understanding Health and Social Services for Seniors in Canada had ALC days. Seniors discharged to residential care waited a median of 26 days in the hospitals; seniors discharged home waited a median of 7 days. (See Table 7.) Table 6 Discharge Destination for Seniors Versus Non-Seniors Designated as ALC, Canada, 2009 10 (per cent) Seniors (age 65+) Non-seniors (age 20 64) Home (w/ support services) 14 17 Home (w/o support services) 12 23 Died 12 8 Rehabilitation 11 20 Long-term care 47 26 Other 4 7 Source: CIHI, Health Care in Canada, 2011, 117. Table 7 Discharge Disposition for Seniors Discharged From Acute Care, by ALC Status, 2007 11 All Discharges Discharged With ALC Days Discharged Without ALC Days Discharge disposition n Percentage of all patients n Percentage of all patients n Percentage of all patients Long-term care 486,266 9.7 183,051 53.5 303,215 6.5 Home w/ support 639,753 12.8 62,738 18.3 577,015 12.4 Home w/o support 3,196,819 64 35,503 10.4 3,161,316 67.9 Died 308,743 6.2 38,352 11.2 270,391 5.8 Rehabilitation 311,128 6.2 14,518 4.2 296,610 6.4 Other 55,396 1.1 7,957 2.3 47,439 1.0 All 4,998,105 100.0 342,119 100.0 4,655,986 100.0 Source: CIHI, Seniors and Alternate Level, 5. Find this and other Conference Board research at www.e-library.ca 52

Chapter 3 The Conference Board of Canada Access to home care and LTC services requires multiple assessments by a variety of agencies and organizations, and access to financial support is not straightforward. Information about these services and how to access them is scattered and not senior-/ family-friendly. The percentage of ALC-related hospitalizations varies significantly across the country. The Canadian Home Care Association has reported the percentage of ALC-related hospitalizations in selected provinces, ranging from 3.5 per cent in Manitoba to 16.6 per cent in Ontario. The latest public analysis and reporting of Canada-wide data on ALC days presents information from 2007 08. Given the societal and economic burden of ALC in Canada, public, timely, and periodical reporting should be in place. In contrast, the NHS in England reports ALC days promptly and consistently on a monthly basis on its delayed transfer of care report. 13 This report presents data for the previous month at the local level and identifies the agencies responsible for the delay. Reporting of this type would enhance system improvement efforts and accountability for results. As suggested by the Wait Time Alliance (WTA) in its 2014 report card, limited access to LTC has consequences for access to specialty care for all Canadians. 14 The WTA suggests that this large and growing issue needs to be addressed with both a national seniors strategy and a more focused national dementia plan. 2. High cost of services: Cost can also be a concern that restricts access to services. In 2014, an EKOS survey found that almost one-third of respondents (32 per cent) cited cost as a reason they did not get the home care they needed. (The highest percentage 64 per cent of respondents was found in British Columbia.) This is despite the financial support already available for seniors outlined in Table 1. 3. Complexity of the system: Access to home care and LTC services requires multiple assessments by a variety of agencies and organizations, and access to financial support is not straightforward. Information about these services and how to access them is scattered and not senior-/family-friendly, which limits the possibility of seniors to successfully and rightfully enjoy these services. Our EKOS survey results found that seniors with higher education and income levels 13 NHS England, Delayed Transfers of Care Data 2014 15. 14 Wait Time Alliance, Time to Close the Gap. Find this and other Conference Board research at www.e-library.ca 53

Understanding Health and Social Services for Seniors in Canada seemed better able to get the public care they need. In addition, given that different thresholds exist to access multiple services, simplifying eligibility would enhance access. Access to seniors health and social services faces key challenges. The demographic shift currently unfolding in Canada will continue adding pressure to the current supply/demand imbalance, particularly in the home care and LTC areas. Operating under this scenario will require a greater degree of innovation from our health care systems to deliver more with less. Special considerations would need to be paid to cost and design of processes to access these services to ensure they are accessible to senior Canadians when they need them, while safeguarding intergenerational equity. Better management and innovation will come from high-quality data and information on how these systems perform. The need to consistently measure and report sentinel indicators across Canada would enhance transparency and accountability and would support improvement and innovation. The Growing Dementia Challenge Dementia is a large and growing issue affecting Canada, as well as millions of people worldwide. Dr. Chris Simpson, the 2014 15 president of the Canadian Medical Association, noted that a significant portion of ALC days in Canada can be linked to the growing issue of dementia. 15 Given the magnitude, complexity, and implications of this challenge, a few organizations, including the Wait Time Alliance, have called for the need to have a national dementia plan. Thirteen countries around the world have already taken the step of developing a national dementia strategy. 16 15 Simpson, Canada Needs a National Dementia Strategy. 16 Ibid. Find this and other Conference Board research at www.e-library.ca 54

Chapter 3 The Conference Board of Canada Incidence and Future Projections In 2012, the World Health Organization published a meta-study on dementia prevalence and provided figures and projections for each global development region. 17 (See Table 8.) Table 8 Global Dementia, 2010 and Future Projections Number of people with dementia (millions) Proportionate increases (%) GBD region Population over 60 years (median, 2010) Crude estimated prevalence (%, 2010) 2010 2030f 2050f 2010 30f 2010 50f Asia 406.55 3.9 15.94 33.04 60.92 107 282 Europe 160.18 6.2 9.95 13.95 18.65 40 87 The Americas North America 120.74 6.5 7.82 14.78 27.08 89 246 63.67 6.9 4.38 7.13 11.01 63 151 Africa 71.07 2.6 1.86 3.92 8.74 111 370 World 758.54 4.7 35.56 65.69 115.4 85 225 f = forecast Source: WHO, Dementia, 18. The Alzheimer Society notes that in 2011 there were 747,000 Canadians living with dementia, or 14.9 per cent of Canadians 65 and older. 18 By 2031, if nothing changes, the figure is projected to be 1.4 million. In 2012, the combined direct (medical) and indirect (lost earnings) costs of dementia totalled $33 billion annually, and may climb to $293 billion annually by 2040. In its 2010 report Rising Tide: The Impact of Dementia on Canadian Society, the Alzheimer Society estimates that there will be 257,811 new dementia cases per year by 2038, compared with 17 WHO, Dementia. 18 Alzheimer Society of Canada, Dementia Numbers. Find this and other Conference Board research at www.e-library.ca 55

Understanding Health and Social Services for Seniors in Canada 103,728 in 2008. 19 Of those, around 50 per cent will be Alzheimer s, and the rest will be vascular or related dementia. The same report provides estimates of the dementia prevalence by care type and of pressure on LTC facilities. (See tables 9 and 10.) Table 9 Dementia Prevalence by Care Type (Ages 65+), 2008 38 Long-Term Care Community Care No Formal Care Year Prevalence of dementia Percentage with dementia Prevalence of dementia Percentage with dementia Prevalence of dementia Percentage with dementia 2008 183,268 45.4 134,416 33.3 85,938 21.3 2018f 249,268 41.8 221,970 37.3 124,553 20.9 2028f 335,882 39.4 337,682 39.6 178,747 21 2038f 442,682 37.6 503,661 42.7 232,146 19.7 f = forecast Source: Alzheimer Society, Rising Tide, 20. Table 10 Supply of LTC Beds and Number of Beds Occupied by Individuals Living With Dementia (65+), 2008 38 Year Number of LTC beds Number of LTC beds occupied by people with dementia Prevalence of dementia that would have been in LTC Excess demand for LTC 2008 285,178 183,268 198,659 15,392 2018f 387,880 249,268 296,473 47,204 2028f 522,657 335,882 422,351 86,469 2038f 688,846 442,682 600,142 157,461 f = forecast Source: Alzheimer Society, Rising Tide, 20. 19 Alzheimer Society of Canada, Rising Tide. Find this and other Conference Board research at www.e-library.ca 56

Chapter 3 The Conference Board of Canada Although recent efforts have been made by the government to advance understanding of dementia, there are concerns that dementia is still underfunded in Canada. Current Response to the Challenge In Canada, the federal government recently announced a National Dementia Research and Prevention Plan. 20 As part of this, a group called the Canadian Consortium on Neurodegeneration in Aging (CCNA) was formed. The CCNA will not only look at research that could reduce the incidence of dementia, but will also support research that provides insights on how to help dementia patients, their loved ones, and the health system and increase quality of life for people with the disease. 21 Another group within the research community in Canada, the Canadian Dementia Action Network (CDAN), has recognized the need for a national dementia strategy since it formed in 2011. This group advocates for the need for more basic research to understand dementia better and hopefully reduce the incidence of this disease in Canada. One of its strategic objectives is focused on the very immediate and pressing need for developing best practices to improve in-community care and delay institutionalization. 22 Although recent efforts have been made by the government to advance understanding of dementia, there are concerns that dementia research is still underfunded in Canada. CDAN notes that the U.S., the U.K., and France have all dramatically increased their support for dementia research recently, with the U.S. commitment from 2010 14 reaching $2 billion annually. To match this, relative to population size, Canada would need to invest $240 million annually. 23 In fact, however, the government of Canada has invested less than one-tenth of that amount $236 million over the 10 years to 2014, or about $23.6 million annually. 24 20 Government of Canada, National Dementia Research and Prevention Plan. 21 Canadian Institutes of Health Research, Canadian Consortium on Neurodegeneration in Aging. 22 Canadian Dementia Action Network, Canadian Dementia. 23 Ibid. 24 Government of Canada, National Dementia Research and Prevention Plan. Find this and other Conference Board research at www.e-library.ca 57

