From Bad to Worse - Amazon S3

From Bad to Worse: Residential Elder Care in Alberta

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Tables and Figures iiiAbbreviations iiiAcknowledgements ivAbouttheauthors ivAboutParklandInstitute vExecutiveSummary 1

1.Introduction 4A. Data 6

2.Background 7A. Terminology 9B. The Sustainability Scare 13

3.Alberta’sElderCareSystem 14 A. The decline of long term care and the rise of assisted living 15 B. The decline of public delivery andtheriseoffor-profitcare 17 C. Conclusion 174.UnmetNeed 18

A. The care gap 19B. The knowledge gap 23C. Workers’ experiences 25D. Conclusion 27

5.Privatization 28A. Caretimebydeliverymodel 29B. Caregiverexpertisebydeliverymodel 30C. Workers’ experiences 33D. Conclusion 34

6.Offloading 34A. Inadequate care 35B. Assisted living 36C. Thecostsofoffloading 38D. Conclusion 41

7.Eldercareforprofit 41A. Private elder care in Alberta 41B. Extendicare 42C. Extractingprofit 44D. Conclusion 46

8.Achievinghighqualityeldercare 47A. Opportunities 48B. Recommendations 50

Appendix 52Endnotes 53

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ParklandInstituteNovember2013

Tables and FiguresTable1:ContinuingcareinAlberta 9Table2:StaffingandadmissionsguidelinesforALandLTC 11Table3:LTCandALspacesinAlberta,1999and2009 16

Figure1:Patientpopulationbyacuity,LTC 19Figure2:Patientpopulationbyacuity,AL 24Figure3:Totaldirectcarehoursperresident-day,LTC 30Figure4:Staffmix,LTC 31Figure5:RNhoursperresident-day,LTC 32Figure6:Returnoninvestment:LTC,AL,andS&P500 45

AbbreviationsAHS: Alberta Heath ServicesAL:assistedlivingALC:alternatelevelofcareC3: Comprehensive Community Care for the ElderlyCHOICE:ComprehensiveHomeOptionofIntegratedCare for the ElderlyHCA: health care aideHFRC:HealthFacilitiesReviewCommitteeLPN:licensedpracticalnurseLTC:longtermcarePACE: Programs of All-Inclusive Care for the ElderlyRCFsurvey:ResidentialCareFacilitiessurveyRN:registerednurseROI: return on investment

From Bad to Worse

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AcknowledgementsInundertakingthisproject,ParklandInstitutehasbenefitedfromthegenerous support of numerous individuals and groups. We are glad to acknowledge the support of the Canadian Union of Public Em-ployees [CUPE]. We would also like to thank project advisors Tamara Daly,MargaretMcGregor,DonnaWilson,PatArmstrong,andIreneJensen.ThecontributionsofMarcyCohenwerealsomuchappre-ciated.BonnieFergusonofCUPEwasagenerousandsupportivecolleague throughout this project.

JanetE.FastandNorahC.Keating,bothwiththeDepartmentofHu-manEcologyattheUniversityofAlberta,providedusefulguidanceand resources.

Parkland is grateful for the support and guidance of other individ-uals and groups involved in working toward improvements in the eldercaresystem,includingBillMoore-KilgannonofPublicInterestAlberta,themembersofPublicInterestAlberta’sseniors’taskforce,SandraAzocarofFriendsofMedicare,JudithGrossmanofUnitedNursesofAlberta,andTrevorZimmermanofAlbertaUnionofPro-vincial Employees. Wendy Armstrong and Carol Wodak generously sharedtheirtimeandknowledge.TonyClarkoftheAlbertaFedera-tionofLaboursharedhisworkoneldercare.

BruceWestoftheAlbertaContinuingCareAssociationansweredquestionsandsharedhisexpertiseonAlbertaeldercare.

Thisreportbenefitedgreatlyfromtheconstructivecriticismofitsanonymousreviewers.TrevorHarrison,RicardoAcuña,NicoleSmith,andRonPattersonhavemadeimportantcontributions.DianaGibsonhelped guide the project in its earliest days.

ParklandInstituteisgratefulfortheinsightssharedbyAlbertanspersonallyinvolvedintheeldercaresystem,whetherasresidents,friendsandfamiliesofresidents,oremployees.

About the authorsShannonStundenBoweristheResearchDirectoratParklandInsti-tute.SheholdsaPhDinGeographyfromtheUniversityofBritishColumbia,andhasabackgroundinsocialandenvironmentaljusticeprojects.

DavidCampanellaisthePublicPolicyResearchManagerforParklandInstituteandisbasedinCalgary.DavidholdsaMaster’sdegreefromYorkUniversity(MES),wherehefocusedonpoliticaleconomy,andanundergraduatedegreefromtheUniversityofWaterloo(BES).

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From Bad to Worse - Elder Care in Alberta

About Parkland InstituteParklandInstituteisanAlbertaresearchnetworkthatexaminespublic policy issues. Based in the Faculty of Arts at the University ofAlberta,itincludesmembersfrommostofAlberta’sacademicinstitutions,aswellasotherorganizationsinvolvedinpublicpolicyresearch.ParklandInstitutewasfoundedin1996anditsmandateisto:

•conductresearchoneconomic,social,cultural,andpoliti- cal issues facing Albertans and Canadians.

•publish research and provide informed comment on current policy issues to the media and the public.

•sponsor conferences and public forums on issues facing Albertans.

•bringtogetheracademicandnon-academiccommunities.

AllParklandInstitutereportsareacademicallypeerreviewedtoensure the integrity and accuracy of the research.Formoreinformation,visitwww.parklandinstitute.ca

Toobtainadditionalcopiesofthisreportorrightstocopyit,pleasecontact:ParklandInstituteUniversity of Alberta 11045SaskatchewanDriveEdmonton,AlbertaT6G2E1Phone:(780)492-8558Fax:(780)492-8738http://parklandinstitute.ca Email: [email protected]

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Executive Summary Albertans,likeotherCanadians,areworriedaboutwhethertheywillreceivethecaretheyneedastheyage.NewsinAlbertaislitteredwithrevelationsaboutproblemswithaccessingappropriateeldercareandquestionsaboutthequalityofavailablecare. Staffem-ployedintheeldercarefieldenduredifficultconditionsthatmakeitchallenging to ensure all elders receive the care they deserve.

Inthiscontext,itisimportanttoaskiftheAlbertagovernmentisensuring elders in this province receive the supports they require tolivewithdignityandincomfort.Inresponsetothisquestion,theParklandInstituteundertookastudyofAlberta’ssystemofresiden-tialeldercare.ThestudydrawsonquantitativedatafromStatisticsCanada’sResidentialCareFacilitiesSurveyandqualitativedatafromthereportsofAlberta’sHealthFacilitiesReviewCommittee,aswellasconversationswithgovernmentandindustryrepresentatives,labourunions,seniorsadvocates,andfront-lineworkers.

Focusingonassistedliving[AL]andlongtermcare[LTC],thisreportexplorestheconsequencesoftwomajor,interrelatedshiftsinAlber-taresidentialeldercareinrecentyears:

1. ThereplacementofLTCwithALElderswhowouldoncehavebeenplacedinLTChaveincreas-inglybeendivertedintoAL.

2. Theexpansionoffor-profitdeliveryofresidentialeldercareElder care services in Alberta are delivered either by a public body,anot-for-profitagency,orafor-profitbusiness.Recentyears have seen a fall in publicly-delivered elder care and a spikeinfor-profitfacilities.

Between1999and2009,relativetothegrowthinnumberofAlber-tansoverage75,thenumberofresidentialeldercare(eitherALorLTC)spacesfellby4%,whilethenumberofLTCspacesfellby20%.By2008,AlbertahadthesecondlowestavailabilityofLTCspacesinthe country.

ProblemsinAlberta’sresidentialeldercarearemanyandvaried,andcannotbeexhaustivelyaddressedinthecontextofthisrelative-lybriefreport.However,thisreportdoesidentifythreeespeciallytroubling areas.

1. AcrossresidentialeldercareinAlberta,asignificantgapexistsbetweenthecareprovidedandthecarerequiredtoensureresidents’dignityandcomfort. Examples of the con-sequences of the care gap include waits of up to 2 hours for

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responsetocallbells,mealsrushedtoapointthatchokingriskisincreased,andinadequatestaffingthatputsbotheldersandcaregivers at risk.

2. BasedonevidencefrombeyondandwithinAlberta,for-prof-iteldercareisinferiortocareprovidedpubliclyorbyanot-for-profitagency.Measuredagainstbenchmarksestab-lishedbyeldercareexperts,LTCinAlbertahasoftenfailedtoachievestaffinglevelsthatpointtominimallyacceptablecare.Between1999and2009,for-profitfacilitiesfellshortofthestaffinglevelsthatindicatereasonablequalityeldercarebyover90minutesofcareperresident,perday.Whilepub-licfacilitiesalsofellshort,theydidsignificantlybetterthanfor-profitfacilities.

3. SignificantoffloadinghasleftmanyelderlyAlbertansandtheirsupportnetworksstrugglingtocopewithburdens,bothfinancialandotherwise,thatatonepointwouldhavebeenalleviatedbytheprovincialgovernment.Offloadingalsohasconsequences for the wider community and the provincial economy.

ThisreportincludesananalysisofAlberta’sfor-profitresidentialel-dercaresector.Whileprovidinginferiorcare,theseoperationsgen-eratesubstantialprofits.Between1999and2009,privatelong-termcarefacilitiesintheprovincehadanaveragereturnoninvestment[ROI]of2.1%.PrivateALfacilitieshadmuchhigherreturnsoverthattime,withanaverageROIof9.14%.ThismeansthatinrecentyearsthereturnsreceivedbytheprivateresidentialeldercareindustryinAlbertahavebeenhigherthanthoseoftheUSstockmarket,whichoverthesametime-framehadanaveragereturnof1.23%.

Thereportalsopointstowarddifficultiesinaccessinginformationaboutresidentialeldercare.InlightoftheterminationoftheSta-tisticsCanadaResidentialCareFacilitiesSurvey,theeliminationoftheHealthFacilitiesReviewCommittee,repeatedchangesinpro-grammesandterminologywithinAlberta,andtheinconsistenciesthatcharacterizeeldercareacrossCanada,thereisaneedtoensureelders do not become lost in a knowledge gap.

Insum,thisreportdocumentssignificantproblemswithresidentialelder care in Alberta. It makes clear how the provincial government’s policiesofprivatizingandoffloadinghavenegativelyaffectedthewell-being of Albertans. The evidence is clear: as more services have beenprovidedbyfor-profitenterprisesandastheavailablesupportshavedecreased,eldercareinAlbertahasgonefrombadtoworse.

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Recommendations

1. ExpandtheCanadianpublichealthcaresystemtoencompasscontinuingcareservices,includingallresidentialandhome-basedformsofeldercare•TheGovernmentofAlbertashouldjoinwithotherprovincesinlobbyingtheFederalGovernmenttoexpandpublichealthcaretoincludecontinuingcareservices,includingallresi-dentialandhome-basedformsofeldercare.

2. Improvestaffing• InrecognitionofthecaregapacrossAlbertaeldercare,theGovernmentofAlbertashouldimmediatelymakeavailablefundstofacilitateimprovedstaffing,withtheprovisionthatalloperators(public,not-for-profit,andfor-profitalike)beobligedtoexpendthesefundsondirectcarestaffing.TheGovernmentshouldensurethatalleldercarefacilitiesarelegallyboundtominimumstaffinglevelsestablishedinrela-tiontoexperts’assessmentsofthelevelsrequiredtoensurequality care.

3. Phase-outprivate,for-profiteldercare• Immediately suspend subsidies and programmes that bene-fitfor-profiteldercarecorporationsandworktophase-outfor-profiteldercareduetotheabundantevidencethatfor-profitcorporationsprovideinferiorqualitycare.

4. Increasepublicaccesstoinformationabouteldercare• Improvemonitoringandreportingpracticestoensurethat

meaningful data about elder care is available to all Albertans.

5. Createawatchdog•Establish an elders’ advocate to report to the legislature. An elders’advocatewouldbepositionedtomonitoreldercare,totrackchangeovertime,andtoensuretheeffectiveintegrationoftheeldercaresystemwithotherpoliciesandpracticesthatbear on the well-being of Alberta elders. The advocate should workcloselywithacommitteeofelderAlbertans.

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1. IntroductionCanadians are worried about whether they will be able to access the caretheyneedastheyage.ArecentCanadianMedicalAssociationpoll indicates broad concern among seniors about whether they will be able to access suitable health care.1InAlberta,thenewsislitteredwithrevelationsaboutproblemswithfindingappropriateeldercare,andquestionsaboutthequalityofavailablecare. Frequent labour disruptionspointtothedifficultworkenvironmentofstaffemployedintheeldercarefield.

Inthiscontext,itisessentialtoaskiftheAlbertagovernmentisensuring elders in this province can access the care they may require to live with dignity and in comfort.2Inresponsetothisquestion,theParklandInstituteundertookastudyofAlberta’ssystemofresiden-tialeldercare.

This report focuses on the experiences of Albertans in what the governmentofAlbertatermsassistedliving[AL]andlongtermcare[LTC],referredtocollectivelyinthisreportasresidentialeldercare.3 It deals only peripherally with home care and other forms of elder care,whicharebesetwiththeirowndistinctchallenges.Ourstudyexplorestheconsequencesoftwomajor,interrelatedshiftsinAlber-taresidentialeldercareinrecentyears:

1. ThereplacementofLTCwithAL

ElderswhowouldoncehavebeenplacedinLTChavebeenincreasinglydivertedintoAL.

2. Theexpansionoffor-profitdeliveryofresidentialeldercare

Elder care services in Alberta are delivered either by a public body,anot-for-profitagency,orafor-profitbusiness.Recentyears have seen a fall in publicly-delivered elder care and a spikeinfor-profitfacilities.

SinceALispredominantlydeliveredbyfor-profitbusinessesandLTCisprimarilyprovidedbygovernment-operatedfacilities,thesetwodevelopmentsarerelated:movingtheresidentpopulationfromLTCtoALamountstoashiftfrompublictoprivatedelivery.Aswillbeexploredfurtherinwhatfollows,theshiftalsoinvolvesasignificantchange in the nature of the care available to residents.

ProblemsinAlbertaeldercarearemanyandvaried,andcannotbeexhaustivelyaddressedinthecontextofthisrelativelybriefreport.However,thisreportdoesidentifythreeespeciallytroublingareas.

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1. Asignificantgapexistsbetweenthecareprovidedandthecarerequiredtoensureresidents’dignityandcomfort.

TheresidentpopulationinLTChasbecomemoremedicallycomplexandacuteinrecentyears,andthelevelofcarehasnotbeenadjustedsufficientlytocompensate.TheresultingcaregaphasmanynegativeconsequencesforAlbertaeldersandtheirfriendsandfamilies,aswellasforworkersemployedinLTC.

AshifttowardgreateracuityisalsoevidentamongresidentsinAL.However,inconsistenciesinmonitoringmeanthatthereisfarlessinformationavailableonwhatthiscaregaphasmeantforresidents,friendsandfamily,andstaffinAL.Unfortunately,recentchangesaffectingbothALandLTCthreatentoexpandthisknowledgegap,makingithardertogainanunderstandingofAlbertans’experienceswithresidentialeldercare.

2. BasedonevidencefrombeyondandwithinAlberta,for-profiteldercareisinferiortocareprovidedpubliclyorbyanot-for-profitagency.

Inamannerconsistentwithpatternsresearchershaveiden-tifiedelsewhere,evidencefromAlbertashowsthatfor-profitfacilitiesprovideaninferiorlevelofcare,withstaffinglevelsfarbelow recommended levels. The evidence also indicates that for-profitcorporationsprovideadifficultworkenvironmentforstaff.

3. SignificantoffloadinghasleftmanyelderlyAlbertansandtheirsupportnetworksstrugglingtocopewithburdens,bothfinancialandotherwise,thatatonepointwouldhavebeenalleviatedbytheprovincialgovernment.

The Alberta government has worked to narrow its range of functionsinrelationtoeldercare,withtheresultthatre-sponsibility for procuring and paying for many services has beenoffloadedontoindividuals.TheproblemofoffloadingisespeciallysevereforelderAlbertansinAL.Theconsequencesofoffloadingincludehigherout-of-pocketcostsandincreasedburdens on social networks.

Ouranalysisrevealssignificantproblemswithresidentialeldercarein Alberta. It makes clear how the provincial government’s policies ofprivatizingandoffloadinghavenegativelyaffectedthewell-be-ing of Albertans. The evidence is clear: as more services have been providedbyfor-profitenterprises,andastheavailablesupportshavedecreased,eldercareinAlbertahasgonefrombadtoworse.

