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