Understanding Health and Social Services for Seniors in Canada Opportunities and Innovations By providing extra supports in patients homes, at the primary care provider, or in assisted living situations, it is hoped that many dementia sufferers can live independently for longer with a better quality of life. Indeed many of the notable provincial initiatives related to LTC and home care we examined are directly related to addressing the requirements of patients with dementia. Some of these examples are listed below: In BC, there is a desire to establish standards for admission to special care units) within LTC facilities. These units involve the most intense level of care and segregate demented and often violent residents from others that are more functional. Currently it is estimated that 70 to 80 per cent of clients in LTC in BC have dementia. In Manitoba, the First Link referral program provides a mechanism for health care professionals to link dementia patients and their caregivers to the Alzheimer s Society for information and support such as local groups, counselling, education sessions, and other health resources. In Ontario, family health teams across the province have introduced a range of programs to support patients with dementia. These include the promising memory clinic model. (See Memory Clinics: An Innovation From the Primary Care Sector. ) In addition a greater number of nurses in these teams are now trained to conduct geriatric and cognitive assessments, which leads to recommendations for treatment, community support, or placement. In Nova Scotia, there are around 400 specialized care beds specifically for people with moderate to severe dementia. However, the Home Again program offers some supports that can benefit dementia patients as well, such as automated medication dispensers. In Newfoundland and Labrador, there is a move toward Protective Community Residences, known as dementia bungalows, which are small assisted living arrangements involving 10 to 12 beds and mildly demented patients who can still take part in running the household (dishes, laundry, etc.), despite elopement risk. These residences have been operating since 2009 10 and have been very successful, receiving positive praise from families involved. Find this and other Conference Board research at www.e-library.ca 58

Chapter 3 The Conference Board of Canada Memory Clinics: An Innovation From the Primary Care Sector As with other chronic diseases, a large amount of dementia care and treatment could be delivered in a primary care setting if the model of primary care is set up to do it. For example, in Ontario, the family health teams (FHT) model of care has allowed practitioners to innovate in many ways to serve the needs of their communities. One such example is the concept of a Memory Clinic. 25 Developed at the Centre for Family Medicine FHT in Kitchener, the clinic utilizes the skills and knowledge of nurses, social workers, pharmacists, and physicians. This team meets with patients and family members to assess and create a plan of care options. The aim is to provide early diagnosis and treatment that can help delay the need for institutionalization and increase quality of life for patients and their caregivers. Among other benefits, the model means that lengthy wait times to see a specialist can often be avoided. With fewer referrals overall, the wait times for those complex patients that do require more specialized care are reduced. This successful model has been replicated across multiple interdisciplinary teams in other FHTs and community health centres. 26 Dementia is a devastating disease and a significant and growing problem that deserves careful consideration. Despite current projections that call for considerable growth in the number of cases over the next 5 to 20 years, Canada has been slow in creating a coordinated action plan and a strategy to successfully address this challenge. The growing incidence and prevalence of dementia brings great societal and economic burden to Canada and has been partly responsible for a shift in the type of institutional services provided to seniors in Canada. And although provinces have been reacting to this challenge, greater research and a coordinated strategy is needed to ensure that patients 25 Lee and others, Enhancing Dementia Care. 26 Ontario College of Family Physicians, The Five Day Education Program to Establish Memory Clinics in Family Practices. Find this and other Conference Board research at www.e-library.ca 59

Understanding Health and Social Services for Seniors in Canada In 2014, Canada spent an estimated $215 billion on health care up 2.1 per cent from the previous year and accounting for 11 per cent of GDP. with dementia, and their families, will have access to timely, safe, and appropriate care care that meets the evolving needs of patients and families as the disease progresses. Restricted Funding to Support Seniors Growing Health Needs In 2014, Canada spent an estimated $215 billion on health care, 27 up 2.1 per cent from the previous year and accounting for 11 per cent of gross domestic product. Compared with some other leading OECD countries, this level of expenditure is high. For example, in 2012, Canada had an estimated per capita health expenditure 28 (expressed in US dollars) of $4,602, while the United Kingdom and Australia stood at $3,289 and $3,997 29 respectively. The recent financial recession created pressures to constrain or reduce spending on health care as much as possible. The year 2014 marked the end of a 10-year Health Accord between the federal and provincial/territorial governments, in which the federal government transferred an additional $41 billion to the provinces and territories over one decade (at about 6 per cent annual increases) to support health system improvement and reform. The Accord had mixed reviews by a senate committee, which stated that, although it helped to stimulate some change, it did not achieve system reform. Changes in the Canada Health Transfer (CHT) system, which took effect in 2014 15, saw a shift to allocation on an equal per capita cash basis. This will lead to some provinces receiving a smaller portion of the transfer total. Additionally, the growth in transfers has been set at 6 per cent until 2016 17. After that, CHT growth will see a minimum increase of 3 per cent. Any increases beyond 3 per cent are tied to a three-year moving average of GDP. 30 27 CIHI, National Health Expenditure Trends. 28 OECD, Total Expenditure on Health. 29 The most recent figures available for Australia are for 2011. 30 Department of Finance Canada, Canada Health Transfer. Find this and other Conference Board research at www.e-library.ca 60

Chapter 3 The Conference Board of Canada Given the expected growth in demand for home care and LTC services, appropriate funding allocation to these two sectors is critical. Health care spending accounts for a large and growing portion of provincial spending (around 30 to 40 per cent depending on the province). Constraining the growth of transfers has already led to provinces trying to find ways to rein in their health budgets. The restrictions in funding are not the only pressure on the provinces however. Population growth and inflation are estimated to have added a combined 2.8 per cent to spending in 2014, while the aging of the population added a further 0.9 per cent. 31 Growth in the seniors population is of course not equal between provinces. This means that the demand for health care services by seniors is also not equal between provinces. This has led some commentators to point out that the changes to the CHT do not take this into account and will place even more pressure on some provinces. 32 Given the expected growth in demand for home care and LTC services, appropriate funding allocation to these sectors is critical. The main funding issues in these two health care sectors are discussed below. Funding of Home Care Services Increased demand for home care in recent years has not been matched by a proportionate increase in funding. The Canadian Home Care Association reported an increase of 55 percent in the number of people receiving home care from 2008 11. Part of this increase is due to the desire and ability of home care services to manage the increasingly complex nature of clients health care needs. Meeting these more complex needs obviously comes at a greater cost because of the requirement for more trained staff and equipment. However, even though expenditure on home care has increased, this increase does not match the increase in demand observed in this sector. As Table 11 shows, home care has received between 1.6 and 6.4 per cent of total public expenditures in recent years, despite the massive increase in the demand for these services. 31 CIHI, National Health Expenditure Trends. 32 Di Matteo, Canada Health Transfer Changes. Find this and other Conference Board research at www.e-library.ca 61

Understanding Health and Social Services for Seniors in Canada Table 11 Public Expenditures for Home Care 2005 06 2006 07 2007 08 2008 09 2009 10 2010 11 2011 12 B.C. Number of recipients 81,452 84,795 85,051 86,389 83,480 Public expenditure ($ millions) 559 610 648 679 699 721 754 Percentage of total 4.6 4.8 4.6 4.6 4.6 4.5 4.5 Alta. Number of recipients 100,277 104,704 Public expenditure ($ millions) 269 284 308 362 383 402 Percentage of total 2.6 2.3 2.5 2.6 2.6 2.4 Man. Number of recipients 37,227 39,067 38,895 39,585 38,679 39,125 Public expenditure ($ millions) 228 239 254 262 274 290 Percentage of total 6.2 6.1 6.2 5.9 5.7 5.8 Ont. Number of recipients 572,950 586,423 603,535 616,952 Public expenditure ($ millions) 1,445 1,576 1,670 1,767 1,882 1,988 2,112 Percentage of total 4.5 4.6 4.4 4.3 4.3 4.4 4.5 Que. Number of recipients 307,785 320,557 321,001 323,176 330,992 Public expenditure ($ millions) 903 996 1,156 1,283 1,358 1,407 Percentage of total 4.6 4.8 5.3 5.5 5.4 5.4 N.B. Number of recipients 43,971 43,487 43,287 48,468 48,952 Public expenditure ($ millions) 132 143 157 171 179 187 Percentage of total 6.2 6.1 6.4 6.5 6.4 6.4 N.S. Number of recipients 20,392 21,112 21,492 22,697 24,262 24,144 Public expenditure ($ millions) 132 152 166 178 183 196 194 Percentage of total 5.1 5.2 5.3 5.4 5.4 5 5.2 P.E.I. Number of recipients 2,097 1 Public expenditure ($ millions) 9 8.1 8.6 9.1 11.2 13 14.1 Percentage of total 2.4 2.1 2 2 2.2 2.3 2.4 N.L. Number of recipients 4,397 4,514 4,721 5,460 6,581 7,374 Public expenditure ($ millions) 68 73 79 88 107 136 155 Percentage of total 4.3 4.3 4.3 4.4 4.9 5.6 6 (continued...) Find this and other Conference Board research at www.e-library.ca 62