“ “theprovincialgovernment’spoliciesofprivatizingandoffload-inghavenegativelyaffectedthewell-beingofAlbertans.

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Thisreportbeginswithasurveyoftherelevantpolicybackground,andthendescribesrecentchangesinAlberta’ssystemofresidentialelder care. It examines in detail the care gaps and knowledge gaps threateningAlberta’selderly,beforeaddressingpronouncedvaria-tionsincarequalitybetweenfor-profit,not-for-profit,andpublicfa-cilities.Theoffloadingofeldercareisconsideredinamannerthatin-cludesattentiontoitseffectsontheelderly,theirfriendsandfamily,and the wider Alberta public. The report then turns to an examina-tionoftheprivateeldercaresector,bylookingcloselyatsomeofthecompaniesprofitingoffeldercareintheprovince.ItconcludesbyofferingconcreterecommendationsofwaystobegintoaddresstheproblemsevidentthroughoutAlberta’sresidentialeldercaresector.

1.A.Data

The data underlying this report derives from the following sources:

• ResidentialCareFacilities[RCF]survey.

Untilitsrecenttermination,StatisticsCanada’sRCFsurveytrackedkeyaspectsofresidentialcarefacilitiesacrossthecountry.TheParklandInstituterequestedAlberta-specificdatapertainingtoresidentialcarefacilitiesprimarilyhousingelderswithage-relatedafflictions.Thedatarelatedtotheperiodbetween1999and2009.

ALwasdisaggregatedfromtheoveralldatabyarepresentativeofStatisticsCanada,basedonacomprehensivelistoffacilitiesderivedfromaGovernmentofAlbertawebsite.TheremainingdatawasassumedtopertaintoLTC,asthisistheonlyothertypeoffacilitywheresignificanteldercareisprovidedintheprovince.

• HealthFacilitiesReviewCommittee[HFRC]reports.

Untilitwaseliminatedin2013,Alberta’sHFRCmonitoredthequalityofcareandaccommodationprovidedinhealth-carefacilities.TheHFRC,consistingofupto12privatecitizenswithvariedbackgrounds,expertise,andworkexperience,conduct-edsurprisereviewsintendedtoobservehealthfacilities’rou-tineoperations.TheHFRCvisitedfacilitiesoperatingundertheHospitals Act,theNursing Homes Act,ortheRegional Health Authorities Act.Eachyear,theCommitteeinspectedbetweenathirdandahalfofLTCfacilitiesandotherhealthfacilitiesthatoffersomeLTC.ALfacilitieswereconsideredoutsidethemandate of the HFRC.

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Forthisstudy,ParklandInstitutereviewedeveryHFRCreportgoingbackthreeyears,basedonthelogicthatsuchanap-proach should encompass at least one report for each facility. HFRC reports from earlier periods were reviewed in a less systematicmanner.

• Conversationsandworkshopswithindustryrepresentatives,representativesfromgovernment,labourunions,AlbertaHealthServices,eldercareactivists,andfront-lineworkers.

• Reviewofrelevantgovernment,academic,andotherexpertexaminationsregardingthecostsandqualityofeldercare.

2. BackgroundTounderstandthestateofresidentialeldercareinAlberta,itiscriticalto recognize how it relates to the Canadian health care system. Cana-diansenjoyhealthcareservicesdeliveredonatax-funded,single-pay-ersystemaslaidoutinthe1984Canada Health Act.ThislegislationlaysoutfivekeyprinciplesthataretodefinetheCanadianhealthcaresystem,whichiscolloquiallyknownasMedicare.Theseare:

• Publicadministration(administeredonanot-for-profitbasis);• Universality (covering all insured persons on uniform terms

andconditions);• Comprehensiveness (covering all medically necessary ser-

vices);• Accessibility (reasonable access on uniform terms and condi-

tions,unimpededbydiscriminationorextrachargessuchasuserfees);and

• Portability(coveragewhileabsentfromhomeprovince).4

The Canada Health Act pertains only to medically necessary physi-cian and hospital services. Falling outside of the Act’s domain are other,increasinglyimportant,areasofCanada’smodernhealthcaresystem,includingpharmaceuticals,homecare,andLTC.AlthoughtheActdoesreferto“extendedhealthservices,”theFederalgov-ernmenthasfailedtodefinetheseservices,ortomandatethattheprovinces provide them.

TheexclusionofresidentialeldercarefromMedicarehasmeanttheprinciples of the Canada Health Act are not applied to the sector. As aresult,thedoorhasbeenleftopenfortheinvolvementoffor-profitbusinesses,thelevyingofcostsonpatients,andtheuseofeligibilitycriteriadesignedtolimitaccess.Further,withouttheapplicationofover-archingfederallegislation,residentialeldercarehasevolveddifferentlyfromprovincetoprovince.

“ “TheexclusionofresidentialeldercarefromMedicarehasmeanttheprinciplesoftheCanada Health Act arenotappliedtothesector.

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InAlberta,thehistoryofeldercareisintertwinedwiththebroaderstory of health care. Both have been subject to ideologically-driv-eneffortstoshiftcostsandresponsibilityfromthegovernmenttoindividualhealthcareusers,andtopromoteincreasedprivate-sec-torparticipation.ThemostaggressiveeffortsinthisdirectioncameunderthePremiershipofRalphKlein.Significantcutstotheacutecaresystemresultedinpatientsbeingshuttledintocontinuingcarebeds,therebylimitingavailabilityforseniorsinneed.CombinedwithapatternofunderfundingservicesforeldersthatpredatedKlein,thesituationinthemid-1990srapidlybecameintolerableforAlbertaelders and their friends and family.5

In the midst of problems in elder care created or exacerbated by PremierKlein’scutstopublicservices,theGovernmentofAlbertaundertookaninvestigationoftheimpactofanagingpopulationonAlberta’shealthcaresystem,withafocusonquestionsoffinancialsustainability.DavidBroda’s1999reporttitledHealthy Aging: New Directions for Care put forward key principles to guide change in elder care.6Theseincludedtheunbundlingofservices;creationofthreecarestreams(thehomecarestream,thesupportivelivingstream,andthefacilitylivingstream)undertheumbrellaofcontinu-ingcare;andembraceofthe‘aginginplace’concept,whichmeantthat elders should be supported in their desire to remain in the loca-tionoftheirchoosing.IntheyearssincethepublicationoftheBrodareport,theseprincipleshavebecomethebasicpillarsoftheGovern-mentofAlberta’sattemptstolimitspendingonservicesforelders.

Inlate2001,thePremier’sAdvisoryCouncilonHealthreleasedareportadvocatingreductionsintherangeofhealthservicespaidbythepublicpurse.TermedtheMazankowskireportafterCouncilchairDavidMazankowski,thisdocument’srecommendationsincludedincreasedcompetitionamongprovidersofhealthservices.7In2002,theMLATaskForceonHealthCareFundingandRevenueGenerationproducedareport(knownastheGraydonreportafterTaskForcechairGordonGraydon)thatcontinuedtheemphasisonshrinkingpublic health care expenditures.8 These reports served to lay further groundworkforcontinuedattemptstoshifteldercarecostsawayfrom the public at large and toward individuals requiring services.

TheimpositionofarbitraryrestraintonpublicspendinghashadconsequencesforthequalityofeldercareinAlberta.InMay2005,theAuditor-Generalreleasedtheresultsofanauditofeldercareinthe province.9 This report made clear that the government had failed toestablishasystemtoensureeldersreceivedadequatecare,andlaidoutspecificrecommendationsforimprovements.TheprovincialgovernmentacceptedalloftheAuditor-General’srecommenda-tions.10Further,thegovernmentfollowedupwithitsowninvesti-gation,theMLATaskForceonContinuingCareHealthServiceandAccommodationStandards.TheTaskForcewasstrucktosolicitinput

“ “EvidenceindicatesthatthequalityofresidentialeldercareinAlbertahasgonefrombadtoworse,withsignificantnegativeconsequencesforelders,theirfriendsandfamily,employees,andsocietyatlarge.

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from members of the public and stakeholders regarding needed im-provementstoAlbertaeldercare.ReleasedinNovember2005,theresultingreportrecordedtheconcernsofAlbertans,andsuggestedfurtherwaysoffixingeldercareintheprovince.11

Unfortunately,thesituationdidnotimproveinthewakeofthe2005reports.Infact,evidenceindicatesthatthequalityofresidentialeldercareintheprovincehasgonefrombadtoworse,withsignif-icant,negativeconsequencesforAlbertansinneedofcare,theirfriendsandfamily,andprofessionalcaregiversemployedinresiden-tialeldercare.Further,theeffectsofinadequateeldercarerippleouttotouchallAlbertans,throughinflatedhealthcostsandothereffects,botheconomicandsocial.

2.A.Terminology

IntheabsenceoffederallegislationdefiningtheshapeofresidentialeldercareacrossCanada,residentialeldercarehasdevelopedinvastlydifferentwaysfromprovincetoprovince.Albertaexhibitsitsowneligibilityrequirements,fundinglevel,ownershippattern,carestandards,andevenitsownterminology.

Albertaincludesresidentialeldercareundertheumbrellaterm‘con-tinuingcare.’Continuingcareencompassesabroadrangeofhealthcareservicesdeliveredoutsideofhospitalsandphysicianoffices,from minor assistance with daily living to intensive 24-hour nursing care.Whilecontinuingcareprimarilyoffersservicesfortheelderly,italsoincludesresidentswhomayrequireongoing,substantialcareforreasonsbesidesage-relatedfrailty,suchasheadinjuriesordegen-erativediseases.AsseeninTable1,continuingcareincludesanex-tremely broad range of services organized into three sub-categories: ‘HomeLiving’,‘SupportiveLiving’,and‘FacilityLiving’.

Facility living refers to care provided in either auxiliary hospitals or

Continuing care in AlbertaSupportiveLivingHomeLiving FacilityLiving

Longtermcarefacilityoranaux-iliaryhospital

Independentlivinginprivateresidence

Level1ResidentialLiving

Level2LodgeLiving

Level3AssistedLiving

Level4Enhanced/Desig-natedAssistedLiving

Table1:AdaptedfromAlbertaHealthandWellness,ContinuingCareStrategy:AgingintheRightPlace(Govern-mentofAlberta:December2008),accessedMarch14,2013,http://www.health.alberta.ca/documents/Continu-ing-Care-Strategy-2008.pdf

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http://www.health.alberta.ca/documents/Continuing-Care-Strategy-2008.pdf

http://www.health.alberta.ca/documents/Continuing-Care-Strategy-2008.pdf


LTCfacilities.Spotsinthesefacilitiesarenowreservedfor“personswith complex and chronic health needs who require support and 24-hourregisterednursingcare.”12 Facility living is governed under either the Nursing Homes Act or the Hospitals Act. These Acts serve toensureaminimumqualityofcareismaintainedatallLTCfacilitiesbysettingminimumstaffinglevels,althoughtheseminimumshavenotbeenupdatedandarenowdrasticallyoutofdate.

Supportivelivingisconceptualizedasaformofeldercarelessintensivethanthatofferedinfacilityliving.Thecareneedsofresi-dentscan“beassimpleasthoseofferedinhomesettings,rightuptofull-servicecarewiththeexceptionofhighlycomplexandserioushealthcareneeds.”13 Inthisway,supportivelivingispresentedas“abridgebetweenhomelivingandfacilityliving.”14

Supportivelivingissubdividedintofourdistinctlevelsofcareaccord-ingtothecareneedsofresidents,withthetwomostintensivelevelsofcaretermedAL.SomeALspaces,principallythosefortheseverelyincapacitated,areknownasdesignatedassistedliving.Thesespacesare governed by a contract between Alberta Health Services (the health authority responsible for delivering medical care on behalf oftheGovernmentofAlberta)andthebuildingoperator.Underthiscontract,AlbertaHealthServices[AHS]“makesdecisionsregardingadmissionanddischarge”andthebuildingoperator“provideshealthandsupportservicesbasedonassessedneed.”15

AHS undertakes assessments of individuals intended to guide de-cision-making about their access to both designated assisted living spacesandLTCbeds,aswellastootherformsofcaresuchashome-care.AccordingtoAHS,theassessmentsareintendedto“ensurethatLTCbedsareusedbythosewhomostneedthem…”16TheeffectofallofthisistopositionAHSasagatekeeperwiththecapacitytorationcare,anapproachthatissharplyatoddswiththeprincipleofuniversality that underlies the Canadian health care system.

ThisreportfocusesonLTC(whichisaformoffacilityliving)andAL(whichconsistsofsupportivelivinglevelsthreeandfour).Table2indicatesthestaffingarrangementsinLTCfacilitiesandthetwomostintensivelevelsofsupportiveliving,aswellasAHS’sdefinitionsofthemedicalconditionandfunctionalstatusoftheresidentswhoshould be residing in them.

Supportivelivingfacilities,includingALanddesignatedassistedliv-ing,aregovernedbytheSupportive Living Accommodation Licensing Act.17ThislegislationinveststheGovernmentofAlbertawiththepowertoregulatesupportivelivingfacilities.Asitcurrentlyexists,however,theSupportive Living Accommodation Licensing Regulation specifiesverylittlebywayofconcreteguidelines.Thedocumentisclearlywrittentoofferflexibilitytooperators,ratherthansafeguards

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toresidents.Further,thedocumentpertainspurelytoaccommo-dationstandards,whichtheprovincialgovernmentdeemsseparatefromhealthcareconsiderations.WhiletheContinuing Care Health Service Standardsformalizecertainaspectsoftheavailablecare,thisdocumentisoftenvagueand,critically,doesnotincludeminimumstaffingrequirements.18

Insupportiveliving,homecareservicesareintendedtoplayakeyroleinmeetingthehealthandpersonalneedsofresidents.Homecareservicescanincludehomesupport(personalcare,housekeep-ing,mealpreparation,andhealthtasks),occupationalandphysicaltherapies,andevenfullnursingandmedicalcare.Homecare,de-finedasanextendedhealthservice,isnotaninsuredhealthserviceunder the Canada Health Act. Decisions are made at the provincial

Staffing and admission guidelines for AL and LTC

HCA:healthcareaide;RN:registerednurse;LPN:licensedpracticalnurse

SupportiveLivingLevel3(assistedliving)

SupportiveLivingLevel4(assistedliving)

SupportiveLivingLevel4Dementia(assistedliving)

LongtermCare

Staffing HCA:24hron-siteRN:24hron-call

LPNandHCA:24hron-siteRN:24hron-call

RN,LPN,HCA:24hron-site

MedicalConditions Stable ComplexbutstableUnscheduledassessmentsmayberequired

ComplexunpredictableneedsbutmedicallystableUnscheduledassessmentsareoftenrequired

FunctionalStatus Mobilizesinde-pendentlyorwithaone-persontransfer;Requiresunscheduledpersonalcaresuchasassistancewithmealsormanagementofincontinence

Willhavecomplexphysicalcareneedsthatmayinclude:completemealassistance,includ-ingtubefeeding,mechanicallifttransfersandtwopersontransfers,totalassistancetomobilize

Mayhavecom-plexcareneedsthatmayin-clude:completemealassistance,includingtubefeeding,mechan-icallifttransfersandtwopersontransfers,totalassistancetomobilize

Willhavecomplexphys-icalneedsthatmayin-clude:complexnutritionalintakerequirements,complexeliminationrequirements

Table2:AdaptedfromAlbertaHealthServices,Admission Guidelines for Publicly Funded Continuing Care Living Options.

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levelregardingwhichservicesarepubliclyfunded,andwhichareprivately paid.

ResidentsinAlbertaresidentialeldercareareleviedcostsrelatedtoroomandboard,basedontheargumentbytheGovernmentofAlbertathatsuchcostsarenotamedicalexpense,andshouldthusbeborneprivately.InLTCanddesignatedassistedliving,perdiemsareapplied.Asof1January2013,thefeesinLTCrangedfrom$48.15perdayforastandardroomto$58.70perdayforaprivateroom.19 Fees currently charged to residents in designated assisted living rangefrom$50.80perdayforasemi-privateroomto$58.70perdayfor a private room.20Further,fordesignatedassistedlivingresidentsinanothersortofaccommodation,aonebedroomortwobedroomapartmentforinstance,AlbertaHealthServices,inconsultationwithfacilityoperators,determineswhatmaybecharged.21

InconsideringAlbertaeldercare,itisimportanttoconsideralter-natelevelofcare[ALC],whichreferstosub-acutecareprovidedinanacutecaresetting,suchasahospital.Thismakeshiftarrangementisoftenemployedtoaccommodatearesidentinhospitalawaitingplacementinacontinuingcarefacility.AccordingtoAlbertaHealthServices,asof31March2012,therewere1,469peoplewaitingtobeplacedinacontinuingcarefacility,with467oftheseindividu-alswaitinginahospital.22ResidentsinALCmaynothaveaccesstothefullsuiteofservices,includingrehabilitation,whichwouldbeavailabletothemincontinuingcare.Also,itcanbemoreexpensivetoaccommodatearesidentinALCasopposedtocontinuingcare.DatafromtheCanadianInstituteforHealthInformationindicatethatbetween2007and2009,3%ofhospitalizationsinAlbertainvolvedALC.Conditionsassociatedwithaging,suchasdementiaandstroke,arestronglycorrelatedwiththeALCresidentpopulation.Between2007and2009,56%ofAlbertaresidentsdischargedfromALCwenttoLTC.23ThisdatasuggeststhatasubstantialproportionofALCresidentsaretherebecauseofinsufficientaccesstoeldercare.Resi-dentsaccommodatedinALCareresponsibleforpayingthesamefeeleviedonresidentsinLTC.24

SomeAlbertaeldersresideinseniors’lodges,whicharefacilitiesoperated under the Supportive Living Accommodation Licensing Act bylocalmanagementbodies.ManylodgesreceivefundingfromtheGovernmentofAlbertaundertheLodgeAssistanceProgram.Seniors’ lodges are designed to provide room and board for seniors whoarefunctionallyindependentwithorwithouttheassistanceofcommunity-basedservicessuchashomecare.Lodgesaregovernedunderprovinciallegislationthatmandatesoperatorstochargeaccommodationratesthatleaveresidentswithaminimumamountpermonthforpersonalexpenses.Asofearly2013,thisminimumamountwassetat$265basedonsemi-privateroomrates.25

12


Even this brief survey of relevant terms makes clear the varied ar-rangements through which elder Albertans receive care. Confusion around terminology is rendered more likely by the government’s fre-quentchangesindefinitions.Termsarealsodeployedinconfusingormisleadingways.Forinstance,governmentofficialsanddocumentsoftenrefertocontinuingcarespaces,whichmeansverylittlegiventhe wide range of services encompassed by that term.

2.B.Thesustainabilityscare

Itisimportanttoaddress,ifonlybriefly,theissueofthefinancialsustainabilityofresidentialeldercare.Foryears,debateabouteldercarehasbeenframedbyinfluentialactorsintermsofabroadfearaboutthepubliccostofanagingpopulation.Agrowingshareofthepopulationbecomingnon-workingelderswhorequireexpensivesupportswilldramaticallyinflatecosts,sotheargumentgoes,ren-dering impossible the maintenance of public elder care. The same argument is levied at the health care system more broadly.

Asaresultofimprovementsinlifeexpectancy,decliningbirthrates,andthelongtermeffectsofthepost-WWIIbabyboomexperiencedinWesterncountries,manycountriesareexperiencingsignificantagingoftheirpopulations.Projectingoutto2061,StatisticsCanadapredictsthatthepercentageofthepopulationovertheageof65willreachbetween24%and28%,comparedto14%in2009.Theagingofthepopulationispredictedtobeparticularlyrapidoverthecomingtwodecades,asthebabyboomgenerationreachesthislandmark.Further,thenumberofworking-ageCanadiansforeveryseniorisexpectedtofallroughlyinhalf,from5:1in2009to2.6:1by2036.26

Muchhasbeenmadeofthistrend.Maclean’sMagazinefeatureda2010articleentitled“Thehealthcaretimebomb,”27 the corpo-rate-fundedFraserInstituteperpetuallyusesthispremisetocallforincreasedhealthcareprivatization,28 and the federal government employedthisrationaletojustifyincreasingtheageofeligibilityforOldAgeSecurityandtheGuaranteedIncomeSupplement.29 Similar statementsabouttheunaffordabilityofpublichealthcarehavebeenmadebyvariousAlbertagovernmentofficials.Suchargumentsareoftenusedtojustifyreducinggovernmentresponsibilitiesforprovid-inghealthcare,infavourofmoreprivatepaymentforprivately-deliv-ered services.

Health experts and economists have exposed such statements as littlemorethanfear-mongering.Whilethelogicmaysoundsuperfi-ciallyplausible,theevidenceshowsthatanagingpopulationposesnothreattothefutureofpublicprogrammessuchasMedicare.Thekeyvariableabsentfromtheaboveanalysesiseconomicgrowth,which creates increasing economic output that can be put toward socialgoodssuchashealthcare.Takingthatcriticalaspectinto

“ “Healthexpertsandeconomistshaveexposedclaimsabouttheun-sustainabilityofpublichealthcareaslittlemorethanfear-mongering.

13


consideration,theshareofnationalincomespentonhealthcareincreasedjust3.1%between1971and2006.30 The cost of maintain-ingexistingservicelevelsdecreasesasashareofGDPoverthenextthreedecadesunderhistoricallyaverageeconomicactivity(3%realGDPgrowthperyear),andiftheeconomyunderperformsrelativetohistoricaltrends(2%realGDPgrowthperyear)costsincreasejust1%by2038.31Thereportofthe2009SenateCommitteeonAgingevenreferredtothedemographicscareasa“pervasivemyth.”32

One of the main cost drivers in Canadian health care is the rising cost ofprescriptiondrugs.Pharmaceuticalsalonehavebeenresponsiblefor25%oftheincreaseinMedicarecostsasashareofGDPsince1975.33Thisisduetobothanincreaseintheprescribingofdrugs,aswell as an increasing cost of the drugs themselves. As many experts havepointedout,acoordinatednationalPharmacareprogramwould do much to contain these rising costs.

The evidence clearly shows that publicly-funded and delivered ser-vicessuchaseldercareandMedicarearenotunderthreatfromanagingpopulation.RobertEvans,aHarvard-trainedeconomistandOf-ficeroftheOrderofCanada,explainsthattheperpetuationofsuchclaimsisnothingmorethana“propagandacampaign”designedtoadvancetheinterestsofthosewhostandtobenefitfromprivatiza-tionbyattemptingtoconvince“agenerallyscepticalandunsympa-theticpublictoacceptthatthecurrentformofpublichealthinsur-ance(whichmostCanadiansstillstronglyprefer)issimplyimpossibletomaintain.”34

Whilethedemographicshiftisreal,thepurportedfinancialcrisiswithinpublicservicessuchasMedicareandeldercareisnot.Ac-cordingly,provincialpolicypertainingtoeldercareshouldnotbejudgedagainstthebackdropofimpendingfinancialstraits.Rather,eldercarepolicyshouldbescrutinizedaccordingtoitsabilitytopro-vide high quality care to all Albertans in need.

3. Alberta’s Elder Care System

Intheearly1990s,residentialeldercareinAlbertaconsistedofthreeoptions:auxiliaryhospitals,designedtobeless-expensiveandprovidemorepermanentcarethanacutecarehospitalbeds;nursinghomes,asstand-alonefacilitiesthatprovidedaslightlylowerlevelofcare;andpubliclodges,whichhousedelderswhorequiredsomeoversightbynon-medicalstaffandbenefitedfromasocialsurrounding.35

The elder care system was rocked by the massive spending cuts thattookplaceinthedecadethatfollowed.Effectsincludedsharp

14


reductionstofront-linestaffinLTCfacilities,theincreaseofLTCac-commodationfees,andthecuttingofseniors’programsthatofferedhousingandhealthbenefits.36Atthesametime,thegovernmenteyedintroducinganew,less-expensivemeanstodelivercaretoelders,ideallywithsignificantinvolvementoftheprivatesector.Sucha vision was in line with its ideological beliefs about the superiority oftheprivatemarketanditsfocusoncuttingsocialwelfareexpen-ditures.Thegovernment’ssolutionwasthecorporateALmodelthatwas rapidly emerging in the United States.

TheessentialideabehindALwastoprovidehealthcaretoseniorsbasedonneedratherthansetting.Theconceptwasoriginallyde-veloped in Denmark as a means to provide elders with the health care services they required outside of a nursing home. As the Danish governmentunderstoodit,evenfairlyindependentseniorswerebeingshoehornedintoinstitutions,becauseitwastheonlysettinginwhichtheycouldreceivepublic-fundedservices,equipment,andmedication.TheDanishmodelofALcombineduniversalcoveragefor 24-hour home care with specialized housing designed to support independent living.

ALinAlberta,however,lookeddistinctlydifferentfromtheDanishideal. In partnership with real estate developers and other corporate interests,theAlbertagovernmentembracedALasawaytoprivatizeand diminish the services provided to elders. There was in Alberta no massiveexpansionofhomecaretocomplementtheshiftawayfromnursinghomes.Instead,eldershavebeenlefttonavigatelargelyontheirownthroughamorecomplexresidentialeldercaresystem,andtoattempttocobbletogethersufficientcarethroughapatchworkofpublic,private,andpersonalarrangements.

3.A.Thedeclineoflongtermcareandtheriseofassistedliving

ALfacilitieshavegrowntremendouslysincetheunderlyingconceptinitiallygainedfavourinAlberta.Butthisexpansionhasnotneces-sarilymeantmoreresidentialeldercare.Instead,thegrowthofALhassimplycompensatedforthedeclineofLTC,atleastintermsofavailable spaces.

Alberta’spopulationhasbeenaging.Overthedecadeendingin2009,thenumberofAlbertansovertheageof75increasedbymorethan50,000.DespitetheincreasedneedforresidentialeldercarespacesingeneralandLTCspacesinparticularthatsuchagingwouldsuggest,theavailabilityofthesespacesactuallydeclinedovertheseyears.Specifically,between1999and2009,thenumberofLTCbedsperAlbertanaged75andoverdecreasedby20%(seeTable3).ThisreductioninLTCavailabilityisevenmoredramaticgiventhatitoc-curredafteradecadeofdeepercuts.Inthe1990s,theAlbertagov-ernmentreducedthenumberofLTCbedspercapitabyover40%.37

“ “Albertaeldershavebeenlefttonavigateacomplexresidentialeldercaresystemandtoattempttocobbletogethersufficientcarethroughapatchworkofpublic,pri-vate,andpersonalarrangements.

15

By2008,Albertahadthesecondlowestavailabilityoflongtermcarebedsinthecountry,andsatfarbelowprovincessuchasSaskatche-wanandManitobaintermsofavailability.38

Table 3 clearly shows the provincial government’s move away from LTCandembraceofAL.ALbedsincreasedbothabsolutelyandrela-

tivetothegrowthoftheelderlypopulation.Indeed,overthedecadeendingin2009,theavailabilityofALbedsperAlbertanaged75andoldernearlydoubled.Theimplicationsofthisdramaticshiftareexplored in detail below. As two Canadian health experts recently concludedaboutthisbroadernationaltrend:

In terms of health care services provided in the home and by communityagencies,therehavebeennewinvestmentsinallprovinces,butprogressisuneven,andnowhereistheinvest-mentsufficient.Despitegovernmentrhetoricaboutrestructur-inghealthcaretoprovideservices‘closertohome’anddespitedecades of studies and commissions calling for investment in homeandcommunitycare,theseservicesremainseverelyunderfunded across Canada. 39

16


LTC and AL spaces in Alberta, 1999 and 2009

Table 3


3. B.Thedeclineofpublicdeliveryandtheriseoffor-profitcare

InAlberta,LTCandALfacilitiesareoperatedbythepublicsector,thenot-for-profitsector,orthefor-profitsector.Thedecadebe-tween1999and2009sawadramaticshiftintheresidentpopulationserved by each of these sectors.

Overtheperiodinquestion,thefor-profitsectorexhibitedthemostprofoundchange,increasingavailablebedsby83%.Thenot-for-profitsectorsawabedincreaseof72%,whilepublicparticipationdecreasedby10%intermsofavailablebeds.Intermsofdeliverymodel,eldercareinAlbertawastransformeddramaticallyinthedecadebetween1999and2009.In1999,roughlyhalfoftheavail-ableresidentialeldercarespaceswerepublicly-operated,withtheremaininghalfalmostequallysplitbetweenthefor-profitandnot-for-profitsectors.By2009,eachsector(public,for-profit,andnot-for-profit)providedroughlyonethirdofAlberta’sresidentialeldercare spaces.

DistinguishingbetweenLTCandALprovidesafurtherviewonthistransformation.TheexpansionofALbetween1999and2009wasdrivenbytheriseoffor-profitoperations.In1999,73%ofALbedswereprovidedbynot-for-profitoperatorsand26%byfor-profitoperators.By2009,whilethemajorityofALbedsremainedinnot-for-profitoperations,thegaphadclosedsubstantially,withfor-profitoperationsnowproviding41%ofbeds.For-profitoperatorshadachievedanincreaseinbedsof510%overthisperiod,whilenot-for-profitsgrew230%.ThepublicsectorhasbutnegligibleparticipationinthefieldofAL.

OwnershippatternshavealsoshiftedinLTC.In1999,publicoper-ationsprovidedjustoverhalfoftheavailablebeds;by2009,thenumberhaddroppedtojustover40%ofthebeds.Not-for-profitoperationsexpandedoverthedecade,increasingto22%theresi-dentpopulationtheyserved.For-profitoperationsgrewevenmoresubstantially,from27%to35%ofavailableLTCbeds.Thedecadeinquestionhasseena45%increaseinfor-profitLTCbeds,andan8%decreaseinavailablepublicLTCbeds.

3. C.Conclusion

Alberta’spopulationhasbeenagingsignificantly.Despitethere-sultingneedformoreresidentialeldercareingeneral,andLTCinparticular,theprovincialgovernmentactuallydecreasedaccesstothese services for elderly Albertans over the years between 1999 and2009.

Inadditiontothisdeclineinaccess,thereweretwokeychangesinAlberta’sresidentialeldercareinthisperiod:

“ “Despitetheneedformoreres-identialeldercareingeneral,andmoreLTCinparticular,theprovincialgovernmentactuallydecreasedaccesstotheseservicesforelderlyAlbertansoverthede-cadebetween1999and2009.

17


1. the decline of long term care and the rise of assisted living

2. thedeclineofpublicdeliveryandtheriseoffor-profitcare

ThesetworelatedshiftsamountedtoasubstantialtransformationofAlberta’seldercaresector,oneinkeepingwiththerecommenda-tionscontainedwithinreportswrittenbyadvocatesofincreasedpri-vatizationandoffloadinglikeBrodaandMazankowski.Theresultisan elder care system with a diminished capacity to cope with highly acuteormedicallycomplexresidents,andonethatdivergesfurtherfrom the principles underlying the Canada Health Act.

4. Unmet Need Between1999and2009,asAlberta’ssystemofresidentialeldercarewastransformedthroughtheexpansionofALandthedeclineofLTC,changeswerealsoevidentwithintheresidentpopulationitself.AcrosstheAlbertaresidentialeldercaresystem,careneedsincreased,andtheelderswiththemostsevereneedsbecamecon-centratedinLTC.TheexperiencesofAlbertaeldersinLTCindicatethatavailablecarehasnotbeenincreasedsufficientlytocompen-sate. The result has been that Alberta’s elder care system has fallen further away from the goal of ensuring dignity and comfort for the province’s elders.

DatafromStatisticsCanada’sRCFsurveymakeclearthechangesthathavetakenplace.Thesurveygroupsresidentsintofourcategories,runningfromleasttomostincapacitated:TypeI,TypeII,TypeIII,andhighertype.AccordingtoStatisticsCanada’sdefinitions,theneedsof Type II residents can predominantly be met by health care and activityaides,whiletheneedsofTypeIIIresidentsaremorecomplexandrequireattentionfromaidesaswellasintensivemedicalcarefromskillednurses.Trackingshiftsamongtheseresidentgroupsoverthedecadeinquestionindicatesthat,acrossLTCandAL,themedicalacuityandcomplexityofresidentsincreasedsubstantially.

Between1999and2009,acrossALandLTC,theproportionofresi-dentsclassifiedasTypeIIIhasincreasedfrom35%to52%.ResidentsclassifiedasTypeIIdeclinedfrom56%to33%.Overthatdecade,thesituationchangedfromoneinwhichthemajorityofresidentswereTypeII,tooneinwhichthemajorityofresidentswereTypeIII.Overthesameperiod,thepercentageofresidentsovertheageof85increasedfrom43%to49%.