Chapter 3 The Conference Board of Canada Table 11 Public Expenditures for Home Care 2005 06 2006 07 2007 08 2008 09 2009 10 2010 11 2011 12 Nun. Number of recipients 1,212 1,361 1,276 1,512 1,681 1,443 Public expenditure ($ millions) 7 7.2 7.4 7.5 7.7 7.8 Percentage of total 3.1 2.8 2.8 2.8 2.8 2.8 N.W.T. Number of recipients 826 989 906 946 953 Public expenditure ($ millions) 3.3 4 4.2 5.3 5.3 4.6 Percentage of total 1.5 1.8 1.7 1.9 1.8 1.6 Y.T. Number of recipients 675 651 709 699 852 1032 Public expenditure ($ millions) 3.2 3.7 3.5 3.8 4.3 4.5 5.4 Percentage of total 2.6 2.6 2.4 2.4 2.3 2.2 2.6 1 as of March 2011 Source: Canadian Home Care Association, Portraits of Home Care in Canada 2013. Find this and other Conference Board research at www.e-library.ca 63

Understanding Health and Social Services for Seniors in Canada Given this scenario, it is not surprising that many Canadians, including seniors, have unmet home care needs. A 2012 Statistics Canada report showed that around 461,000 Canadian adults needed help but did not receive any care, and a further 331,000 received some but not all the help they thought they needed. 33 The report also found that people who have partially or totally unmet home care needs had higher feelings of loneliness, stress, and sleep problems. Funding allocation formulas for this sector need to be revisited to ensure enough resources are available not only to cope with demand, but also to contribute to overall system improvement. Funding and Pre-Savings to Appropriately Meet LTC Needs in Canada LTC costs in Canada are covered through public (government plans and subsidies) and private (fees paid by residents) contributions. Adequate funding levels ensure LTC facilities have the resources to attract qualified staff and deploy innovations to better meet clients needs. However, as Table 12 shows, with the exception of Nova Scotia, every province operates its LTC sector at a net deficit. This situation calls for a review of funding formulas. These deficits highlight the importance of the public and private contributions to the sustainability of the sector. However, public and private payers seem to be unprepared to face future long-term care commitments. About half of Canadians have considered some kind of long-term or supportive living arrangement in their future planning. 34 If the current system remains unchanged, there will be a funding gap for long-term care in Canada over the next 35 years. A recent report by the Canadian Life and Health Insurance Association claims that, conservatively, the cost, in current dollars, of providing long-term care over the next 35 years is almost $1.2 trillion, but current levels of government program 33 Turcotte, Canadians With Unmet Home Care Needs. 34 CIHI, How Canada Compares. Find this and other Conference Board research at www.e-library.ca 64

Chapter 3 The Conference Board of Canada Table 12 LTC Facilities, Beds, Residents, Total Cost, and Net Income, by Province, 2012 Facilities Beds Residents Total cost ($) Net income ($ 1 ) B.C. 230 22,028 21,135 1,406,142,728 246,582,703 Alta. 112 16,188 15,671 952,659,154 42,617,328 Sask. 122 7,542 7,189 701,234,447 119,086,527 Man. 77 9,329 9,185 639,583,776 55,816,192 Ont. 612 78,396 76,008 5,018,219,761 111,145,529 Que. - - - - - N.B. 77 4,418 4,261 326,873,835 2,059,112 P.E.I. 15 1,237 1,134 82,317,552 20,309,703 N.S. 73 6,188 6,001 436,288,878 6,072,754 N.L. 39 3,103 2,751 194,859,785 8,509,543 TE 2 7 270 255 29,789,542 11,864,774 1 Net income includes funding from provincial government departments and municipalities, payments by residents, and other sundry earnings. 2 TE = Territories. Information from Statistics Canada was not available for individual territories. Sources: The Conference Board of Canada; Statistics Canada. and funding support will cover approximately half (about $595 billion). As a result, Canadians have an unfunded liability for long-term care of $590 billion, which is the equivalent of about 95 per cent of all individual registered savings plans in Canada today. Adding to this challenge is the fact that Canadians generally do not understand that the support for LTC is limited in Canada and often income-tested. More public information explaining LTC funding in Canada is needed. In addition, it is necessary to understand the reasons for inadequate retirement savings, and offer incentives to the population and employers to counter them. Reasons for the inadequacy of savings include: longer life spans low workplace pension coverage (66 per cent of the working population in Ontario do not have a pension plan) low personal savings and high household debt in recent years Find this and other Conference Board research at www.e-library.ca 65

Understanding Health and Social Services for Seniors in Canada A few options, which have been proposed to encourage Canadians to save for LTC services, include a registered LTC savings plan; long-term care insurance subsidized by governments; and a tax-sheltered saving, such as an enhanced CPP. A few options to encourage Canadians to save for LTC services have been proposed and are under evaluation in each province. These include the following: A Registered LTC Savings Plan, into which Canadians could make contributions each year to save toward long-term care costs. These would be structured in a similar way to RESPs whereby payments by Canadians are supported by contributions from the Government of Canada. Compared with alternate saving vehicles, this option has a number of advantages. Income created from this type of savings vehicle is not taxed until it is withdrawn from the plan. When money is eventually withdrawn, it is generally taxed at a lower rate then it otherwise would be. Finally, because the government provides contributions that help lever individual contributions, it is attractive even for modest-income earners who stand to gain relatively little through tax deferral. Long-term care insurance subsidized by governments (U.S. model). Long-term care insurance is a type of supplemental insurance payable when an individual is afflicted with a debilitating, severe, or chronic illness. Such insurance generally takes one of two forms. One reimburses the holder for payments made as services are received, up to a pre-set maximum. The alternative is an income-style plan, which gives the insured a monthly payment. Typically, this income begins when an individual can no longer perform two or more normal daily activities (e.g., bathing and dressing). Payments would also take effect if an individual requires daily supervision due to cognitive impairment. A tax-sheltered saving such as an enhanced Canada Pension Plan. A disadvantage is that those lower-income households that most require extra savings have an incentive not to save in this way because of the effect it would have on their Guaranteed Income Supplement (GIS). 35 Inadequate preparation for future LTC commitments is a large and complex challenge. Provinces have been studying options to become better prepared, but no policy or strategy is in place yet. These policies 35 Dodge and Dion, Macroeconomic Aspects. Find this and other Conference Board research at www.e-library.ca 66

Chapter 3 The Conference Board of Canada would need to encourage new optional personal saving vehicles targeting future personal or family LTC costs, force more saving through automatic mechanisms (such as taxation), or both. Limited Senior-Friendly Mechanisms for Redress Poor care is distressing for seniors and their loved ones. In cases of abuse there are well-established resources dedicated to prevention and reporting. 36 Beyond these, a clear and transparent mechanism for dealing with complaints related to the quality of services is required. In most provinces the complaints process is designed to progress through three different levels. First, the management of a care services provider can be approached. In some provinces, standards for service providers include a requirement to have a complaint resolution process. If the issue is unresolved it can then be taken to a government body or department with responsibility (sometimes licensing authority) for the area. Ultimately the issue can be taken to a provincial ombudsman if the complaint has still not been resolved to the satisfaction of all parties. Only a few provinces have adopted a model where a seniors advocate is appointed to become the go-to person for all complaints related to seniors health and social services. This customer-centric model represents a good step forward as a method of simplifying the process of redress for seniors. Table 13 presents a summary overview of these mechanisms across Canada. 36 Government of Canada, Provincial and Territorial Resources. Find this and other Conference Board research at www.e-library.ca 67

Understanding Health and Social Services for Seniors in Canada Table 13 Redress Mechanisms, by Province Province B.C. 1 Description There is a three-step process defined by legislation, ending with the Patient Care Quality Review Board. The review board is part of the provincial government. Unresolved complaints can go to the Office of the Ombudsperson. A seniors advocate, who is independent from the health system, has just been appointed. This person will be accessible to the public by telephone and e-mail and will periodically make recommendations to the government. Alta. 2 In the first instance, a complaint can go to the relevant government office, such as through the Ministry of Health accommodation complaint line or the Alberta Health Services Patient Relations Office. Appeals can go to the Office of the Ombudsman. Alberta implemented a seniors advocate in July 2014. This person can help seniors navigate the continuum of care and address all their complaints or redirect them to the correct body. Sask. 3 The Government of Saskatchewan Personal Care Homes Program is a licensing and regulatory agency that establishes standards, monitors the operation of care homes, investigates complaints, and takes appropriate action to ensure compliance. Appeals can go to the Office of the Ombudsman. Man. 4 Ont. 5 Que. 6 N.B. 7 N.S. 8 The Manitoba Health Appeal Board gives residents of Manitoba access to an independent appeal process in the event of dissatisfaction with a financial or operational aspect of their health care. A person may, for instance, appeal a decision about long-term care placement or home care eligibility. The Protection for Persons in Care Office (PPCO) of Manitoba Health, Healthy Living and Seniors upholds the Protection for Persons in Care Act, which deals with issues of abuse while receiving care in personal care homes, hospitals, or any other designated health facility. Complaints about long-term care homes can go to the government via letter or the Long-Term Care Action Line. Complaints are referred to ministry inspectors for the purposes of conducting an inquiry or inspection, where appropriate, to ensure that LTC homes are compliant with legislation. Unlike in other provinces, the Ontario Ombudsman does not have jurisdiction over LTC homes. However, Ontario is planning to appoint an ombudsman specifically for patients. This position will look at unresolved complaints from hospital patients, LTC home residents, and CCAC clients. There is concern, though, that this position will not be an independent officer of the legislature. Complaints can go to the regional service quality and complaints commissioner, and can be appealed to the Health and Social Services Ombudsman. The Office of the Ombudsman has been given powers to investigate long-term care facilities. Nursing homes are licensed under the Nursing Homes Act; other residential homes are licensed under the Family Services Act. The Office of the Ombudsman has staff dedicated to seniors issues. The Department of Seniors is available to help with complaints. District health authorities have appeal processes for matters such as levels of care and fee assessments. (continued...) Find this and other Conference Board research at www.e-library.ca 68