TheexpansionofALandthecomparativestagnationofLTC,com-bined with the increased acuity and medical complexity of the pop-ulationservedbyresidentialeldercare,hascreatedasignificantgap

18


between residents’ needs and the available care.4.A.Thecaregap

Between1999and2009,adramaticshiftinpatientpopulationisevidentwithinLTC.In1999,theresidentpopulationwasmadeupof36%TypeIIIresidentsand58%TypeII.By2009,thecountshadnearlyreversed,with58%ofLTCresidentsbelongingtoTypeIIIand33%toTypeII.Throughoutthisperiod,theremainingsmallportion

of residents fell into either Type I or Higher Type.Increasedacuityisnotnecessarilyaproblem,ifsufficientresourcesareputinplacetoensureadequatecare.However,giventhedimin-ished capacity of Alberta’s elder care sector to cope with severely incapacitatedeldersinlightoftheshifttowardAL,itisnotsurpris-ingthatincreasedacuityhasmeantthatelders,theirfriendsandfamilies,andemployeesintheLTCsectorhavebeensufferingtheconsequencesofacaregap.Itisnoexaggerationtosaythatthegapbetweenincreasedneedsandavailablecareisdevastatingthelivesof Albertans.

HFRC reports document the consequences of this care gap. The

19

Patient Population by Acuity, LTC

1999 2009

0%

25%

50%

75%

100%

Figure1:StatisticsCanada,ResidentialCareFacilities.

HigherTypeIII

TypeIITypeI

5%

58%

36%

1% 1%

7%

33%

58%

*Valuesmaynotaddupto100%duetorounding.


HFRCwasapanelofnon-expertschargedwithconductinganinfor-mal,qualitativeassessmentofthehealthfacilitiesthatfallunderitsmandate.MembersoftheCommitteewereappointedfromdiversebackgrounds,withtheideaofrepresentingacross-sectionofAlber-ta’spopulation.Membersservedonapart-timebasis,andwerenotprovincial government employees. They conducted unannounced re-viewsofhealthfacilitiesthatwereintendedtooffersnapshotviewsofatypicaldayinanAlbertahealthfacility.Theyalsoinvestigatedcomplaints. 40

AsthereportsoftheHFRCmakeclear,employeesworkinginLTC,fromupperadministrationthroughcarestaff,understandthecaregap to have been created through increased resident acuity in the absenceofincreasedstaffinglevels.

WhenmembersoftheHFRCvisitedtheNorthcottCareCentreinFebruary2012,theDirectorofCarecommentedthat“inthefiveyearsshehasbeenatthefacilityacuitylevelshavedoubled,butthefundingforcarestaffhasremainedthesame.”41 Through conver-sationwiththeCEO,co-owner,anddirectorofresidentcareoftheVentaCareCentre,membersoftheHFRCrecordedconcernsthatincreased acuity has not been matched with increased funding for staff.42 AstheDirectorofCareputit:“Thelowstaffingratiodoesnotallowforqualitycareandoftenresultsinovertimecosts,frustratedstaff,andupsetresidentsandfamilies.” 43 The Director of Care went ontoexplainthatLTChas“becomethenew‘endoflife’orpalliativecarewithouttheappropriatefundingtoprovidetheservice.”44

AtMountRoyalCareCentre,staff“emphasizedthattheacuityofmanyoftheresidentsisalmostatthelevelofacutecare,andstaffingisnotadequatetoaddressthecomplexityoftheircare.”45

Inthesecentresandmanyothers,directorsandstaffwereloudlysoundingthealarmaboutthecaregapinLTC.

The reports of HFRC contain many examples of compromised care clearlyrelatedtoinadequatestaffing.Thecaregapwasevidentinavarietyofways,including:

• Responsetocallbells

MembersoftheHFRCrecordedthateldersinLTChadtowaitbetween30minutesand2hoursforaresponsetotheircallbell. 46 Thisledtosituationsinwhichresidentswouldbewetorsoiledbeforecarestaffcouldrespond.Inoneinstance,whenmembersoftheHFRCbroughtthemattertotheattentionofanexecutivedirector,itwasexplainedthattheheavycareneedsofresidentslimitedtheabilityofstafftorespondmorequickly. 47

The members of the HFRC heard from family members that

20

“ ““…theacuityofmanyoftheresidentsisalmostatthelevelofacutecare,andstaffingisnotade-quatetoaddressthecomplexityoftheircare.”


residents were regularly humiliated by having accidents when obliged to wait excessively for care.48Whileeldersmaysufferfromincontinenceduetoconditionsassociatedwithaging,thesituationcanbeexacerbatedinsituationsthatdonotallowforadequate care. 48

• Incontinencecare

Managingage-relatedincontinenceinamannerthatpreservesresident dignity is a basic element of quality elder care. The reports of the HFRC provide evidence that the care gap has contributedtosituationsinwhichthishasnotbeenachieved.AttheVentaCareCentre,forinstance,adaughterfoundthat“hermotherwasputinadiaperandonlytoiletedthreetimesaday.”49AtCarewest’sGarrisonGreencarefacility,themem-bersoftheHFRCheardoffecessoiledclothingoftenleftonthefloorinresidents’roomsforseveralhours,sometimesovernight. 50

• Bathing

MembersoftheHFRCheardconcernsthatthecaregapputresidents’scheduledbathsatrisk.Forinstance,inJanuary2012,HFRCmembersheardfromaresidentatValleyviewContinuingCareCentrethatshewasconcerned“shemightnotgetherweeklybathbecauseofstaffshortages.”51 In a 6 December2012lettertotheEdmontonJournal,L.G.AndersonofSpruceGrovereportedonasimilarsituation.AthercarefacilityinStonyPlain,Anderson’smother-in-lawrequiredtwostaff-membersinordertobathesafely.AsAndersonputit,aninadequateresident-to-staffratioledtoa“backlogonsched-uledbaths.”

AttheCarewestGarrisonGreenfacility,numerousresidentsindicatedthat,shouldtheymisstheirbaths,theywouldhavetowaituntilthefollowingweek’sscheduleisstarted.52 At the WingKeiCareCentre,bathsarehardlypleasantexperiences.Familymembersadvisedthatcarestaffarerushedtogiveresidentstheirbaths,whichresults“intheresidentsnotbeingproperlywashed,driedorre-clothed.”53

• Dining

TherecordsoftheHFRCdocumenttheeffectsofthecaregaponelders’diningexperiences.AttheCarewestGarrisonGreenfacility,residentsreportedbeingtakenearlytothediningroom,andthenhavingtowaitforanhourorlongeruntilthemealwasserved,asasmallnumberofstaffworkedtotrans-port a large number of residents.54 AttheStettlerHospitaland

21


CareCentre,thedieticianraisedaconcernthatsomeresidentscouldusemoreassistanceduringmealtimes.Staffmembersobligedtocareforalargenumberofresidentshavelittlechoicebuttorushpeoplethroughtheirmeals,resultinginsituationsinwhicheldersmaynothavetheopportunitytoeattosatiety.Inthedietician’sexpertopinion,thissituationcanincreasetheriskofchoking,andresultinharmfulweightlosson the part of residents.55

• Therapies

Theeffectsofthecaregaparealsoapparentwithreferencetotheavailabletherapies.AttheBrooksHealthCentre,HFRCmembersheardthatcurrentstaffinglevels“arenotleavingtimetoprovideresidentswiththephysiotherapynecessarytohelpthemmaintaintheirstrengthandmobility.”56 At Edmon-tonGeneralContinuingCareinOctober2010,oneresidentand several family members expressed concern for a resident whohadbeentransferredfromacutecareaftersufferingastroke.Thewomanwasadmittedwithaphysician’sorderforphysiotherapy,butinthefourmonthssinceherarrival,shehad only seen a therapist twice.57The care gap also bears on residents’abilitiestoaccesswhattherapiesmaybeavailable.AtCapitalCareDickinsfield,membersoftheHFRCfoundthatlackofstafftohelpintransportationlimitsresidents’partic-ipationinrecreationalactivities.58Similarly,atExtendicareMichenerhill,staffshortagesmean“thatresidentsdon’tgettransportedtoactivitiesortherapiesintime.”59

• Riskofinjury

AttheValleyviewContinuingCareCentre,HFRCmemberscommentedthatshortstaffingwasresultingin“nursingstaffbeingrushedthroughmedicationadministration,whichcouldresultinerrors.”60StaffattheStettlerHospitalandCareCentre worried about whether their training was adequate to copewithresidentswith“verycomplexhealthconditions,”feelingthat“staffwithhigherqualifications”wouldbebet-ter equipped to meet residents’ needs.61Inadequatestaffingcanleadtosituationsinwhichresidentsaremorelikelytobeplacedinriskysituations.Forinstance,aresidentadvisedvisitingmembersthatthereisnotalwaystwostaffmemberspresentwhentheyaretransferringherinalift.62 This poten-tiallydangeroussituationcouldresultininjurytotheresidentandthestaffmember.

Clearly,thecaregapisaffectingthelivesofAlberta’seldersinimportant ways. It impedes their ability to live with dignity and in comfort,andcarriesrealconsequencesfortheirphysicalandmental

“ “Inadequatestaffinghasresultedin“nursingstaffbeingrushedthroughmedicationadministration,whichcouldresultinerrors.”

22


health.Itisalsoacauseofdistressforfriendsandrelativesofeldersincarefacilities,andofhardshipforemployeesworkinginresiden-tialeldercare.

ThedirectconnectionbetweentheexpansionofALandthecreationofthecaregapinLTCisapparenttothoseworkinginresidentialel-dercare.ThemedicaldirectorattheBowViewManor,forinstance,reportedthat“thecomplexityoftheresidentpopulation’sconditionisskyrocketing”becausewithAHS“movingresidentstoALfacilities,itisbecomingtougherandmoredifficulttoqualifyforadmissiontoaLTCfacility.”63

Notably,theAlbertagovernmentwaswarnedasearlyas1999aboutthe need to adequately accommodate a more acute resident popu-lationinLTC.Asitwasarguedinthe1999Brodareport,“AdditionalfundingshouldbedirectedtoincreasingthenumberofqualifiedfrontlinestaffavailabletoaddresstheincreasingacuityofpeopleinLTCcentres.”64 Unfortunately,itseemsthatBroda’srecommendationaboutstaffingincreasesfellondeafears.So,too,havetheveryclearindicationsprovidedbyprofessionalcaregiversabouttheproblemsintheeldercaresector.Asaresult,ithasbecomeasadjokeamongAlbertaeldercarestaffthatitismuchbettertobeaprisonerthanasenior in Alberta.65

4.B.Theknowledgegap

Between1999and2009,ALexperiencedanincreaseinresidentacuitycomparabletothatseeninLTC.WithinAL,residentsrequiringTypeIcaredeclinedfrom47%to30%,whilethoserequiringTypeIIcare held steady. The big change was in the percentage of residents requiringTypeIIIcare,whichincreasedfrom17%to34%between1999and2009.In1999,closetohalfofALresidentswereofTypeIandonly17%wereofTypeIII.Butby2009,ALwassplitrelativelyevenlyamongresidentsrequiringTypeI,TypeII,andTypeIIIcare.Thischangeamountstoamajorinfluxofhigh-acuityresidentsintofacilitiesdesignedforless-acuteneeds.

The records of the HFRC made it possible to put a human face on the caregapinLTC.ItisdifficulttodosomethingsimilarforALbecausetheHFRCdidnotvisitthosefacilities.ALdidnotexistwhenthemandateoftheHFRCwasdefineddecadesago,andnoeffortwaslatermadetobringALunderitspurview.Thisdearthofinformationamounts to a knowledge gap regarding the experiences of elder AlbertansinAL.

Theknowledgegapalsorelatestotheregulatorydifferencesbe-tweenALandLTC.UndertheNursing Homes Act or the Hospitals Act,LTCfacilitiesareobligedtomeetsomekeystandards.Forex-ample,LTCoperatorsarerequiredtoprovideelderswithaccesstoa

“ “Comparedwithlongtermcare,thereisadditionaluncertaintyregardingthecareavailabletoresidentsinassistedliving.

23

representativeoftheirreligion.Theymustsupplythreedietician-ap-provedmealsperday,accommodatespecialdietaryrequirements,andprovidecontinualaccesstosnacks.OperatorsofLTCfacilitiesmustofferanannualstaffeducationprogramontopicsincludinggerontologyandinfectioncontrol.LTCfacilitiesarealsoobligedtomeetcertainstandardsrelatedtostaffing,bothintermsofminimumcaretoresidentsandminimumtraininglevelsforstaff.Whilethesestandardsfallfarshortofexpertrecommendationsregardingthestaffinglevelsnecessarytoensureadequatecare,theydoamounttoameasureofprotectionthatisunavailablewithinAL.66

Regulated by the Supportive Living Accommodation Licensing Act,ALfacilitiesaresubjecttoverylittlebywayoflegalrequirements,beyondbasicprovisionsforsafetyandcleanliness.NeithertheSupportive Living Accommodation Licensing Regulation nor the Continuing Care Health Service Standards fillsthegapbyprovidingmeaningfulassurancesthatresidentsinALcanrelyoncarethatwillsafeguard dignity and comfort. Considering also the role of home careinsupportingresidentsinAL,thelinesofaccountabilityaresubstantiallylessdirectwithinALascomparedwithLTC.Asaresult,thereisadditionalscopeforuncertaintyregardingthecareavailable

24

Patient Population by Acuity, AL

1999 2009

0%

25%

50%

75%

100%


TypeI

TypeII

TypeIII


47%

35%

17%

30%

35%

34%

1%

Higher

*Valuesmaynotaddupto100%duetorounding.


toresidentsinAL.

Asof2013,theknowledgegapinAlbertaeldercarehasexpandeddramatically.TheGovernmentofAlbertahaseliminatedtheHFRC,claiming that various other government programmes make its work redundant. It should be noted that the HFRC was by no means an ideal mechanism through which to monitor elder care. As noted above,thecommitteelackedamandatetoverifycompliancewithbasicstandards,ortoassessqualityofcareinarigorousmanner.Committee-memberswerenottrainedhealthprofessionals.Mostimportantly,thereislittleevidencethatthereportsoftheHFRChavepromptedmeaningfulchangesingovernmentpolicy.Bothlimitationsinthescopeofthecommittee’sinvestigationsandlimitationsintheinfluenceoftheresultingreportskepttheHFRCfromhavingsub-stantialeffectonthedeliveryofhealthservicesinAlberta.However,thereportsoftheHFRCdidprovidesomerecordofresident,friendandfamily,andstaffexperiencesthatmaynototherwisehavebeenpreserved.Certainly,itisunclearthatotherexistinggovernmentpro-grammeswillmakepublicinformationcomparabletothatavailablethrough the reports of the HFRC.

The severity of the knowledge gap is redoubled by circumstances not under the control of the provincial government. Within the context ofthisreport,itwaspossibletoassesstheincreasedresidentacuityinAlbertaeldercarethroughexaminationofStatisticsCanada’sRCFsurvey.Thisdataserieswasterminatedin2010andhasnotbeenreplacedbyanyotherstatisticaldocumentationofresidentialeldercareacrossCanada.Fromthisperspective,Albertaresidentialeldercarefallswithinanation-wideknowledgegap.

4.C.Workers’experiences

Asincreasedresidentacuityhasaffectedresidentandfamilyexperi-encesinnegativeways,sohasitaffectedthepeopleworkingintheeldercaresector.Intheabsenceofresourcessufficienttocompen-sateforchangedresidentpopulations,amoreincapacitatedresidentpopulationhascreatedanextremelydifficultsituationforAlbertansemployed as caregivers.

The records of the HFRC make clear that employees have sought to makeupforinadequatestaffing,evenattheexpenseoftheirownphysicalandmentalwellbeing.StaffattheVegrevilleCareCentreindicatedthat“theydidnothavetimetotaketheirbreaksbecauseoftheworkload.”67FamilymembersofresidentsintheGoodSamar-itanSouthRidgeVillageexpressedconcernsthatstaffmembersareworkingtoohard,indicatingthat“theyneverhaveabreak!”68 At the EdithCavellCareCentreinLethbridge,staffexplainedtomembersoftheHFRCthedirectconnectionbetween“theincreasedcomplex-ityofcare”and“increasedinjuryandillness”amongstaff.69 These

“ “Intheabsenceofappropriateworkplacesupports,residents’increasedmedicalacuityandcom-plexityhascreatedanextremelydifficultsituationforAlbertansemployedascaregivers.

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Alberta-specificexamplesconfirmthesignificantriskstoeldercarestaffthatnationalandinternationalresearchersworkingonLTChave documented.70

Staff-membersforcedtooverextendthemselvesmaythenbeobligedtomissworkinordertorecover.Givenapparentemployerdifficul-tiesinsecuringreplacementworkers,theresultisthattheacuitygapisrenderedevenmoreseverebystaffabsences.ThesituationwasapparenttofamilymembersattheGoodSamaritanSouthRidgeVillage,whoobservedthatemployeesareoftenobligedtoworkshort-staffed,asthefacility“can’tgetsomeonetocomeintocoverifstaffareoffsick.”71Employeesworkinginresidentialeldercarewhowere consulted through the research process for this report have indicatedthatworkingshort-staffedisstandardpractice.

Labourconditionshaveadirectbearingonresidentexperience.Staffturnover can seriously erode resident quality of life due to the value ofinterpersonalrelationships,particularlyinlightoftheintimatenatureofmanytasksundertakenbyeldercarestaff.72At Carewest GarrisonGreen,oneresidentsaidthatresidentsneverhavethesamehealthcareaide(HCA)attendingtothemformorethanafewdays,sotheynevergettoknowtheaide,andtheaidenevergetsto know them.73InalettertotheRedDeerAdvocatepublished15January2013,R.DeanCowanofRedDeerworriedthatastrikeathiswife’sfacility(SymphonySeniorLiving,AspenRidge)wouldseriouslyaffectherwell-being.Hisdementiastrickenwifedependedonherfamiliarcaregivers,withwhomshehadbuiltrelationships.Cowanwrotethat,“wheneveranewemployeestarts”hiswife“becomesquiteaggressivetowardsthem.”Thisexamplevividlyillustrateshowupsettingstaffinstabilitycanbeforelders.

Researchers have documented the risk of physical violence faced byeldercarestaffintheirday-to-daywork.74Inconversationswithfront-linestaffundertakenforthisreport,workersreportedbeingpunched,hit,spiton,bitten,andhavingtheirhairpulled.Eldercareworkersalsosufferintellectuallyandemotionally.AtElkPointHealthcareCentre,theHFRCspokewiththeheadnurse,healthcareaides,andotherstaff,allofwhomexpresseddistressatwhattheysawastheinadequatecareprovidedtoresidents.MembersoftheHFRCnotedthatmanystaff-memberswereveryemotionalaboutthissituation,exhibitingsadnessandfrustration.ThereportoftheHFRCconcludedthatfeelingsofstressamongststaffderivedfromtheirperceivedinabilitytoprovidetimelyandadequatecareareaffectingresidentcareandstaffmorale.75Researchers examining workers’experiencesinresidentialeldercarehaveappliedthecon-cept of structural violence as a means of describing the poor working conditionsandlackofsupportexperiencedbyeldercareworkers.Structural violence impedes careworkers from providing the quality of care that they recognize should be available to elders.76

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Inconversationswithresidentialeldercarestaffundertakenforthisreport,arecenttrendbecameapparent.Numerousemployeesdocumentedincreasingconcernwith‘customerservice’amongtheownersandoperatorsofeldercarefacilities.Further,Extendicare,alargecorporateproviderofeldercarewith246facilitiesacrossCanadaandtheUnitedStates,notesinitsannualreportthatithasimplementedacustomerservicetrainingprogram(CourtesyAttitudeResponsibilityExcellence,orCARE)totrainallfrontlineworkersonhowtheycanimprovetheircontributiontomanaginganddeliveringuponcustomerserviceexpectationsinacompetitivemarket.77

Disturbingly,thisconcernwith‘customerservice’ismanifestnotasrenewedattentiontothewell-beingofelders,butaspreoccupa-tionwithcultivatingapositiveimpressionofthefacilityamongthefriendsandfamilyofresidents.Somefacilitieshavebegunemployinggreeterstointerceptvisitorsatthedoor,andtoensureinsofaraspossiblethattheyarepleasedwithwhattheysee.Staffresponsibleforresidentcarehavebeenorderedtoavoidmentioningiftheyareshort-staffed,asthismayleavefriendsandfamilywithanegativeimpression. Some workers in the elder care sector tell of operators instructingfamiliestocallbeforetheyvisit,whichsuggestsapoten-tialvariationinlevelofcarebasedonwhetheravisitispending.

Inasituationwheretheprimaryfocusremainedonensuringqualitycareforresidents,therewouldcertainlybenoharminalsoworkinginasinceremannertoimprovetheexperienceofvisitingfriendsandfamily.However,inasituationinwhichemphasisisplacedoncul-tivatingapositiveimpressiondespiteclearevidenceofinadequatecare,thereisreasonforconcern.Workersintheeldercaresectorarebeingaskedtoparticipateinfurtheringaknowledgegapthatmay mislead friends and family about the quality of care their loved ones are receiving.

4.D.Conclusion

TheshifttowardAL,motivatedbygovernmentdesiretotrimpublicexpendituresandexpandopportunitiesavailabletofor-profithealthcareproviders,hashadseriousnegativeconsequencesforAlbertansservedbytheeldercaresystem.Theconcentrationofseverely-inca-pacitatedelderswithinLTChascontributedtoadiscrepancybe-tween residents’ needs and available care. This care gap has caused inconvenience,discomfort,andahigherriskofinjurytoeldersinLTC.

Thefacilitiesmentionedbynameinthisreportareillustrativeofabroaderpattern.RoughlyhalfoftheHFRCreportsexaminedforthisreportincludedatleastoneexampleofinadequatecareattributabletothecaregap,andmanyfacilitiesincludedmultipleexamples.ItisclearthatdifficultconditionsinAlbertaresidentialeldercarehave

27


seriousnegativeconsequences,notonlyforeldersandtheirsupportnetworks,butalsoforemployeesworkinginresidentialeldercare.

ThissectionalsoconsiderstheknowledgegapinAlbertaresiden-tialeldercare,whichinhibitsattemptstocloselyexamineresidentexperienceswithinAL.IntheabsenceofreportsfromtheHFRC,andinlightofthelesserregulationtowhichALissubjectincom-parisonwithLTC,thereisamplereasonforconcern.ThesituationisrenderedevenmoreworrisomebytheeliminationoftheHFRCandthecancellationoftheRCFsurvey,thekeyStatisticsCanadadatasetaddressingresidentialeldercare.Ultimately,withrespecttotheavailabilityofinformationabouttheexperiencesofeldersinresiden-tialcare,thesituationisbecomingincreasinglydireinbothLTCandAL.

5. PrivatizationAlongwithsignificantevidenceofunmetneedacrossAlberta’sentireresidentialeldercaresystem,thereisalsoreasonforconcernthatthequalityofcaremaybedrasticallyunevenamongtheprovince’sresidentialeldercarefacilities.Thissectioncomparescarequalityamongpublic,not-for-profit,andfor-profitLTCfacilities.

Itseemsintuitivelyobviousthatmoreskilledcaregivers,withmoretimetospendoneachresident,providebetterqualitycare.Thisrela-tionshipbetweenstaffingandcarequalityhasbeensubstantiatedby academic experts.78A key factor bearing on the quality of care is theratioofcaregiverstoresidents,withmorecaregiversassociatedwithbettercare.Anotherimportantfactoristheleveloftrainingandexpertiseamongprofessionalcaregivers.

StatisticsCanada’sRCFsurveyprovidesdataonstaffhoursandnum-berofresidentsinLTCfacilities.Byincorporatingexpertbenchmarksoncaretimeneededtoachieveminimallyacceptableandreason-ablequalitycare,itispossibletogaugewhetherAlbertaeldershaveaccess to appropriate levels of care.79Thefindingsaredisturbing.LTCin Alberta only very rarely meets or exceeds the benchmark for min-imallyacceptablecare.Inthevastmajorityofyears,acrossdeliverymodels,thebenchmarkforqualitycareisfaroutofreach.ThesefindingsfurthersubstantiatetheexistenceofacaregapinAlbertaresidentialeldercare.

Importantly,thecaregapvariesinseverityaccordingtodeliverymodel.ThissectionexploresthesignificantdifferencesinstaffingpatternsamongAlbertaLTCfacilitiesthatareoperatedpublicly,byanon-profitgroup,orbyafor-profitenterprise.InAL,careisoftenprovidedprimarilythroughhomecare,whichisnotassessedintheStatisticsCanadadatasetemployedhere.

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“ “LongtermcareinAlbertaonlyveryrarelymeetsorexceedsexperts’benchmarksforminimallyaccept-ablecare.Inthevastmajorityofyearsconsideredhere,thebench-marksforqualitycareremainfaroutofreach.


5.A.CaretimebydeliverymodelSchematicliteraturereviewsarescholarlyattemptstoanalyzethefindingsofalargenumberofstudiesonagiventopic.Twosuchrecentreviewshavebeenconductedonthetopicofvariationsincarequalitybetweeneldercarefacilitiesoperatedpubliclyorbyfor-profitornot-for-profitenterprises.Inareviewofrelevantstudiespublishedbetween1990and2002,Hilmeretal.establishedthatnursingstafflevelswerelowerinfor-profitfacilities.80In an even largerexaminationofstudiespublishedbetween1965and2003,Comondoreetal.foundthatnot-for-profitfacilitiesexhibitedmoreorhigherqualitystaffing.81

Recent years have seen the expansion of research along these lines inaCanadiancontext.NumerousstudiesoftheOntariosituationhaveconnecteddeliverymodeltostaffinglevels.A2005analysisofOntarioLTCfacilitiesbetween1996and2002foundthatpublicfacilitieshadhighernursingintensitylevelsandhigherdirectcarestaffinglevelsthanotherdeliverymodels,whilefor-profitfacilitieshavesignificantlylowerlevelsthanotherfacilitytypes.82A2005studyoftheBritishColumbiasituationfoundthemeannumberofhoursperresident-daywashigherinthenot-for-profitfacilitiesthaninthefor-profitfacilitiesforbothdirect-careandsupportstaff,andfor all facility levels of care.83Studieshavelinkedstaffingdifferencestoresidentoutcomes,withresidentsfaringbetterinbetter-staffedfacilities.84

Albertalongtermcareconformstothesebroaderpatterns,exhib-itingsignificantvariationamongstaffinglevelsbetweendeliverymodels. Total direct care hours per resident-day encompasses the variousservices(includingnursingandpersonalcare)thateldersinlongtermcarereceivefromregisterednurses[RNs],licensedpracti-calnurses[LPNs]andHCAs,measuredinhoursperresidentperday.AsdisplayedinFigure3,onaverageacrossthedecadebetween1999and2009,publicfacilitieshoveraroundthebenchmarkforminimalcare.Non-profitfacilitiesare,onaverageovertheperiodconsidered,justover40minutesshortoftheminimalcarebenchmark.For-prof-itfacilitiesfaretheworstofall,averagingroughlyanhourandtenminutes short of the minimal care benchmark.

ItiscriticaltonotethatthefiguresanalyzedaboveoverstatethedirectcarereceivedbyLTCresidents.TheStatisticsCanadadataemployedhereaddressedtimepaid,nottimeworked.Paidhoursincludeholidays,sicktime,andothercompensationoverandabovetimespentengagedinlabour.AstudyofcarefacilitiesinBritishColumbiafoundthatpaidhourswere15to30percenthigherthanactual hours worked.85 Had it been possible to subtract paid hours notspentindirectresidentcare,thesituationwouldberevealedaseven more dire.

“ “Albertalongtermcareexhibitssig-nificantvariationsinqualityamongfor-profit,not-for-profit,andpublicdeliverymodels,withfor-profitfacilitiesofferinginferiorcare.

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ThesituationinAlbertaLTCfacilitiesconformstotheprevailingna-tionalandinternationalpatternwithrespecttodifferencesincarequalityacrossdeliverymodels,asindicatedbystaffinglevels.Basedontheirstudiesinotherjurisdictions,expertsHarringtonetal.havecometotheconclusionthat,ineldercare,“profitseekingdivertsfundsandfocusfromclinicalcare.”86 Another Canadian study con-cluded that “public money used to provide care to frail elderly peo-plepurchasessignificantlyfewerdirect-careandsupportstaffhoursperresidentdayinfor-profitLTCfacilitiesthaninnot-for-profit.”87

TheseassertionswouldseemtoholdtrueinAlberta.Inexpandingopportunitiesforfor-profitparticipationinAlbertaeldercare,theprovincial government has promoted a move toward a delivery mod-el that is associated with lower quality care.

5.B.Caregiverexpertisebydeliverymodel

Carequalityisaffectednotonlybytheamountofcareavailable,butalsobytheexpertiseofthosedeliveringthecare.Whileinasupport-iveworkenvironment,allcaregivershavethecapacitytoperformtheirdutiesconscientiouslyandcompassionately,theadvanced

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QUALITY CARE

2.00

2.25

2.50

2.75

3.00

3.25

3.50

3.754.00

4.25

4.50

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

MINIMUM CARE

PUBLIC

NOTFORPROFIT

PRIVATE

Total Direct Care Hours Per Resident-Day, LTC



HOURS

Private Not For Profit Public


trainingpossessedbystaffsuchasLPNsandRNsallowsthemtoofferspecializedcareortoperformtasksthatarebeyondHCAs.

Overthedecadebetween1999and2009,adramatictransforma-tiontookplaceinthestaffmixwithinAlbertaLTCfacilities.ThisisdocumentedinFigure4.TheproportionofcareprovidedbyHCAshasincreasedacrossalldeliverymodels.TheproportionprovidedbyLPNshasdecreaseddrastically,whiletheproportionprovidedbyRNshasdecreasedmoremodestly,thoughstillsignificantly.Overall,theseshiftsamounttoade-skillingoftheLTClabourforce,creatingasituationinwhichtherearefewerstaff-memberspositionedtoprovide specialized nursing care. This is occurring even as the acuity andcomplexityoftheresidentpopulationisincreasing.

Inrelationtothecareavailablefromhighly-trainedstaff,thereareimportantdifferencestonotebetweendeliverymodels.Figure5makes clear that all delivery models fall far short of the 69 minutes ofcareperresidentperdaybyRNsthatisconsideredthebenchmark

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{ { { {45%

41% 33%35% 37%42%

50%

1999 - 2001 2002 - 2004 2005 - 2007 2008 - 2009

Staff Mix in Alberta LTC Facilities

RN’s

LPN’s

CareAides

20% 18% 17% 17%


for quality care.88Overtheyearsinquestion,publicfacilitieshoveredaround the minimal care benchmark of 45 minutes per resident per day.89Bothnon-profitandfor-profitfacilitiesfellshortoftheminimalcarebenchmark,withfor-profitsaveragingtheworstofallovertheperiodinquestion.Ofalldeliverymodelsbetween1999and2009,publicfacilitiescametheclosesttohittingthequalitycarebench-markin2002,whentheyoffered52minutesofcare.Incontrast,overthedecadeconsideredhere,privatefacilitiesoffered,atmost,just under 35 minutes of care.

Notably,inresearchworkshopswithstaffworkingintheeldercaresector,participantscommentednumeroustimesthatRNsarein-creasinglyplacedinadministrativeandsupervisorypositions.Theirtimemightbespentoverseeingthoseengagedinhands-onresidentcare,orinpreparingresidentreports.ItispossiblethatresidentsfailtoreceivesignificantbenefitfromeventheminimalperiodofexpertRNcarethatthisdatawouldsuggestisavailabletothem.

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1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 20090.40

0.50

0.60

0.70

0.80

0.90

1.00

1.10

1.20 QUALITY CARE

MINIMUM CARE

PUBLIC NOTFORPROFIT PRIVATE

RN hours per resident-day, LTC


HOURS


Further,onceagain,thesemeasurementsofcaretimepertaintothehoursforwhichemployeesarepaid,notthehourstheyactuallyspentworkingwithresidents.Subtractingpaidtimenotspentindirectresidentcare,ifthedatamadeitpossibletodosoaccurately,wouldprovideamorerealisticpictureofthecareavailabletoelderAlbertans.

5.C.Workers’experiences

Private delivery of elder care has consequences for employees work-ingintheeldercaresector.AnOntariostudylinkedfor-profitowner-shipwithhigherratesofworkplaceinjury,moresevereinjuries,andgreaterfearofrepercussionsforreportinginjuries.90Further,privateoperatorstypicallyofferlessercompensationpackagestotheirstaff.ThevariationisevidentinrecentAlbertacollectivebargainingexpe-riences.

• In2012,theAlbertaUnionofProvincialEmployeesachievedfirstcontractsfortheworkforcesatHardistyCareCentre91 and DevonshireCareCentre,92 both owned by BC-based Park Place SeniorsLivingInc.Themajorachievementinbothcontractswastobringstaffwagesinlinewithratesofpayatpublicfacil-ities.WorkersatHardistywereonstrikefortwomonthsbeforeasettlementwasachieved.

• InNovember2012,theCanadianUnionofPublicEmployeesreachedasettlementforworkersatafor-profiteldercarecen-trethatofferedauxiliarynursingstaffsalaryincreasesof10.9%overthreeyears,andimprovementsinshiftandweekendpre-miums in order to bring them in line with rates paid at public facilities.93Thissettlementwasachievedwiththeassistanceofa mediator.