Chapter 3 The Conference Board of Canada Table 13 (cont d) Redress Mechanisms, by Province Province P.E.I. 9 N.L. 10 Description Complainants can fill in the government complaint-form brochure or go online. A board created by the Community Care Facilities and Nursing Homes Act monitors residential facilities via annual inspections. The board has the power to revoke facility licences. There is currently no ombudsman. Complaints about a long-term care centre can go to the integrated health authority. 1 Patient Care Quality Review Boards, Make a Complaint. 2 Alberta Health, Resolving Concerns Within Alberta s Health System. 3 Government of Saskatchewan, Personal Care Homes. 4 Government of Manitoba, Protection for Persons in Care; Health Appeal Board. 5 Ontario Ministry of Health and Long-Term Care, Long-Term Care Home Complaint Process. 6 Government of Quebec, Service Satisfaction and Complaints. 7 Government of New Brunswick, Province to Expand Mandate of Ombudsman. 8 Nova Scotia Office of the Ombudsman, Seniors Service. 9 Government of PEI, Health PEI, Compliments and Complaints. 10 Seniors Resource Centre, Looking Beyond the Hurt, Appendix 2: Making an Official Referral/Report in Newfoundland and Labrador. There are global practices from which Canada might learn: Denmark offers the simplest model of redress for recipients of government health care. The National Agency for Patients Rights and Complaints is a single gateway for all complaints. Patients are offered a dialogue with the provider and can then decide if the complaint should be put to trial at this government agency. 37 In Sweden there are financial incentives to encourage higher standards of care. Performance on quality metrics related to patient safety and care are linked to monetary transfers to municipalities. Beyond this, unfair treatment by an administrative authority is dealt with by the parliamentary ombudsmen; patients can also complain to a patients advisory committee within the central government. 38 In the U.K., [the] Care Quality Commission (CQC), an independent regulator of health and adult social care, is responsible for assuring safety and quality [in LTC]. The CQC is an executive, non-departmental 37 OECD, OECD Reviews of Health Care Quality. 38 OECD, Sweden: Highlights From: A Good Life in Old Age?; Government Offices of Sweden, Health and Medical Care; The Commonwealth Fund, International Profiles of Health Care Systems, 2013. Find this and other Conference Board research at www.e-library.ca 69

Understanding Health and Social Services for Seniors in Canada public body of the department of health. CQC inspections enforce minimum requirements of quality. The National Institute for Health and Clinical Excellence (NICE) has also been given responsibility to develop quality standards. Complaints for NHS services can go to clinical commissioning groups (administrative organizations that include all of the local general practitioners) in the first instance, and if they are not satisfied, to the Parliamentary Health Service Ombudsman. Those assessed as ineligible for NHS continuing health care, which provides fully funded nursing care and care home fees, can appeal via a twostage process: a local review by the clinical commissioning group and an independent panel. If the outcome is still not satisfactory, the case can be taken to the Health Service Ombudsman. 39 The Current Federal Role in Key Health and Social Services for Seniors The federal government defines broad guidelines for health care services through the Canada Health Act (CHA) and transfers funds to provinces and territories to contribute to the financing of those services through the Canada Health Transfer. These are the two main mechanisms by which the federal government influences health care delivery, including health care for seniors. It is important to note, however, that home care and LTC (which are essential to sustain and restore seniors health, autonomy, and quality of life) are considered extended health services and therefore are not included under the CHA. Currently, these parts of the care continuum are governed by and under the responsibility of provincial and territorial legislation and governments. As a consequence, there is often inconsistency across jurisdictions in terminology used to describe different services and facilities, and how these are governed or owned. 40 The Romanow Commission recommended that a home care transfer should be set up to provide 39 NHS Choices, Making a Complaint; OECD, United Kingdom: Highlights From: A Good Life in Old Age?; Jones, Continuing Healthcare. 40 Health Canada, Health Care System. Find this and other Conference Board research at www.e-library.ca 70

Chapter 3 The Conference Board of Canada Through the Canada Pension Plan and Old Age Security, the federal government contributes to the decrease of elderly poverty. some home care services and ongoing support for informal caregivers under an expanded CHA. 41 This was echoed in a standing committee report from 2002. 42 As these recommendations were not acted on, Health Canada s main role on issues related to LTC, home care, and community care is more limited than it would otherwise be, consisting mainly of research and policy analysis in the area. In addition to its responsibility in health care in Canada, the federal government also plays a significant role in addressing some key determinants of health. For example, through the Canada Pension Plan and Old Age Security, the federal government contributes to the decrease of elderly poverty. These government transfers are important because they reduce income inequality. 43 Although Canada s wealth is distributed more equally than in the U.S., income inequality, as well as elderly poverty, 44 has increased in Canada over the past 20 years. Personal revenues provided by these government transfers enhance the ability of seniors to pay for home, LTC, or other health and personal services when these are needed to restore their health, maintain their autonomy, or improve their well-being and quality of life. A specific area where there have long been calls for more federal involvement and a national strategy is pharmacare. As noted in the introduction to this report, seniors take more prescription drugs than any other age group and have elevated risks of adverse side effects due to adverse drug interactions. 45 The CHA ensures everyone has access to drugs delivered in acute care, but does not cover other parts of the health continuum. The current system, where provinces and private insurance companies are free to administer their own programs, has produced a patchwork of coverage across Canada. A recent report on the suitability of income-based public pharmaceutical benefits for 41 Health Canada, Health Care System. 42 Kirby, The Health of Canadians. 43 The Conference Board of Canada, How Canada Performs: Income Inequality. 44 Canadian Medical Association, Health Care in Canada. 45 CIHI, Seniors and Prescription Drug Use. Find this and other Conference Board research at www.e-library.ca 71

Understanding Health and Social Services for Seniors in Canada The inconsistency among jurisdictions regarding home care, LTC, palliative care, and pharmacare has created health inequities across the country. the aging Canadian population found that the effect of such programs on seniors is negative. While provinces are shifting to such systems they create another barrier to access, which evidence suggests will reduce adherence to treatment plans among seniors. 46 This, of course, has a negative effect for health outcomes and future requirements for even more health care. A national pharmacare program has been advocated by Dr. Eric Hoskins, Ontario s Minister of Health and Long- Term Care, among others. His recent op-ed in The Globe and Mail 47 notes that Canada is the only country with universal health insurance, but no national pharmacare policy. It also notes that a national policy should increase coverage to improve equity of access, and that national coordination could save billions of dollars through bulk purchasing alone. This would be on top of the health and cost benefits from increased treatment adherence discussed above. The inconsistency among jurisdictions regarding home care, LTC, palliative care, and pharmacare has created health inequities across the country. As noted in this report and by many others, including the Romanow Commission, there are discrepancies in the type of care offered, the intensity of services available, and how much individuals are expected to pay across the country. 48 These inconsistencies may be partially responsible for the health disparities that exist across Canada. Research has demonstrated that people in British Columbia on average live over 10 years longer than people in Nunavut and that mortality due to diabetes is 250 per cent higher in Newfoundland and Labrador than in Prince Edward Island. These discrepancies are very significant, and unacceptable in a country like Canada. Given the demographic differences across Canada s provinces and territories, pressure on health services for seniors will be felt unequally across the country, which may exacerbate the health disparities that already exist. A greater federal role in health care in Canada can be a strong catalyst to reduce some disparities. 46 Morgan, Daw, and Law, Are Income-Based Public Drug Benefit Programs. 47 Hoskins, Why Canada Needs a National Pharmacare Program. 48 Romanow, Building on Values. Find this and other Conference Board research at www.e-library.ca 72

Chapter 3 The Conference Board of Canada The current role of the federal government is very limited in areas that are growing and are critical to seniors: home care, LTC, pharmacare, and palliative care. One area of successful federal involvement has been in addressing wait times. The federal government provided funding for wait reductions as part of the 2004 Health Accord, appointed a federal advisor on wait times, and supported provinces to initiate development of wait time benchmarks. 49 A 2012 senate committee report remarks that these successes could be built upon by both updating existing benchmarks and expanding to include others. 50 Home care, end-of-life care, and continuing care were specifically mentioned as areas that the federal government should work on with others to develop indicators to measure the quality and consistency of services across the country. The Wait Time Alliance contends that action in these areas would greatly reduce wait times in other areas of the health care system. 51 Furthermore, one of the WTA s eight recommendations for the federal government is to develop a pan-canadian seniors strategy and a national dementia strategy. This is part of the federal government s role in providing strategic leadership through its research and policy analysis functions. In summary, the current role of the federal government is very limited in areas that are growing and critical to seniors: home care, LTC, pharmacare, and palliative care. This has led to inconsistencies and inequalities across the country. As demographic trends continue to unfold in Canada, the need for greater federal involvement in funding and in the identification of guidelines to define these critical services and standardize the offering to Canadians, no matter where they live, is becoming more critical. 49 Wait Time Alliance, Timely Access to Care for All Canadians. 50 Ogilvie, Time for Transformative Change. 51 Wait Time Alliance, Timely Access to Care for All Canadians. Find this and other Conference Board research at www.e-library.ca 73