• InApril2013,alabourdisputeatMontereyPlaceeldercarefacilityinCalgarywasfinallyresolvedaftera280-daylock-out.Whilethesettlementbroughta44%increaseinhealthcareaides’wagesanda40%increaseinlicensedpracticalnurses’wages,attheendofthefouryeardeal,TripleALivingCommu-nitiesInc.,thefacility’soperator,willstillbepayingitsstaffatlevelsbelowtheratesofferedtoemployeesinpublicfacili-ties.94

Itisobviousthatcollectivebargainingachievementsbenefitwork-ers by improving wages for the work of caring for the elderly. What maybelessobviousishowtheybenefitAlbertansatlarge.AlbertaHealthServicesfundsallfacilitiesinamannerthatassumeswagerates equivalent to those paid under Alberta Health Services col-lectiveagreements.95 So private operators are funded to pay their nursingstaffatthesamelevelasAlbertaHealthServicesemployees

33


doingthesamejob,butsomeoperatorsneverthelesscontinuetopay lower wages. The result is that public funds intended to ensure sufficientnumbersofqualifiedeldercarestaffaredivertedtowardfacility owners.

AsworkersatHardistyCareCentrefound,strikeactionmayevenbenecessary in order to secure wages paid at the rate Alberta Health Servicesassumesprivateoperatorsarepayingtheirstaff.Consideringthis,itisworryingthattheAlbertaContinuingCareAssociation,thelobby-groupfortheeldercareindustry,hasbeenpressuringtheGov-ernment of Alberta to take away the right to strike from workers at unionizedprivateandnon-profitLTCandsupportivelivingfacilities.96

5.D.Conclusion

ThissectionconsidersthequalityofcarereceivedbyAlbertaeldersinLTC.Itmakesclearthat,measuredaccordingtothebenchmarksestablishedbyexperts,LTCstaffinghaslargelyfailedtomeetthelevels deemed necessary to ensure even a minimal quality of care. Italsomakesclearthatwhileevenpublicfacilitiesfailtoachieveadequatestaffing,not-for-profitfacilitiesdoworse,andfor-profitfacilitiesworstofall.Thisisconsistentwithresearchconductedelsewhere,whichhasestablishedalinkbetweenfor-profitown-ershipandlowerstaffinglevels.Giventheestablishedconnectionbetweenstaffinglevelsandcarequality,thisamountstoalowerqualityofcareforAlbertaeldersinfor-profitLTCfacilities.Thissectionalsomakesclearhowinadequatewagespaidatfor-profitfacilitiesamounttoadiversionofpublicfundstowardthecoffersof private operators.

Overthepast15years,residentialeldercareinAlbertahasbeenadministeredinamannerthathasledtotheincreasedparticipationoffor-profitenterprises.ThisquestionableapproachtoresidentialeldercarehasresultedinnegativeeffectsonAlbertansineldercare,theirfriendsandfamilies,andemployeesworkingintheeldercaresector.

6. Offloading Offloading,theprocessoftransferringcostsandresponsibilitiesfromthepublicsystemtoprivatecitizens,isbasictoeldercareinAlberta.Suchtransfershavebeenpresentedasmeansoflimitingpublic expenditures on elder care. But changing who pays for or provides care does not make it free. To gain a true understanding ofthecostsofeldercare,includingitsconsequencesforAlberta’ssocietyandeconomy,itisessentialtotracktheeffectsofoffload-ing.Thisbroaderconceptualizationemphasizesboththeeconomicandnoneconomicconsequencesofoffloadingandmakesclearthat

34


offloadingisnotinthebestinterestofelders,theirfriendsandfamily,orthebroaderAlbertapublic.

ElderAlbertansareevaluatedforplacementinLTCorALthroughanassessmentofunmethealthneeds.AsdefinedbyAlbertaHealthServices,unmethealthneedsare“carerequirementsthatremainaftertheabilitiesandexistingsupportsoftheclient,familyandofthecommunityhavebeenconsidered….”97 The system is structured toensurethecapacitiesoffriendandfamilycaregiversareexploitedtothemaximumbeforepublicsupportsareputinplace.Inthisway,the goal of minimizing the role of the public system is built into the process through which elders’ needs are assessed.

Ashasalreadybeennoted,residentsinLTCandALareleviedacostfortheiraccommodation.TheAlbertagovernmentcontendsthatthespecializedaccommodationprovidedinthesefacilitiesisnotahealthservice,withtheresultthatthegovernmentisnotobligedtoensurefreeaccesstoall.Thisunbundlingofaccommodationandhealthservicesrestsonthequestionablenotionthat,forelders,healthservicesandaccommodationarrangementscanbeseparated.Inreality,ofteneldersarefacedwithlittlechoicebuttoaccessthespecializedaccommodationthatmakespossiblethehealthcareser-vicestheyrequire.Notably,Alberta’sAuditorGeneralhassaidthatthecostsleviedonresidentswithrespecttoaccommodationarenotbasedonanyactualsummingofrelevantexpenses.Infact,theAuditorGeneralwentontoexplainthattheGovernmentofAlbertahasnot“definedwhatservicesaccommodationratescover.”98 There isreasontoquestionboththeideathathealthandaccommodationservicescanreasonablybedividedandthespecificamounttheGov-ernmentofAlbertahasseenfittolevyasaccommodation-relatedcharges.

Beyond the charges they are assessed with respect to accommoda-tion,residentsinLTCarealsogenerallyobligedtopayout-of-pocketforcostssuchaslaundry,hair-dressing,andtelevision.Personalcareitems such as toiletries and oral care supplies are also a cost to the resident.

6.A.Inadequatecare

Evenonceeldersareacceptedintotheresidentialeldercaresystem,substantialresponsibilitiesremainforfriendsandfamily-members.IntheAlbertacase,friendsandfamilyofelderswithinLTChavebeenobligedtocontributesubstantiallyinordertocompensateforaninadequatestandardofcare.Thesecontributionshavecomeeitherintheformoffinancialoutlaysoroutlaysoftime.

TherecordsoftheHFRCdocumenteffortsbyfamiliestohiresupple-mentarycaregivers.AtCapitalCareDickinsfield,theHFRCnotedthat

“ “FriendsandfamilyofeldersinAlbertalongtermcarehavebeenobligedtocompensateforinade-quatecarebypayingformorecareorperformingcarethemselves.

35


some families felt obliged to hire private caregivers “to provide one-on-onecareandattentiontotheirlovedones.”99Thesecaregivers,committeemembersgoontoexplain,alsofacilitatebasicrecreation-alopportunities,suchasgoingforwalksordoingsomeshopping.

InresponsetoaconcernoftheHFRCwithrespecttostaffing,anad-ministrator with the Edith Cavell Care Centre noted that the facility is “fullystaffedaccordingtotheAlbertafundingrequirements.”100 The administratorthenwentontonotethatdissatisfiedfamilies“haveaccess to paid companions that provide extra hours for feeding res-identsandsupport.”101AtBarrheadContinuingCare,inresponsetoconcernsoverbathingfrequency,staffadvisedmembersoftheHFRCthat those desiring more frequent bathing could pay for the service throughaprivateprovider,attheirowncost.102Suchsuggestionsfromeldercareprovidersindicatethatthepracticeofpayingoutofpocket to ensure adequate care has become well-entrenched across theresidentialeldercaresystem.

Theseexamplesillustratethefinancialoutlayrequiredofresidentsand their families in order to achieve a minimum standard of life and qualityofcare.Suchexamplesalsoraiseconcernsaboutvariationsin care quality among those able to pay and those of more modest resources.

The reports of the HFRC also document instances of family mem-bers’attemptstocompensateforinadequatecarethroughtheirownunpaidlabour.AtCarewestGarrisonGreen,theHFRCfoundatroublingsituationinrelationtomorningdining.Membersobservedthat,onbothdaystheyvisited,therewerenostaff-membersassist-ing residents with their meals. What assistance residents did receive wasofferedbyafamilymemberwhowasdeliveringfoodfromthekitchen to the residents. The family member informed the HFRC that shehadbeguncomingtohelpherfatherwithhisbreakfast,buthadbeen so disturbed by the lack of assistance provided to others that she decided to take the training course that would enable her to par-ticipateinservingmeals.Shenotedthathersisterhadalsotakenthecourse,sohersisterwouldbeabletoassistwiththeeveningmeal.103

InAlbertaLTC,friendsandfamilyofeldershavebeenobligedtoeitherpayforadditionalservices,ortoprovidetheseservicesthem-selves,inordertoensurethattheirlovedonesreceiveaverybasicstandardofcare.InadequatecarethroughouttheLTCsystemhasresultedinrampantoffloadingontothefriendsandfamilyofelders.Thissituationalsoraisesconcernsaboutelderswhomaylacksuchpersonal support networks.

6.B.Assistedliving

WhileoffloadingexiststhroughoutAlberta’sresidentialeldercare

36


sector,itismoreextremeinALthaninLTC.ResidentsinALareobligedtopaycostsrelatedtoaccommodation,asinLTC.Theyarealsosubjecttoawiderarrayofadditionalcosts.Theseincludecostsrelated to:

• Medications

MedicationcostsareabsorbedbythepublicsystemwhentheresidentisinanacutecarehospitaloranLTCfacility.SeniorsinALhaveaccesstothedrugcoveragetheGovernmentofAlbertaextendstoallseniors.Whilethiscoverageisinfluxatthemomentduetochangesannouncedwiththe2013provin-cialbudget,tothispointallAlbertaeldershavehadaccesstoBlueCrosscoverage,includingupto$25,000inhealth-relatedbenefitsperyear.Roughly30%ofavailabledrugswerenotcoveredbyBlueCross,andthereforeresidentswereobligedtopurchasethemprivately.Further,elderswerealsoexpectedtopayupto$25perprescriptionorrefill.

Additionally,certainALfacilitiesestablishconditionsthatincreasedrugcosts,suchasrequiringresidentstohavetheirmedicationsbubblepacked(whichisavailablefrompharma-ciesforafee),ortostoreonlyamonth’sworthofmedicationatatime(whichobligeselderstopaypharmacydispensingfeesmoreoften).

• Specializedsuppliesandequipment

InLTC,specializedsuppliesandequipment(suchasinconti-nenceproducts,lifts,grabbars,walkers,andsuppliesrelatedtodiabetesmanagement)areprovidedtoeldersinneed.InAL,withtheexceptionofselectedpurpose-builtfacilitiesthatmayincludemodificationssuchasgrabbars,itistheresident’sresponsibility to purchase needed supplies and equipment pri-vately,ortotaketheirneeddirectlytoAlbertaHealthServices.

Thefinancialburdenofpurchasingsuchsuppliescanbesubstantial.Further,eveninsituationswherefinancialassis-tanceisavailable,residents’abilitiestoaccessthespecializedsupplies and equipment they need depend on their success innavigatinganunfamiliar,bureaucraticprocess.Additionally,theGovernmentofAlbertaandprivateinsurancecompaniesmustthenprocesseachandeveryclaim,anarrangementthatcarriessubstantialcostsintimeandhumanresources.

• Therapies

ALdoesnotincludetherapies(occupational,physical,orrecre-ational)thatwouldbeincludedinLTC.Whatevertherapymay

37

“ “Whilemanyresidentsinassistedlivingmaypaythesamedailyrateleviedonlongtermcareresidents,theiradditionalcostsmaybesub-stantiallyhigher.


be available is administered separately through Alberta Health Services,whichservestoincreasetheadministrativeburdenonresidentsandtheirfriendsandfamilies.Further,ALfacil-itiesoftendonotincludethespecializedspacesrequiredforeffectivetherapy.Gettingtherapymaymeantravelingoff-site,aprocessthatcanbedifficultforelders,andwhichcreatesadditionalcostsrelatedtotransportationandaccompaniment.

Notably,itisnotonlyresidentsinALwhomaybeobligedtopay privately for therapies in order to ensure adequate care. AccordingtotherecordsoftheHFRC,afamilymemberataLTCfacilityindicatedthat“inorderforherhusbandtomaintainhis mobility she takes him to a private clinic for therapy several timesaweekbecausethereisnotenoughtherapyavailableonsite.”104ThissuggestshowoffloadingthroughinadequatecaremaybeservingtoerodethedifferencesbetweenLTCandAL.

TheseexamplesmakeclearthatwhilemanyresidentsinALmaypaythesamedailyfeerelatedtoaccommodationthatisleviedonLTCresidents,additionalcostsmaybesubstantiallyhigher.Further,thereisasignificantburdenoflabourthataccompaniesthefinancialburden.Elders,ormoreoftentheirfriendsandfamily,areobligedto seek out and arrange all of the various goods and services nec-essarytosupplementtheverybasicofferingsinALfacilities.What-everfinancialsupportsmaybeavailablemustbeidentifiedandarranged,whichfurtherincreasesthelabourburden.Asoffloadingoccurs,fragmentationofservicedeliveryalsobecomesaproblem,asresidentsandfamiliesincrisisareobligedtonegotiatewithvariousprovidersinordertofulfillcareneeds.

AnotherissueisthegreaterunpredictabilityofcostsinALascom-paredtoLTC.Manyelderslivingonfixedincomesexperiencesignif-icantdifficultyincopingwithpricevolatility.Becauseprivateopera-torsworkatleastinpartonafee-for-servicebasis,theseoperatorshaveanincentivetotrytoupselltheirclients.Vulnerableeldersmayend up paying for services that are not strictly necessary or desir-able. There is evidence out of the United States that unnecessary servicesareprovidedatafarhigherratebyfor-profitratherthannot-forprofitoperators.105

6.C.Thecostsofoffloading

Offloadingdoesnotmaketheneedsofeldersdisappear.Rather,itshiftstheresponsibilityformeetingtheseneeds,furtherburdeningeldersandtheirfriendsandfamilies.Notably,thecostsofoffloadingarenotlimitedtothosewithimmediatecontactwiththeresidentialeldercaresystem.Rather,theeffectsofoffloadinghaveconsequenc-es that extend to society at large.

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“ “Offloadingcostsandresponsibilitiesfromthepublicsystemtoindivid-ualsinneedcarriesconsequencesthatextendtosocietyatlarge.


ScholarsJanetE.Fast,DeannaL.Williamson,andNorahC.Keatinghave undertaken a review of academic research on what is called friend/familycaregiving.Fromthatbasis,theydevelopedalistofstakeholdersaffectedbyoffloading,includingcarerecipients,caregivers,familiesofcaregivers,andemployersofcaregivers.Theyfoundthatfriend/familycaregiving“isassociatedwithanumberofhidden costs that seldom enter into discussions about health care andsocialpolicy.”106ThissectionemploysthelistofstakeholdersdevelopedbyFast,Williamson,andKeatingtostructureadiscussionoftheconsequencesofoffloading.

Costs associated with friend and family caregiving include:

• Coststoinformaleldercarerecipients

Primarilynon-economic,thesecostsarelargelyemotionaland relate to concerns over loss of independence and fears of becoming a burden. Evidence suggests that these costs are greaterforseniorsreceivingcarefromfriend/familycaregiversthan from professional caregivers. Costs can also be related to riskstocarerecipients’physicalhealth,incaseswhereover-whelmed caregivers may increase the risk of elder abuse. Costs mayalsobeeconomic,relatinginlargemeasuretosubsidiestothelivingexpensesoftheircaregivers,orotherformsoffinancialassistancethatmayormaynotbeexplicitlytiedtocaregiving. Care receivers may also try to reciprocate with labour insofar as they are able. Providing childcare to grand-children is one example.

• Coststofriend/familycaregivers

The well-documented costs associated with providing infor-maleldercareincludeimpairedemotionalwell-being(asininstancesofresentmentorstressovercaregiving),aswellasriskstophysicalhealth(asindisruptionstosleeporotherformsofstrain).Therearealsocostsintermsofsocialwell-be-ing,asthetimededicatedtocare-givingcancutintotimethatwouldotherwisehavebeendedicatedtocultivatingotherrelationships.Theeconomiccostsassociatedwithprovidinginformal elder care are also established through research. Caregiverstypicallycontributeasubstantialamountofunpaidlabour,whichmayimpedetheirabilitytosucceedoradvanceinthepaidworkforce.Informalcaregiversalsooftenabsorbsubstantialout-of-pocketcostsassociatedwithcare-giving,including those associated with the purchase of specialty supplies,aswellasthoserelatedtofeedingandhousinganadditionaladult.Further,somecaregiversmaketimeforcaringby purchasing services such as childcare or yard work. Respite

39


care,purchasedtogivecaregiversabreak,isanotherout-of-pocket cost.