CHAPTER 4 Emerging Approaches in Canada and Beyond Chapter Summary Many of the innovative solutions to the myriad challenges facing seniors care focus on supporting seniors to live autonomously and independently for as long as possible, thereby also reducing care needs and costs. A strategic national approach is required with extra emphasis on developing and adopting innovations on prevention and integrated care, as well as seniorfriendly environments. Find this and other Conference Board research at www.e-library.ca

Chapter 4 The Conference Board of Canada Throughout this report, we have noted examples of promising developments within seniors care across Canada. The common focus of most efforts revolves around keeping elderly patients out of expensive acute care settings. Every province hopes to improve its system of home care and the roster of services that are available through home care. Even if new funding may not be available for all new measures, a reallocation of existing resources is envisioned. Notably, several provinces have implemented rapid response units. Some examples are provided below. Ontario s Association of Community Care Access Centres has built out its team of rapid response nurses. They contact patients within the first day of their discharge from hospital to connect these patients with a physician or nurse and to arrange a follow-up appointment within a week. They can be deployed quickly at other times when needed. 1 Winnipeg is piloting hospital health teams. These units provide 60-day intensive case management for high users of emergency departments. They help seniors transition to core programs that are available within their communities and that can help them stay out of hospitals. For the last several years, Women s Hospital in Toronto has been trialrunning virtual wards. These units, consisting of a doctor, a pharmacist, care coordinators, a team assistant, and nurses, are designed to support patients who are at high risk of 30-day readmission to acute care, by providing the best elements of hospital care at home. 2 1 Ontario Association of Community Care Access Centres, Rapid Response Nurses. 2 Division of General Internal Medicine, What Is the Virtual Ward? Find this and other Conference Board research at www.e-library.ca 75

Understanding Health and Social Services for Seniors in Canada Convalescent and restorative programs work with physiotherapists and occupational therapists to improve mobility, and with companies that provide assistive devices for ambulation and seating. Most provinces are also looking to create or expand half-way destinations that offer a level of care between home care and LTC facilities. Whether known as assisted living or supportive living facilities, the idea is to build environments in which seniors who can no longer live at home, yet do not need full-time medical attention, receive the right level of support in conjunction with organized daily activities and social stimulation. We have already noted the success of dementia bungalows in Newfoundland. Expansion of convalescent and restorative care programs are being considered by several provinces. They are a means by which seniors who have been discharged from hospitals can be slowly rehabilitated to a level of health and wellness that obviates readmission or LTC institutionalization. Convalescent and restorative programs work with physiotherapists and occupational therapists to improve mobility and with companies that provide assistive devices for ambulation and seating. Paramedics are being sought to provide services traditionally provided by nurses or doctors by applying existing scopes and roles in new environments in a collaborative practice model alongside other care providers, which keeps long-term care patients safely in their homes. In 2011, Halifax initiated its Extended Care Paramedic (ECP) program, whereby specially trained paramedics provide primary acute care to seniors in their nursing homes. These paramedics can tend to minor injuries and work with family members and nursing home personnel to develop care plans. If necessary, the paramedics can also arrange for facilitated emergency room visits, whereby the paramedic confers with an online physician prior to the senior s arrival at the hospital. 3 As most nursing home residents have some degree of cognitive impairment, transfer to an acute care setting can be confusing. Avoiding unnecessary shuttling and long wait times in emergency rooms avoids undue bodily stress. 3 Moulton, Paramedic Program Reducing Emergency, E631 32. Find this and other Conference Board research at www.e-library.ca 76

Chapter 4 The Conference Board of Canada Given the magnitude of the demand, innovative technologies offer a possibility to expand the reach and quality of health care services. The use of innovative solutions and technologies for telemonitoring and telehealth is in exploration and trial in some provinces but, overall, Canada has been slow in adopting these solutions. Other countries have been pursuing a more systematic and concerted effort to develop and embrace technologies that support healthy aging. For example, the European Commission has identified active and healthy aging as a major societal challenge and has been supporting a few projects to ensure Europe will lead the world in providing innovative responses to this challenge. The European Innovation Partnership on Active and Healthy Ageing is pursuing a triple win for Europe: 1. Enabling EU citizens to lead healthy, active, and independent lives while aging. 2. Improving the sustainability and efficiency of social and health care systems. 3. Boosting and improving the competitiveness of the markets for innovative products and services, responding to the aging challenge at both EU and global level, thus creating new opportunities for businesses. The aim of the European Innovation Partnership on Active and Healthy Ageing will be to extend the mean healthy lifespan of citizens by two years by 2020. The Partnership aims to improve the environment for uptake of innovation; leverage financing and investments in innovation; and improve coordination and consistency between funding for research and innovation at the European, national, and regional level in Europe. Six action groups made up of universities and research groups; public authorities; health providers; industry; non-governmental organizations representing citizens; older people; patients; and others have been formed to advance the following areas: Find this and other Conference Board research at www.e-library.ca 77

Understanding Health and Social Services for Seniors in Canada The innovative approaches that have emerged in the last few years in an attempt to better meet the needs of seniors and their families have been piecemeal and reactive to changes in demand. Prescription and adherence to treatment Fall prevention Prevention of functional decline and frailty Integrated care Independent living Age-friendly environments Under independent living two projects deserve particular attention: The SILVER (Supporting Independent LiVing for the Elderly through Robotics) project looks for new technologies to support seniors in their everyday lives. Through the use of robotics-based technologies, seniors can carry on living independently at home even if they have physical or cognitive impairments. Innovative technologies and solutions are sought by using a pre-commercial procurement (PCP) process, which supports the development and commercialization of promising ideas. The HAPPI (Healthy Ageing Public Procurement of Innovations) project seeks to establish the conditions for health institutions throughout Europe to collaborate in the purchase of innovative aging well and health products, services, and solutions for the long term. Aging well in health facilities is an area where innovation does not at present have a high profile. This is either because it has not been fully promoted or that administrators do not perceive it to be of sufficient value. However the issue of aging well is of great importance for institutions and product manufacturers. To cover the needs of the elderly in terms of autonomy, dignity, mobility, health, and well-being, hospitals and nursing homes have to hunt for innovation in order to control their expenses. To address this challenge, the HAPPI project brings together a consortium of procurement organizations and innovation experts to detect and assess innovative products or services that will support aging well. The project focuses on the procurement of existing innovation, meaning off-the-shelf solutions new to the market. The innovative approaches within Canada that have emerged in the last few years in an attempt to better meet the needs of seniors and their families are a testament to the creativity and dedication of our health Find this and other Conference Board research at www.e-library.ca 78

Chapter 4 The Conference Board of Canada care workforce. These approaches have been piecemeal and reactive to changes in demand, complexity, fiscal environment, and demographics. A more strategic approach focusing on healthy aging, national in scope, leveraging our talent, and including the critical roles that people, technology, and processes play in prevention, independent living, integrated care, and on creating senior-friendly environments will serve Canadians well. Such an approach would support seniors remaining independent for longer, while simultaneously encouraging greater participation and contribution to society. Expansion of existing innovative approaches and the creation of new ones will be best achieved if all stakeholders work together. This means active involvement by all levels of government along with greater participation from the private sector and, of course, seniors themselves. Find this and other Conference Board research at www.e-library.ca 79

CHAPTER 5 Conclusion Chapter Summary Seniors are more frequent and heavier users of health care services. Services and programs for seniors need to be well designed to meet future needs while being sustainable. There are currently many gaps in seniors care across Canada, creating inequity of access and compounding health disparities. Addressing the many challenges facing seniors care will be facilitated by a coordinated approach from all stakeholders. Find this and other Conference Board research at www.e-library.ca

Chapter 5 The Conference Board of Canada Seniors are heavy users of the country s provincial and territorial health care systems and related facilities whether primary care, home care, long-term care, palliative care, or wellness and prevention programs in the community. Their use is not just more frequent but also more intense, given the rising prevalence of dementia and the general ailments and disabilities of old age. As many of the services and programs available to seniors are partially or fully subsidized by governments, it is imperative that they be properly designed and implemented in order to meet the special needs of seniors as well as to ensure value for money and fiscal sustainability. This report provides an overview of the current continuum of care available to seniors in the various jurisdictions in Canada in order to help us meet the above-mentioned goals. Most of the information in this report is part of the public domain, but the details are not always easy to find, or to decipher even when they can be readily found. This report brings together all the most relevant details in one place. It is a uniquely comprehensive record of the state of affairs in seniors care as it stands in the second decade of the new century. The analysis undertaken draws out noticeable gaps in seniors care, whether lack of funding for prioritized services, ostensibly poor utilization of specialized programs, or unduly restricted access to or narrow eligibility for certain programs. Considerable room for improvement in the existing infrastructure in Canada does remain, and better collaboration between the different parts of the continuum of care within each jurisdiction would do much to ensure better allocation of resources. Find this and other Conference Board research at www.e-library.ca 81

Understanding Health and Social Services for Seniors in Canada Responding to contemporary demographic change need not be an insurmountable challenge. By taking heed of the current trends, as well as the strengths and weaknesses of our present arrangements in seniors care, Canada s health care systems and ancillary organizations can adapt to meet the needs of our oldest citizens. Some of the major challenges in Canada are the inconsistency among jurisdictions in services provided, the terminology used to describe these services, and the requirements to access them. Other countries have taken a more centralized approach for planning and coordinating health services for seniors. Issues around seniors health and health care services are complex; successfully addressing them would require cooperation between federal, provincial, and territorial governments, as well as key health care stakeholders and communities. There is an opportunity for the federal government to help eliminate the many discrepancies in services and access that exist today. Just as it did half a century ago when it moved to create Canada s national medicare program to meet the needs of a previous generation, the federal government could play a notable role in coordinating and standardizing the current health needs of our seniors. It is now the time to carefully design the services and programs that are so essential for today and for Canada s future. Tell us how we re doing rate this publication. www.conferenceboard.ca/e-library/abstract.aspx?did=7025 Find this and other Conference Board research at www.e-library.ca 82

Appendix A The Conference Board of Canada APPENDIX A Bibliography Accreditation Canada. Geriatric Program Assessment Teams (GPAT). 2013. www.accreditation.ca/node/6492 (accessed December 16, 2014). Age UK. Attendance Allowance: Extra Money to Help You. 2014. www.ageuk.org.uk/documents/en-gb/information-guides/ageukig49_ attendance_allowance_inf.pdf?epslanguage=en-gb?dtrk=true. Alberta Health. Coverage for Seniors Benefit. 2014. www.health.alberta. ca/services/drugs-seniors.html (accessed December 14, 2014). Alberta Seniors. Dental and Optical Assistance for Seniors. 2014. www.seniors.alberta.ca/seniors/dental-optical-assistance.html (accessed December 12, 2014). Astles, Philip, Trevor Foster, Jeannette Lye, and Gabriela Prada. Paving the Road to Higher Performance: Benchmarking Provincial Health Systems. Ottawa: The Conference Board of Canada, 2013. Alzheimer Society of Canada. Dementia Numbers in Canada. 2014. www.alzheimer.ca/en/on/home/about-dementia/what-is-dementia/ Dementia-numbers.. Rising Tide: The Impact of Dementia on Canadian Society. Toronto: Alzheimer Society of Canada, 2010. www.alzheimer.ca/~/media/files/ national/advocacy/asc_rising_tide_full_report_e.pdf. British Columbia Office of the Ombudsperson. The Best of Care: Getting It Right for Seniors in British Columbia (Part 1). Public Report no. 46. Victoria: BC Office of the Ombudsperson, December 2009. www.ombudsman.bc.ca/images/resources/reports/public_reports/ public_report_no_46.pdf (accessed December 17, 2014). Find this and other Conference Board research at www.e-library.ca 83

Understanding Health and Social Services for Seniors in Canada Canada Gazette, vol. 146, no. 9. http://gazette.gc.ca/rp-pr/p2/2012/indexeng.html. Canadian Dementia Action Network. Canadian Dementia Action Network Proposal. 2009 10. www.cdan.ca/articles/cdan-complete-0824-m.pdf. Canadian Home Care Association. Portraits of Home Care in Canada 2013. Ottawa: Canadian Home Care Association, 2013. www.cdnhomecare.ca/content.php?doc=274. Canadian Hospice Palliative Care Association. Fact Sheet: Hospice Palliative Care in Canada. www.chpca.net/media/7622/fact_sheet_hpc_ in_canada_may_2012_final.pdf (accessed December 18, 2014). Canadian Institute for Health Information. How Canada Compares: Results From The Commonwealth Fund 2014 International Health Policy Survey of Older Adults. Ottawa: CIHI, 2015.. National Health Expenditure Trends, 1975 to 2014. Ottawa: CIHI, October 2014. www.cihi.ca/web/resource/en/nhex_2014_report_en.pdf (accessed December 23, 2014).. Benchmarks for Treatment and Wait Time in Canada. 2013. http://waittimes.cihi.ca/all (accessed December 23, 2014).. Health Care in Canada, 2012: A Focus on Wait Times. Ottawa: CIHI, 2012. https://secure.cihi.ca/free_products/hcic2012-fullreport- ENweb.pdf (accessed September 12, 2014).. Health Care Cost Drivers: The Facts. Ottawa: CIHI, November 2011. https://secure.cihi.ca/free_products/health_care_cost_drivers_the_facts_ en.pdf (accessed February 11, 2015).. Seniors and the Health Care System: What Is the Impact of Multiple Chronic Conditions? Analysis in Brief. Ottawa: CIHI, January 2011. https://secure.cihi.ca/free_products/air-chronic_disease_aib_en.pdf (accessed December 16, 2014).. Health Care in Canada, 2011: A Focus on Seniors and Aging. Ottawa: CIHI, 2011. Find this report and other Conference Board research at www.e-library.ca 84

Appendix A The Conference Board of Canada. Seniors and Falls. Series on Seniors. Ottawa: CIHI, 2010. www.cihi.ca/cihi-ext-portal/pdf/internet/seniors_falls_info_en (accessed December 18, 2014).. Seniors and Prescription Drug Use. Series on Seniors. Ottawa: CIHI, 2010. www.cihi.ca/cihi-ext-portal/pdf/internet/seniors_drug_info_en (accessed December 14, 2014). Canadian Institutes of Health Research. Canadian Consortium on Neurodegeneration in Aging (CCNA). www.cihr.gc.ca/e/46475.html. Canadian Medical Association. Health Care in Canada: What Makes Us Sick? 2013. Care Link Advantage. Care Link Advantage. www.carelinkadvantage.ca/ carelink_advantage.php (accessed December 18, 2014). CarersUK. Factsheet: Carer s Allowance. 2014. www.carersuk.org/files/ helpandadvice/71/factsheet-uk1025--carers-allowance.pdf.. Factsheet England & Wales: Assessments. 2014. www.carersuk.org/ files/helpandadvice/2589/factsheet-ew1020--assessments.pdf. CBC News. Yukon Long-Term Care Fees to Rise. May 13, 2013. www. cbc.ca/news/canada/north/yukon-long-term-care-fees-to-rise-1.1373339. Chappell, Neena L., and Marcus J. Hollander. An Evidence-Based Policy Prescription for an Aging Population. HealthcarePapers 11, no. 1 (April 2011): 8 18. Community Care Access Centres. Erie St. Clair CCAC LTC Wait Times: March 2014. February 28, 2014. http://healthcareathome.ca/eriestclair/ en/documents/ltchs/wait%20time%20documents/ltcwaittimes_ MARCH2014.pdf (accessed December 17, 2014). Constant, Alexandra, Stephen Petersen, Charles D. Mallory, and Jennifer Major. Research Synthesis on Cost Drivers in the Health Sector and Proposed Policy Options. CHSRF Series on Cost Drivers and Health System Efficiency. Paper 1. Ottawa: Canadian Health Services Research Find this report and other Conference Board research at www.e-library.ca 85

Understanding Health and Social Services for Seniors in Canada Foundation, February 2011. www.cfhi-fcass.ca/sf-docs/default-source/ hospital-funding-docs/chsr-constantsynthesiscostdriverseng_1. pdf?sfvrsn=0 (accessed December 11, 2014). Davis, Karen, Kristof Stremikis, David Squires, and Cathy Schoen. 2014 Update: Mirror, Mirror on the Wall: How the Performance of the U.S. Health Care System Compares Internationally. New York and Washington, DC: The Commonwealth Fund, June 2014. www. commonwealthfund.org/~/media/files/publications/fund-report/2014/ jun/1755_davis_mirror_mirror_2014.pdf (accessed December 15, 2014). Department of Finance Canada. Economic and Fiscal Implications of Canada s Aging Population. 2012. http://publications.gc.ca/collections/ collection_2013/fin/f2-217-2012-eng.pdf (accessed February 11, 2015).. Canada Health Transfer. www.fin.gc.ca/fedprov/cht-eng.asp. (accessed January 15, 2015). Department of Health and Community Services, Newfoundland and Labrador. Dental Services. September 26, 2014. www.health.gov.nl.ca/ health/dentalservices/general_info.html (accessed December 14, 2014). Di Matteo, L. Canada Health Transfer Changes: The Devil Is in the Details. http://umanitoba.ca/outreach/evidencenetwork/archives/4833 (accessed January 15, 2015). Division of General Internal Medicine, Department of Medicine, University of Toronto. What Is the Virtual Ward? January 16, 2015. www.gim.utoronto.ca/research/vward.htm (accessed January 16, 2015). Dodge, D., and R. Dion. Macroeconomic Aspects of Retirement Savings. Bennett Jones, LLP, 2014. Dowdall, Brent. Feeling at Home? A Survey of Canadians on Home and Community Care. Ottawa: The Conference Board of Canada, forthcoming. Drummond, Don. Therapy or Surgery? A Prescription for Canada s Health System. C.D. Howe Institute: Benefactors Lecture. Held at Toronto, November 17, 2011. Find this report and other Conference Board research at www.e-library.ca 86