• Coststofamiliesoffriend/familycaregivers

Caregivers’ families share in some of the burdens borne by the caregivers.Thequalityofsocialrelationshipswithinafamilymaybeaffectedinanegativemanner.Theadditionalburdenoncaregivers’timeisakeyfactorhere.Disruptionstosched-ulesandlossofprivacyareotherconsiderations.Resentmentsmay develop among family-members who may be involved to varying extents in caregiving.

• Coststoemployersoffriend/familycaregivers

Employers can experience costs related to employees’ care-givingobligations.Theseincludeabsenteeism,turnover,lostproductivity,andlowerqualitywork.Attemptstoaccommo-date the needs of employees engaged in caregiving through family-friendly working arrangements (such as extended leave andemployeeassistanceprogrammes)cancarryeconomicexpenditurestoemployers,evenastheseprogrammesstandtoreduceconflictsbetweencaregivingandpaidwork.

Fast,Williamson,andKeatingalsohighlightthecoststosocietyasafurther,iflesswell-researched,areaofconcern.Asexamplesofconcrete,society-wideimpactsoffriendandfamilycaregiving,theauthors point to decreased tax revenues from unemployed or un-deremployedcaregivers,andincreasedexpendituresonhealthcareforexhaustedinformalcareproviders.Afurtherconsiderationisthesubstantialregulatorycostrequiredtoensurecompliancewithcarestandardsinaheavilyprivatizedsector.107

Fast,Williamson,andKeatinghavedeterminedthat“informaleldercareisnot,infact,thecostlesssolutionitoftenhasbeenassumedtobe.”108Ultimately,theyfindtheargumentthattherearefewereconomic and non-economic costs associated with friend and family caregiving “is untenable when costs beyond public sector costs are considered.”109

Ofcourse,theconsequencesofrelyingonfriendandfamilycare-giversarenotjustnegative.Forinstance,caregiverscanexperiencebenefitssuchassatisfactionintheirtask,andincreasedunderstand-ing of others. Care receivers might experience diminished loneliness or boredom as compared to other seniors.110However,recognizingtheseconsiderationsshouldnotdetractfromanunderstandingthatreliance on friend and family caregivers is an approach that carries costs of its own. These expenditures are experienced not only by the individualsdirectlyinvolved,butalsobythewidercommunity.

40


Unpaidcaregivingoftenfallstowomen.Regardlessofemploymentstatus,womenaretypicallymoreheavilyengagedthanmeninmeet-ing the health care needs of friends and family members.111 Because theybeartheheaviestburdenofcare,womenalsoexperiencethemostdramaticconsequencesfromtheircaregiving,includingconse-quencesforpaidwork,physicalhealth,andemotionalwellbeing.112

6.D.Conclusion

ThesignificantoffloadingofcostsandresponsibilitiesinAlbertaALis a major factor that makes this care model appeal to a government focusedoncuttingpublicexpenditures.Butoffloadingservestosignificantlyincreasetheburden,financialandotherwise,oneldersand their families.

Notably,thecostsofoffloadingarenotbornesolelybythosewithintimateinvolvementintheeldercaresystem.Rather,care-givers’families,theiremployers,andevensocietyatlargebearthe related costs.

7. Elder care for profitTheexpansionofALinAlbertawasmotivatedbythegovernment’sgoalofcuttingpublicexpenditures,butalsobyitsdesiretoopenopportunitiesforfor-profitenterprise.Thissectionconsidersthecur-rentstateoffor-profitresidentialeldercareinAlberta.Itbeginswithasurveyoftheparticipationbyprivate,for-profitenterprisesbeforemovingtoacloseexaminationofthetrack-recordofExtendicare,amulti-nationaleldercareoperatorcurrentlyactiveintheprov-ince.Extendicareispublicly-traded,whichobligesittomakepublicsignificantinformationaboutitsfinancialsituationandgovernancestructure.Becauseofthis,itoffersawindowonbroaderoperationswithintheprivateeldercaresector.Finally,thissectionaddressesthefinancialrewardsachievedbyfor-profitresidentialeldercareprovidersoperatinginAlberta.

7.A.PrivateeldercareinAlberta

Awidevarietyoffor-profitentitiesthatspecializeineldercarehavebeenattractedtoAlberta.Thesectorrangesfromsmall,private-ly-heldcompanieswhoownoneortwofacilities(e.g.TripleALivingCommunitiesorAdaptaCarePersonalCareHomesInc.),tomajormulti-provincialandmulti-nationalcorporations(e.g.Revera,Diver-sicare,andChartwell).Therearealsomedium-sizedcompaniesandcorporationswithachainoffacilitieslocatedpredominantlywithinAlberta(e.g.AgeCare,IntegratedLifeCareInc.,andQualicareHealthServicesCorporation),aswellasmedium-sizedchainsthatarepre-dominantly based outside of Alberta and currently have only a toe-

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“ “Theresidentialeldercaremarketisquiteconcentrated,withthetopsixcompaniesbynumberofbedscontrolling45%ofalleldercarespacesandowning40%ofthefacilities.


holdintheprovince(e.g.GoldenLife,CalebGroup,orTouchmark).Intotal,therewere35privatebusinesseslicensedtooperatecon-tinuingcarefacilitiesinAlbertaasofMarch2013.InvestmentisdirectedmoretowardALandlesstowardLTC,with93privateALfacilitieshousing11,615beds,and43LTCfacilitieshousing5,304beds.WhiletheprivateALfacilitiesareownedby30separatecom-panies,mostofwhichowntwoormore,theprivateLTCsectorislimitedtojust13companies,withnearlyhalfownedbytwomajor,multi-nationalcorporations:ReveraandExtendicare.113MostprivatebusinessesoperatinginAlberta’seldercaresectorspecializeinALfa-cilities,andusuallyownmorethanone.Consideringcompanieshavemorefreedomtodecidetheservicesprovided,thequalificationsandnumbersofstaff,andthepriceschargedtoresidents,itisnotsur-prisingthatcompanieswouldseegreateropportunitytoprofitfrominvestinginAL,asopposedtoLTC.

Overall,theresidentialeldercaremarketisquiteconcentratedamong a few large players. The top six companies by number of beds control45%ofalleldercarespaces,andown40%ofthefacilities.ReveraandExtendicareeachown15facilities.Revera’sholdingsaresplitbetweenALandLTCfacilities,whileExtendicare’sholdingsareweightedtowardLTCfacilities.TheotherfourofthetopsixAlbertaeldercarecompaniesaremedium-sizedchaincompanies,noneofwhicharepubliclytraded,andarethereforenotobligedtopubliclyreportontheiroperations:AgeCareLtd.,RosedaleDevelopments,IntegratedLifeCareInc.,andStatesmanCorporation.

AgeCare,thethirdlargesteldercarecorporationintheprovince,wasco-foundedin1998byKabirJivraj,ayearbeforehebecametheChiefMedicalOfficeratCalgaryRegionalHealth.Jivraj,afinancialsupporteroftheProgressiveConservativeparty114 has seen his com-panysecure$24.6millioningovernmentgrantsfrom2006to2011,andgrowtoinclude7ALfacilitiesand3LTCfacilities.115 Statesman CorporationisarealestateandresortdevelopmentcorporationfoundedbyGarthMannthathasgrowntoincludeluxuryretirementandALfacilitiesinAlberta,Ontario,andtheUnitedStates.Accom-modationfeesatonesuchfacility,StaywellManor,beginat$48,000peryear.TheperdiemrateatAlbertaLTCfacilities,incomparison,addsuptoanannualrateof$17,575peryear.

7.B.Extendicare

Takingacloserlookatalargeeldercarecorporationprovidesanadditionalperspectiveontheworldoffor-profiteldercare.Extendi-careisthelargestprivateoperatorofLTCcentresinCanada,includ-ing78centersinfourCanadianprovinces.Asof31December2011,Extendicareoperatedanother183facilitiesintheUnitedStates.Itcurrentlyoperates14AlbertaLTCfacilitieswith1406residents.ExtendicarealsooperatesALservices,andinearly2011,itopened

42


itsfirstAlberta-basedALfacilitiesinLethbridgeandRedDeer.WhileExtendicarehasrecentlyconvertedtoacorporatestructure,itoperatedforyearsasanincometrust,orflowthroughentity,astructureadoptedinordertolimitthefirm’sobligationtopaytaxes.Theimplicationsofthisattheprovinciallevelaresignificant,asnon-Albertan investors are not obliged to pay tax on their returns totheGovernmentofAlberta.In2006,theGovernmentofAlbertaestimatedanetrevenuelossofapproximately$400millionbecauseoftherapidgrowthofflowthroughentities.116

TheGovernmentofAlbertahasofferedsignificantsubsidiestosupportExtendicareinexpandingitsoperationsintheprovince.Forinstance,between2008and2011,forgivableloansweregrantedtoExtendicarebyseveralregionalHealthAuthoritiestobuildfourcontinuingcarefacilities:LTCandALcentersinRedDeer;anALcenterinLethbridge;andaLTCcenterinEdmonton.117 A forgivable loanisessentiallyafinancialpayment,asmoneyisloanedandthen,aftercertainrequirementsaremet,theloanisforgiven.Theseveryfavourable terms mean that public dollars helped provide the corpo-rationwithvaluableinfrastructure.ConsideringExtendicarethenre-ceivesitscontractsfromtheprovincialgovernment,thecorporationbenefitsfromsubstantialincentivestoundertakerelativelylow-riskconstructionprojects.

Extendicareincludespoliticallyprominentindividualsonitsboard.Forinstance,MichaelJ.L.Kirby,amemberoftheExtendicareboardsince1987,wasamemberoftheSenateofCanadafrom1984to2006.WhileontheExtendicareboard,hechairedaSenateStand-ingCommitteethatreleasedTheHealthofCanadians–TheFederalRole.118Knownasthe“KirbyReport,”itadvocatedfortheprivatiza-tionofhealthservices,achangethatExtendicarewouldcertainlyhavebeenwell-positionedtocapitalizeon.Extendicaremanagementincludesindividualswithexperienceingovernment.Forinstance,PaulTuttle,theheadofCanadianoperationsforExtendicare,waspreviouslyemployedbytheOntarioMinistryofHealthandLongTermCare,mostrecentlyasDirectoroftheLongTermCareBranch.119

Largecorporateplayersineldercaredonotlimitthemselvestoasinglesector.Extendicare,forinstance,alsooperatesParamed,ahomecareagencyactiveinAlbertaandOntario.GiventhatinALhealthandpersonalservicesarelargelyprovidedbyhomecare,Ex-tendicare clearly perceives another avenue through which to access profit.MikeHarris,formerPremierofOntarioandboardmemberofChartwell,anothermajorfor-profiteldercarecorporation,hasrecently opened a home care franchise in Toronto.

ExtendicareprovidesanexampleofaneldercarecorporationprofitingfromAlbertaeldercare.Thismeansassumingcorporate

43


structuresthatminimizeitstaxpayments.Italsoinvolvescultivatingrelationshipswithpoliticalpowerbrokers,andincludesprovidingopportunitiesforindividualstomovebackandforthbetweengov-ernmentandtheprivatesector.ItisdifficulttoperceivehowsuchprocessesservetoimprovethelivesofAlbertansinresidentialelder care.

7.C.Extractingprofit

UsingAlberta-specificdatafromStatisticsCanada’sRCFsurvey,thissectionconsiderstheprofitsachievedintheLTCandALsectors.

PrivatelyownedresidentialeldercarefacilitiesarequiteprofitableinAlberta.InbothLTCandAL,facilityownershaveseensubstantialreturns.Between1999and2009,privateLTCfacilitiesintheprov-incehadanaveragereturnoninvestment[ROI]of2.1%.120 Private ALfacilitieshadmuchhigherreturnsoverthattime,withanaverageROIof9.14%.Incomparison,overthesametimeperiodStandard&Poor’s500(anindexwidely-usedtorepresenttheperformanceoftheUSstockmarket)hadanaveragereturnof1.23%.121 This means thatinrecentyears,thereturnsreceivedbytheprivateresidentialelder care industry in Alberta have been higher than those of the USstockmarket(seeFigure6).Evendiscountingfortheeffectsofthe2008GreatRecessionbylookingattheyears1999to2007,the9.14%ROIofprivateALfacilitiesisnearlythreetimesthe3.17%ROIStandardandPoor’s500averagedoverthattime. Theserelativelyhighratesofreturntranslatedintosignificantprofits.PrivateLTCfacilitiesaccumulatedover$58millioninprofitoverthedecade.ThemuchsmallerprivateALsectorenjoyedprofitsof$35.5million.Andtheseprofitshavebeenincreasingovertime.Overthefiveyearsbeginningin1999,theprivateALindustrytookin$3.7millioninprofits.Inthefiveyearsendingin2009,theindustrymade$27.9millioninprofits.Incontrast,thenot-for-profitandpublicsec-torshavehadexceptionallytightbudgets,andmoreoftenthannotoverthedecadeconsideredhere,theirexpensesoutstrippedtheirrevenues.

Howdofor-profiteldercareprovidersachievesuchreturns,partic-ularly in comparison with the experiences of the public and not-for-profitsector?Factorsincludespendinglessondirectcarecosts,andcultivatingapopulationoflessseverelyincapacitatedelders.Bothare examined below.

Directcarecostsincludecostsrelatedtostaff,pharmaceuticals,andmedicalsupplies.InAL,despitesomevariationinexpendituresoverthedecade,for-profitoperatorsexpendedonlyaslightlyhigheramountondirectcarein2009thantheydidin1999.Incontrast,not-for-profitfacilitieshaveseenalmostcontinuallyincreasingexpendi-

44

“ “ThereturnsreceivedbyAlberta’sprivateresidentialeldercareindus-tryarehigherthanthoseoftheUSstockmarket.


turesoverthedecade.In2009,not-for-profitoperationsexpended

$46.94moreondirectcareforeachresidenteverydaythandidfor-profitfacilities.IntheLTCsector,overtheentiredecadeunderstudy,publicandnot-for-profitoperatorsspentsignificantlymoreondirectcarethandidfor-profitoperators.In2009,forinstance,publicfacilitiesspent$71moreondirectcareperresidentperdaythandidfor-profitfacilities.

Dataonresidentacuitybydeliverymodelbetween1999and2009indicatesthat,inbothALandLTC,for-profitoperatorsmanagedtoincreasetheirintakeoftheleast-severelyincapacitatedelders,andlimittheirintakeofseverelyincapacitatedelders.IntheALsector,for-profitfacilitiesexperiencedanover-alldeclineintheacuityoftheirresidentpopulation.Incontrast,not-for-profitfacilitiesex-periencedadramaticincreaseinacuity.Giventheoverallincreaseinacuityacrosstheresidentialeldercaresector,itistellingthatfor-profitALoperatorsmanagedtoachieveareductioninresidentacuityovertheperiodbetween1999and2009.InLTC,for-profitoperators were not spared the increased acuity evident across res-identialeldercare.However,theywerefarlessseverelyimpactedthanthenot-for-profitorpublicoperators.Between1999and2009,

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Return on investment: LTC, AL, and S&P 500

1999 - 2009

1999 - 2007

0 2.5 5.0 7.5 10.0

9.14%

9.14%

2.1%

1.29%

1.23%

3.17%

S&P500

LTC

AL


theLTCsectorsawthepublicsystemprovidecareforthemostneedyelderly,whilefor-profitoperatorsaccommodatedtheleastincapacitated.

Lowerresidentacuityfacilitatesprivateoperators’scrimpingondirectcareexpensesinanefforttogenerateprofitfromcaringforAlberta’selderly.ResearchindicatesthattheconcentrationofhigheracuityresidentsinpublicfacilitiesishardlyuniquetoAlberta.A2005articlebasedonstatisticaldataonLTCfacilitiesoperatinginOntariobetween1996and2002foundthatnon-profitfacilitiesprovidedcaretomoreresidents85yearsofageandolderthandidfor-profitandgovernment-ownedfacilities,whilegovernment-ownedfacilitiesprovidedcaretoagreaterproportionofhigherneedsresidents.122

TheGovernmentofAlbertahasargued,followingtheMazankow-skireport,thatintroducingcompetitionintoeldercarewouldleadtoimprovementsinqualityandefficiencybecauseofcompetition.However,Alberta’seldercaresectorhas,overthepast15years,seenthegrowthofsomethingquitedifferent.Whathasemergedisasituationinwhichprivatefacilitiesearnedsubstantialprofitsbyscrimpingoncareforlessacuteresidents,leavingmoreacuteresi-dentsfornon-profitandpublicfacilities.Theresultisasituationinwhichthenon-profitandpublicsystembearstheburdenofthemostexpensiveresidents,andfor-profitoperatorsmaximizetheirprofitsbyconfiningthemselvestothelessexpensivetaskofprovidingcarefor the less needy.