Appendix A The Conference Board of Canada Employment and Social Development Canada. Canadians in Context Aging Population. December 11, 2014. www4.hrsdc.gc.ca/.3ndic.1t.4r@- eng.jsp?iid=33 (accessed December 12, 2014). Fukushima, Nanna, Johanna Adami, and Marten Palme. The Long- Term Care System for the Elderly in Sweden. ENEPRI Research Report No. 89, June 15, 2010. www.ancien-longtermcare.eu/sites/default/files/ ENEPRI%20_ANCIEN_%20RR%20No%2089%20Sweden.pdf. Gill, Vijay, James Knowles, and David Stewart-Patterson. The Bucks Stop Here: Trends in Income Inequality Between Generations. Ottawa: The Conference Board of Canada, 2014. Gneezy, Uri, and Aldo Rustichini. A Fine Is a Price. The Journal of Legal Studies 29 (January 2000): 1 17. Government of Canada. National Dementia Research and Prevention Plan. http://healthycanadians.gc.ca/diseases-conditions-maladiesaffections/disease-maladie/dementia-demence/plan-eng.php.. Provincial and Territorial Resources on Elder Abuse. www.seniors. gc.ca/eng/pie/eaa/help.shtml. Government Offices of Sweden. Health and Medical Care in Sweden. www.government.se/sb/d/15660 (accessed January 20, 2015). Health Canada. First Minister s Meeting on the Future of Health Care 2004. 2004. www.hc-sc.gc.ca/hcs-sss/delivery-prestation/fptcollab/2004- fmm-rpm/index-eng.php.. First Nations & Inuit Health: Home and Community Care. www.hc-sc.gc.ca/fniah-spnia/services/home-domicile/index-eng.php (accessed December 23, 2014).. Health Care System: Long-Term Facilities-Based Care. www.hc-sc.gc.ca/hcs-sss/home-domicile/longdur/index-eng.php. Health Canada, and Public Health Agency of Canada. Evaluation of the First Nations and Inuit Home and Community Care Program 2008 2009 to 2011 2012. Ottawa: Health Canada, 2013. Find this report and other Conference Board research at www.e-library.ca 87

Understanding Health and Social Services for Seniors in Canada Health Council of Canada. Canada s Most Vulnerable: Improving Health Care for First Nations, Inuit, and Métis Seniors. Toronto: Health Council of Canada, 2013. Health Quality Council of Alberta. Review of Alberta s Health Services Continuing Care Wait List: First Available Appropriate Living Option Policy. March 2014. https://d10k7k7mywg42z.cloudfront. net/assets/538f4ef14f720a2000000016/faalo_final_report.pdf (accessed December 17, 2014). Health Quality Ontario. Long-Term Care. www.hqontario.ca/publicreporting/long-term-care (accessed December 17, 2014). Heckman, George A., Frank J. Molnar, and Linda Lee. Geriatric Medicine Leadership of Health Care Transformation: To Be or Not To Be? Canadian Geriatrics Journal 16, no. 4 (September 2013). www.cgjonline.ca/index.php/cgj/article/view/89/157 (accessed December 15, 2014). Hermus, Greg, Carole Stonebridge, Louis Thériault, and Fares Bounajm. Home and Community Care in Canada: An Economic Footprint. Ottawa: The Conference Board of Canada, May 2012. Holt-Lundstad, Julianne, Timothy B. Smith, and Bradley J. Layton. Social Relationships and Mortality Risk: A Meta-Analytic Review. PLoS Medicine 7, no. 7 (July 2010): 1 20. (accessed June 11, 2014). Home Care Ontario. Facts and Figures Publicly Funded Home Care. 2014. www.homecareontario.ca/home-care-services/facts-figures/ publiclyfundedhomecare (accessed December 16, 2014). Hoskins, E. Why Canada Needs a National Pharmacare Program. The Globe and Mail, October 14, 2014. Institute for Health Metrics and Evaluation. GBD Profile: Canada. Country Profiles. 2010. www.healthmetricsandevaluation.org/gbd/countryprofiles (accessed May 9, 2014). Jones, Rupert. Continuing Healthcare: What You Need to Know. The Guardian, November 9, 2013. Find this report and other Conference Board research at www.e-library.ca 88

Appendix A The Conference Board of Canada Johansson, Lennarth, Helen Long, and Marti G. Parker. Informal Caregiving for Elders in Sweden: An Analysis of Current Policy Developments. Journal of Aging & Social Policy 23, no. 4 (2011): 335 53. Kirby, J.L. The Health of Canadians The Federal Role. Volume Two: Current Trends and Future Challenges. Standing Senate Committee on Social Affairs, Science and Technology, January 2002. www.parl.gc.ca/content/sen/committee/371/soci/rep/repjan01vol2-e. htm#_toc533246192. KPMG. Tax Facts 2014 2015. Toronto: KPMG, 2014. www.kpmg.com/ ca/en/services/tax/documents/taxfacts-2013-2014-v2.pdf (accessed October 8, 2014). Lalonde, Dawn. Family Health Team Participation Day. Espanola Regional Hospital and Health Centre. MidNorth Monitor, June 19, 2013. www.espanolaregionalhospital.ca/index.php/news-andcommunity/news/194-family-health-team-participaction-day (accessed December 23, 2014). Lee, Linda, Loretta M. Hillier, Paul Stolee, George Heckman, Micheline Gagnon, Carrie A. McAiney, and David Harvey. Enhancing Dementia Care: A Primary Care-Based Memory Clinic. Journal of the American Geriatrics Society 58, no. 11 (2010): 2197 204. Live!y. Personal Emergency Response Reimagined. 2014. www.mylively.com/ (accessed December 18, 2014). Manitoba Health, Health Information Management. Annual Statistics, 2012 2013. www.gov.mb.ca/health/annstats/as1213.pdf (accessed December 17, 2014). Manitoba Health, Healthy Living and Seniors. What Health Services Are Available to You in Manitoba? www.gov.mb.ca/health/guide/4.html (accessed December 17, 2014). Find this report and other Conference Board research at www.e-library.ca 89

Understanding Health and Social Services for Seniors in Canada Morgan, Steven G., Jamie R. Daw, and Michael R. Law. Are Income- Based Public Drug Benefit Programs Fit for an Aging Population? Institute for Research on Public Policy, December 3, 2014. http://irpp.org/ research-studies/study-no50/. Moulton, Donalee. Paramedic Program Reducing Emergency Room Congestion. Canadian Medical Association Journal 183, no. 10 (July 2011): E631 32. www.cmaj.ca/content/183/10/e631 (accessed January 16, 2015). NHS Choices. Making a Complaint. www.nhs.uk/choiceinthenhs/ Rightsandpledges/complaints/Pages/AboutNHScomplaints.aspx (accessed January 21, 2015). NHS England. Delayed Transfers of Care Data 2014 15. www.england. nhs.uk/statistics/statistical-work-areas/delayed-transfers-of-care/ delayed-transfers-of-care-data-2014-15/. Nova Scotia. Continuing Care. August 31, 2014. http://novascotia.ca/dhw/ ccs/supportive-care.asp (accessed December 15, 2014).. Medication Dispenser Assistive Technology. Continuing Care. http://0-fs01.cito.gov.ns.ca.legcat.gov.ns.ca/deposit/b1065981x.pdf (accessed December 16, 2014).. Personal Alert Assistive Program. October 18, 2013. www.novascotia.ca/health/ccs/personal-alert-assistance.asp (accessed December 16, 2014). Nova Scotia Health and Wellness. Facility Placement Policy. January 24, 2011. http://novascotia.ca/dhw/ccs/policies/policymanual/facility_ Placement_Policy.pdf (accessed December 17, 2014). OECD. Total Expenditure on Health Per Capita 2014/1. http://dx.doi. org/10.1787/hlthxp-cap-table-2014-1-en (accessed December 23, 2014).. OECD Reviews of Health Care Quality: Denmark 2013. Paris: OECD, 2013. Find this report and other Conference Board research at www.e-library.ca 90

Appendix A The Conference Board of Canada. Sweden: Highlights From: A Good Life in Old Age? Monitoring and Improving Quality in Long-Term Care. 2013. www.oecd.org/els/healthsystems/sweden-oecd-ec-good-time-in-old-age.pdf.. United Kingdom: Highlights From: A Good Life in Old Age? Monitoring and Improving Quality in Long-Term Care. 2013. www.oecd.org/els/health-systems/unitedkingdom-oecd-ec-good- Time-in-Old-Age.pdf.. Denmark: Long-Term Care. 2011. www.oecd.org/denmark/ 47877588.pdf. Office of the Auditor General of Ontario. Annual Report, 2014. www.auditor.on.ca/en/reports_en/en14/2014ar_en_web.pdf (accessed December 18, 2014). Ogilvie, K.K. Time for Transformative Change: A Review of the 2004 Health Accord. Ottawa: Standing Senate Committee on Social Affairs, Science and Technology, 2012. Olejaz, M., A.J. Nielsen, A. Rudkjøbing, H.O. Birk, A. Krasnik, and C. Hernández-Quevedo. Denmark: Health System Review. Health Systems in Transition 14, no. 2 (2012): 192. Ontario Association of Community Care Access Centres. Rapid Response Nurses. http://oaccac.com/innovations-in-care/nursing- Initiatives/rapid-response-nurses (accessed January 16, 2015). Ontario College of Family Physicians. The Five Day Education Program to Establish Memory Clinics in Family Practices: The Missing Link in Diabetes Care. Toronto: Ontario College of Family Physicians, 2012. Parliamentary Committee on Palliative and Compassionate Care. Not to Be Forgotten: Care of Vulnerable Canadians. 2011. http://pcpcc-cpspsc. com/wp-content/uploads/2011/11/reporten.pdf. Prince Edward Island. Backgrounder: Long-Term Care. www.gov.pe.ca/ photos/original/hw_speechback5.pdf (accessed December 17, 2014). Find this report and other Conference Board research at www.e-library.ca 91

Understanding Health and Social Services for Seniors in Canada Public Health Agency of Canada. The Chief Public Health Officer s Report on the State of Public Health in Canada, 2010: Growing Older Adding Life to Years. Ottawa: PHAC, 2010. www.phac-aspc.gc.ca/ cphorsphc-respcacsp/2010/fr-rc/pdf/cpho_report_2010_e.pdf (accessed February 11, 2015). Romanow, R.J. Building on Values: The Future of Health Care in Canada. Commission on the Future of Health Care in Canada, 2002. Saskatchewan Ministry of Health. Housing Options for Saskatchewan Seniors. Provincial Advisory Committee of Older Persons. October 2008. www.health.gov.sk.ca/seniors-housing-options (accessed December 17, 2014). Service Canada. Employment Insurance Compassionate Care Benefits. September 26, 2014. www.servicecanada.gc.ca/eng/sc/ei/benefits/ compassionate.shtml (accessed December 16, 2014). Silversides, A. Long-Term Care in Canada: Status Quo No Option. Ottawa: Canadian Federation of Nurses Unions, 2011. Simpson, Dr. Chris. Canada Needs a National Dementia Strategy. Toronto Star, September 13, 2014. Smith, Joy. Chronic Diseases Related to Aging and Health Promotion and Disease Prevention. Report of the Standing Committee on Health. May 2012. www.parl.gc.ca/content/hoc/committee/411/hesa/reports/ RP5600467/hesarp08/hesarp08-e.pdf (accessed December 14, 2014). Spalding, Karen, Jillian R. Watkins, and A. Paul Williams. Self Managed Care Programs in Canada: A Report to Health Canada. Ottawa: Health Canada, June 2006. www.hc-sc.gc.ca/hcs-sss/alt_formats/ hpb-dgps/pdf/pubs/2006-self-auto/2006-self-auto-eng.pdf (accessed December 16, 2014). Statistics Canada. Adult Correctional Services, Average Counts of Offenders by Province, Territory and Federal Programs. www.statcan. gc.ca/tables-tableaux/sum-som/l01/cst01/legal31a-eng.htm. Find this report and other Conference Board research at www.e-library.ca 92

Appendix A The Conference Board of Canada. CANSIM table 052-0005. Projected Population by Age Group According to Three Projection Scenarios. www.statcan.gc.ca/ tables-tableaux/sum-som/l01/cst01/demo08a-eng.htm. (accessed December 11, 2014).. CANSIM table 105-0501. Population With a Regular Medical Doctor, by Age Group and Sex. www.statcan.gc.ca/tables-tableaux/sum-som/l01/ cst01/health75b-eng.htm (accessed December 15, 2014).. Income Composition in Canada. National Household Survey, 2011. Ottawa: Ministry of Industry, 2013. www12.statcan.gc.ca/nhs-enm/2011/ as-sa/99-014-x/99-014-x2011001-eng.pdf (accessed December 14, 2014).. Income in Canada. May 2, 2013. www.statcan.gc.ca/ pub/75-202-x/2010000/analysis-analyses-eng.htm (accessed December 12, 2014).. Population Projections for Canada, Provinces and Territories, 2009 to 2036. Ottawa: Ministry of Industry, 2010. Stunt, Victoria. Use of Surveillance Tech to Monitor Seniors at Home on Rise. CBC News, March 9, 2014. www.cbc.ca/news/technology/ use-of-surveillance-tech-to-monitor-seniors-at-home-on-rise-1.2535677 (accessed December 18, 2014). Sun Life Financial. What Does Long-Term Care Cost? October 2012. www.sunlife.ca/canada/sunlifeca/health/long+term+care+insurance/ What+does+long-term+care+cost?vgnLocale=en_CA (accessed December 16, 2014). Thaler, Richard H., and Cass R. Sunstein. Nudge: Improving Decisions About Health, Wealth, and Happiness. New York: Penguin Books, 2009. The Commonwealth Fund. 2014 Commonwealth Fund International Health Policy Survey of Older Adults in Eleven Countries. 2014.. International Profiles of Health Care Systems, 2013. 2013. www.commonwealthfund.org/~/media/files/publications/fund%20 Report/2013/Nov/1717_Thomson_intl_profiles_hlt_care_sys_2013_v2.pdf. Find this report and other Conference Board research at www.e-library.ca 93

Understanding Health and Social Services for Seniors in Canada The Conference Board of Canada. Final Report: An External Evaluation of the Family Health Team (FHT) Initiative. Ottawa: The Conference Board of Canada, 2014.. How Canada Performs: Elderly Poverty. January 2013. www.conferenceboard.ca/hcp/details/society/elderly-poverty.aspx (accessed January 23, 2015).. How Canada Performs: Income Inequality. www.conferenceboard.ca/ hcp/details/society/income-inequality.aspx (accessed January 23, 2015). Treasury Board of Canada. Public Service Health Care Plan. www.tbs-sct.gc.ca/hr-rh/bp-rasp/benefits-avantages/hcp-rss/hcp-rss-eng. asp (accessed January 21, 2015). Turcotte, Martin. Canadians With Unmet Home Care Needs. 2014. www.statcan.gc.ca/pub/75-006-x/2014001/article/14042-eng.htm#a3. Vérificateur général du Québec. Vérification de l optimisation des ressources, printemps 2012: services d hébergement. www.vgq.qc.ca/ fr/fr_publications/fr_rapport-annuel/fr_2012-2013-vor/fr_rapport2012-2013-vor-chap04.pdf (accessed December 17, 2014). Veterans Affairs Canada. Benefits and Services Programs of Choice (Poc). www.veterans.gc.ca/eng/services/health/treatment-benefits/poc (accessed January 21, 2015).. Long Term Care. www.veterans.gc.ca/eng/services/health/long-termcare (accessed December 23, 2014).. Palliative Care. www.veterans.gc.ca/eng/about-us/policy/ document/1237 (accessed January 21, 2015). Veterans Ombudsman. A Review of the Support Provided by Veterans Affairs Canada Through Its Veterans Independence Program. Government of Canada, 2013. Wait Time Alliance. Time to Close the Gap: Report Card on Wait Times in Canada (2014). Wait Time Alliance, 2014. Find this report and other Conference Board research at www.e-library.ca 94

Appendix A The Conference Board of Canada. Timely Access to Care for All Canadians: The Role of the Federal Government. 2014. www.waittimealliance.ca/ wp-content/uploads/2014/09/wta-fall-event-2014-position- Paper-English-FINAL.pdf. Winnipeg Health Region. Is PRIME Right for You? www.wrha.mb.ca/ wave/2010/10/prime-info.php (accessed December 16, 2014).. What Is GPAT? www.wrha.mb.ca/wave/2011/05/gpat.php (accessed December 16, 2014). World Health Organization. Dementia: A Public Health Priority. UK: WHO, 2012.. Global Age-Friendly Cities: A Guide. Geneva: WHO, 2007. www.who. int/ageing/publications/global_age_friendly_cities_guide_english.pdf (accessed January 26, 2015).. Global Health Risks: Mortality and Burden of Disease Attributable to Selected Major Risks. Geneva: WHO, 2009. www.who.int/healthinfo/ global_burden_disease/globalhealthrisks_report_full.pdf (accessed May 9, 2014). Find this report and other Conference Board research at www.e-library.ca 95

Insights. Understanding. Impact. e-library. Do you want to have access to expert thinking on the issues that really matter to you and your organization? Our e-library contains hundreds of Conference Board research studies in the areas of Organizational Performance, Economic Trends and Forecasts, and Public Policy. www.e-library.ca

About The Conference Board of Canada We are: The foremost independent, not-for-profit, applied research organization in Canada. Objective and non-partisan. We do not lobby for specific interests. Funded exclusively through the fees we charge for services to the private and public sectors. Experts in running conferences but also at conducting, publishing, and disseminating research; helping people network; developing individual leadership skills; and building organizational capacity. Specialists in economic trends, as well as organizational performance and public policy issues. Not a government department or agency, although we are often hired to provide services for all levels of government. Independent from, but affiliated with, The Conference Board, Inc. of New York, which serves nearly 2,000 companies in 60 nations and has offices in Brussels and Hong Kong.

Insights. Understanding. Impact. 255 Smyth Road, Ottawa ON K1H 8M7 Canada Tel. 613-526-3280 Fax 613-526-4857 Inquiries 1-866-711-2262 conferenceboard.ca PUBLICATION 7025 PRICE: Complimentary