7.D.Conclusion

Thissectionhassurveyedfor-profiteldercareinAlberta,providingsomebasicinformationaboutprivateoperatorsactiveintheprov-ince,andadetailedpictureofExtendicare,amajor,publicly-tradedcompanyoperatingintheprovince.Itmakesclearhowfor-profitelder care enterprises have sought to expand their reach by diversi-fyingtheirservicesandcozyinguptothoseinpoliticalpower.Finally,thissectionalsoexplainshowfor-profitenterprisesmanagetoextractprofit:throughpursuingalessacuteresidentpopulationandscrimping on resident care.

Previoussectionsofthisreporthavemadeclearhowtheprivatiza-tionofresidentialeldercareinAlbertahasbeenassociatedwithlowerqualitycareforresidentsandmoredifficultworkingconditionsforemployees.Thissectionhashighlightedwhatprivateeldercareprovidersprioritizeabovethewell-beingofresidentsandemploy-ees:theaccumulationofprofit,aswellastheexpansionoftheirpoliticalinfluenceandmarketshare.

Clearly,theprivatizationofresidentialeldercaredoesnotservethepublic interest.

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8. Achieving high quality elder care

Overthepast15years,residentialeldercareinAlbertahasun-dergoneadramatictransformation.Thistransformationwastwo-pronged,drivenbythegrowthofALandthestagnationofLTContheonehand,andtheexpansionoffor-profitandtheretrenchmentofpublic elder care on the other. The evidence suggests that this trans-formationhasonlyservedtoworsenconditionsinwhatwasalreadyahighlyflawedsystemofresidentialeldercare.

Thisreporthasdocumentedtheexistenceofacaregapinresidentialeldercare,adiscrepancybetweentheneedsofeldersandthecareprovidedineitherLTCorAL.ParticularlyinLTC,itisclearthatstaffinglevelsinAlbertafacilitieshavenotincreasedsufficientlytocompen-sate for increased resident acuity and medical complexity. The result hasbeenaverydifficultsituationforAlbertaelders,theirfriendsandfamily,andstaffworkingintheeldercaresector.

WhileacaregapalsoexistsinAL,thereislessinformationavailableabout the experiences of elders accommodated in that care model. Theresultingknowledgegapisworrying,particularlyinthecontextoftheterminationofStatisticsCanada’sResidentialCareFacilitiessurvey,whichwasanimportantsourceofinformationonresidentialelder care in Alberta and across Canada.

WhileacaregapexiststhroughoutAlbertaeldercare,thereareimportantdifferencesinitsseverityamongfor-profit,not-for-prof-it,andpubliceldercarefacilities.AcrossLTCandALintheperiodexaminedhere,for-profitfacilitiesofferedinferiorstaffing,whichtranslatedintolowerqualitycare.For-profitfacilitiesalsoprovideamoredifficultworkingenvironmentforstaff.Theevidenceisclear:privatizationisassociatedwithlowerqualityresidentialeldercare.

TheshiftsinAlberta’sresidentialeldercaresystemhavebeendrivenin part by the provincial government’s goal of minimizing public expenditures.Theresulthasbeenincreasedunbundlingandoffload-inginAlberta,ashealthservicesaredividedup,andresponsibilityfor arranging and paying for them is passed to those in need. The inadequatestandardofcarethroughouttheAlbertaresidentialeldercaresystemamountstoanoffloadingofcostsandresponsibilitiesontoresidents’friendsandfamilies.Further,inAL,responsibilitiesandcostsrelatedtomedications,specializedequipment,andtherapiesoftenendupbeingbornebyresidentsandtheirfriendsandfamilies.Offloadinghassignificantconsequencesthataffectcarerecipients,theirfriendsandfamilieswhoprovidecare,thelovedonesand

47

“ “ThechangesinAlbertaresidentialeldercareoverthepast15yearshaveonlyservedtoworsencondi-tionsinwhatwasalreadyahighlyflawedsystem.


employersofcaregivers,andsocietyatlarge.Manyoftheseconse-quencesarenegative.Changesinresidentialeldercarehavealsobeendrivenbytheprovincialgovernment’sgoalofcreatingopportunitiesforawell-po-sitionedfewtoprofit.PrivateoperatorsinboththeLTCandtheALsectorshaveenjoyedsubstantialprofitsduringthedecadebetween1999and2009.Byseekingoutlessseverelyincapacitatedresidents,andspendinglessmoneyondirectcare,for-profitoperatorshaveredirected public funds away from needy elders and toward corpo-ratecoffers.

Alberta elder care is in crisis. There is strong evidence that the AlbertagovernmentpoliciesofexpandingALandprivatizingeldercare have been associated with a degraded quality of care. Changes inAlbertaresidentialeldercareoverthepast15yearsareastoryofgoing from bad to worse.

8.A.Opportunities

InAlberta,thegoalofachievinghighqualitycareforeldersremainselusive.Still,itispossibletofindexamplesofpromisingopportu-nitieswithintheprovince.AlongwiththechangestoLTCthatarenecessarytoensurethathighqualityresidentialeldercareisavail-abletoallwhorequireit,theGovernmentofAlbertamightlooktotheprogrammesoutlinedbelowasexamplesofadditionalwaystopursue the goal of high quality elder care.

• TheCHOICEprogramme

TheComprehensiveHomeOptionofIntegratedCarefortheElderly [CHOICE] programme was launched by the Edmonton Capital Regional Health Authority in 1996. CHOICE was based onsuccessfulprogrammesintheUnitedStates,mostnotablyPrograms of All-inclusive Care for the Elderly [PACE]. PACE sought to provide the robust supports necessary to enable seniors to remain in their own homes for longer.123 As of early 2013,therearefiveCHOICEsitesinEdmonton.124In2001,theCalgaryHealthAuthoritylauncheditsversionofCHOICE,whichis called the Comprehensive Community Care for the Elderly program[C3],with90spaces.125

CHOICE’smandateistoextenda‘onestopshop’approachtoelderswhorequireavarietyofservices,includingmedical,re-habilitative,social,andsupportive.126 CHOICE operates through adayprogrammemodel,basedoutofacommunityfacilityin-tegratedwithadequatehomesupportsavailableinoff-hours,includingthepossibilityofas-needed,short-term,overnightstays.Thegoalistoreduceoreliminaterelianceonacutecare,

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“ “Albertagovernmentpoliciesofexpandingassistedlivingandprivatizingeldercarehavebeenassociatedwithadegradedqualityofcare.


anddelayoreliminatetheneedforadmissiontoresidentialelder care.127 There is evidence that the programme has an effect.InthesixmonthsbeforejoiningCHOICE,clientsvisitedemergency299times;inthesixmonthsafter,theymade210emergencyvisits,a30percentdecrease.128

• Thelodgeprogramme

Sincethe1950s,theprovinceofAlbertahasbenefitedfromasystemofseniors’lodges.UniquetoAlberta,theselodgesemergedfromcollaborationbetweentheprovinceandlocalmunicipalities.Fordecades,lodgeshaveprovidedaccommo-dationtoelderswhoarefunctionallyindependent(atleastwithsomeassistancefromhomecare)butnolongerwillingorable to undertake the labour associated with living in a private home.Throughthesupportsavailableinthelodgesystem,manyseniorsareabletolivelongerintheircommunities,inamanner consistent with the aging in place concept.129 In June 2012,therewereapproximately150lodgesoperatingacrossthe province.

Fromitsinception,thelodgesystemhascateredtolow-in-come seniors. Current arrangements are designed to ensure residentsretain$265afterpayingforrent,basedonsemi-pri-vateroomrates.However,theabilityoflodgestoservetheneedsoflowincomeseniors,andindeedeventheviabilityofthelodgesystemitself,hasbeenputatriskinrecentyearsthrough changes to available provincial funding. In its early decades,theprovincialgovernmentsplitanyoperatingdeficitona50/50basiswiththerelevantmunicipality.From1994,however,thegovernmenthasmovedtoacappedgrantcalledtheLodgeAssistanceGrant,withmunicipalitiesresponsiblefor all remaining costs. This has resulted in increased costs and risksdownloadedontomunicipalities.Further,manylodgestructureshavedeterioratedsubstantiallyinthepastfewde-cades,andtheprovincehasmadeonlyminimalcontributionstoinfrastructuremaintenanceormodernization.

Alberta’s lodges provide an example of a public system posi-tionedtocontributetoensuringqualityeldercareforallAlber-tans,includingthosewholacksufficientfinancialresourcestoaccessotheroptions,suchasprivateAL.ExpandingsupporttothelodgesystemwouldincreaseoptionsforelderlyAlbertans.

Achievingthepromiseoftheseinnovativeprogrammeswouldrequirethatsubstantialpublicresourcesbeputintothepersonal,home,andmedicalsupportsrequiredbyelderslivingathome,orinhome-likesettings.Itwouldinvolvelookingbeyondfurtherprivatiza-tiontofocusonevidence-basedoptionsforprovidinghigh-quality,

49


cost-effectiveeldercareforAlbertaelders.Ultimately,itisthroughmeanssuchasthese,incombinationwithanexpandedandim-provedLTCsystem,thathighqualityeldercarecanbemadeavail-able to all Albertans who need it.

8.B.Recommendations

BasedonresearchconductedontheAlbertasituationandonex-perts’viewsofhowtobestprovidehighqualityeldercare,ParklandInstituteoffersthefollowingrecommendations:

ExpandtheCanadianpublichealthcaresystemtoencompasscontinuingcareservices,includingallresidentialandhome-basedformsofeldercare

• TheGovernmentofAlbertashouldjoinwithotherprovincesinlobbyingtheFederalGovernmenttoexpandpublichealthcaretoincludecontinuingcareservices,includingallresiden-tialandhome-basedformsofeldercare.Thiswouldcompelgovernments to develop the resources necessary to provide free,universalaccesstoeldercareforallCanadians,aswellasto ensure consistent standards across provinces. It would also helppositionthehealthsystemtoworkmoreeffectivelyandefficiently,byeliminatingproblematicdistinctionsbetweenacutecareandcontinuingcare.Expandingthepublichealthcaresystemwouldhaveimportant,far-reachingimplicationsfor how elder care is provided in Alberta and across Canada. This change would lay the groundwork for improved care in years to come.

Improvestaffing• InrecognitionofthecaregapacrossAlbertaeldercare,the

GovernmentofAlbertashouldimmediatelymakeavailablefundstofacilitateimprovedstaffing,withtheprovisionthatalloperators(public,not-for-profit,andfor-profitalike)beobligedtoexpendthesefundsondirectcarestaffing.

• Ensurethatallresidentialeldercarefacilitiesarelegallyboundtominimumstaffinglevelsestablishedinrelationtoexperts’assessments of the levels required to ensure quality care. Theselevelsshouldalsoallowforsubstantialimprovementsintheworkingconditionsexperiencedbyprofessionalcaregiv-ersworkingineldercarefacilities.Theprovincialgovernmentshould provide whatever enforcement is necessary to ensure specifiedstaffinglevelsaremet.

Phase-outprivate,for-profiteldercare• Immediately suspend subsidies and programmes that bene-

fitfor-profiteldercarecorporationsandworktophase-outfor-profiteldercare,duetotheabundantevidencethatfor-profitcorporationsprovideinferiorqualitycare.

50


• Build on successful programmes such as CHOICE and seniors’ lodges in developing a robust public elder care system.

Increasepublicaccesstoinformationabouteldercare• Improvemonitoringandreportingpracticestoensurethat

meaningful data about elder care is available to all Albertans. This data should be:

° Orientedtothereportingofmeaningfulindicators,suchasstaffinglevels;

° Developedinamannerthatfacilitatesthecollectionandpublicreportingofindividuals’experienceswitheldercarefacilities,inordertoensurethattheelim-inationoftheHFRCdoesnotresultinareductionofavailableinformationaboutAlbertans’experiences;

° Structured in a manner that reveals trends through timeandbyotherkeyconsiderations,suchasgeo-graphicalregion;

° Easilyaccessibletothepublicovertheinternet,aswellas through other means.

• Lobbythefederalgovernmenttodevelop,inconsultationwithqualifiedexperts,aneffectivenation-widedatasetthatwouldmakeitpossibletocompareeldercareacrossCanada,andtotrackchangesovertime.

Createawatchdog• Establish an elders’ advocate to report to the legislature. The

complexity of the elder care sector and the need for ongoing scrutinyofitsoperationsmakesitnecessarytocreateawatch-dog to monitor elder care and all related issues. An elders’ advocatewouldbepositionedtooffercriticalassessments,totrackchangeovertime,andtoensuretheeffectiveintegrationoftheeldercaresystemwithotherpoliciesandpracticesthatbear on the well-being of Alberta elders.

• Ensurethattheelders’advocateoperatesinconsultationwithacommitteeofelderAlbertanspositionedtoprovidefirst-handinsightintotheoperationoftheprovince’sservicestothe elderly.

51


AppendixThisappendixprovidessomeadditionalinformationaboutthedatafromStatisticsCanadathatunderliesmuchofthereport.

Untilrecentyears,StatisticsCanadaannuallyadministeredamanda-torysurveyoftheoperationsofresidentialcarefacilitiesinCanada.AcustomtabulationofRCFsurveydatawasrequestedfromStatisticsCanadaforuseinthisstudy.ThecustomtabulationisolatedfordatapertainingonlytothoseAlberta-basedfacilitiesthatidentifiedtheprincipalcharacteristicofitsresidentstobe“aged,”fortheyears1999to2009.IntheAlbertacontext,thesefacilitieswouldincludethoseprovidingLTCandAL.TheStatisticsCanadadatawasdisaggre-gatedinattempttoisolatefortwobroadstreamsofcare:LTCandAL.Todoso,alistofeverylicensedALfacilityinoperationasofOctober2012wasobtainedfromtheGovernmentofAlberta’sAccommoda-tionStandardsandLicensingwebsite.ThelistwassubmittedtoaStatisticsCanadaemployee,whoisolatedthosefacilitiesthatwerealsoincludedintheRCFsurvey.ThosefacilitiesincludedintheRCFsurveythatdidnotappearonthegovernment’slistofsupportivelivingfacilitieswere,forthepurposesofthisstudy,assumedtobeLTCcenters.

TheRCFsurveydatawasusedtomakecalculationsregardingstaff-inglevelsatthethreedeliverymodelsofLTCfacilitiesinAlberta.Tocalculatestaffhoursperresident-day,the“totalaccumulatedpaidhours”foraspecificstaffcategorywasdividedby365.25andthenumberof“totalresidents.”TheRCFsurveydidnotisolatehealthcareandnursingaidesasaspecificstaffcategory,insteadgroupingthemunder“otherdirectcarestaff”alongwithdieticians,counsel-lors,child-dareworkers,orderlies,socialworkers,graduatenurses,chaplains,etc.Becausehealthandnursingaidesaretheonlyoneofthesestafftypesthatwouldbeofanyprominenceineldercare,forthepurposeofthisstudy“otherdirectcarestaff”wasassumedtoequalhealthcareandnursingaides.TheRCFsurveystaffingdatadidnot include voluntary workers.

52


1PatrickSullivan,“Seniors’CareNowaDominantCanadianConcern:CMASurvey,”http://www.cma.ca/index.php?ci_id=206148&la_id=1,(accessedAugust28,2013).

2 It should be noted that not all elders are in need of care. In fact, many elders provide care to friends or relatives in need. 3 The Government of Alberta has repeatedly changed the terms used to describe the provin-cial elder care system. To promote ease of understanding, terminology current as of spring 2013 has been adopted throughout this report.

4 IreneJansenandJaniceMurphy,Residential Long-Term Care in Canada: Our Vision for Better Senior’s Care,CanadianUnionofPublicEmployees,October2009,9.

5 KevinTaft,Shredding the Public Interest: Ralph Klein and 25 Years of One-Party Government (Edmonton:UniversityofAlbertaPressandParklandInstitute,1997),15-39.

6 GovernmentofAlbertaLongTermCarePolicyAdvisoryCommittee,Healthy Aging: New Directions for Care, Part One: Overview(AlbertaHealthandWellness:November1999),accessedMarch4,2013,http://www.health.alberta.ca/documents/Healthy-Aging-Overview-1999.pdf.

7 Premier’sAdvisoryCouncilonHealth,A Framework for Reform(December2001),accessedMarch4,2013,http://www.assembly.ab.ca/lao/library/egovdocs/alpm/2001/132279.pdf. 8 MLATaskForceonHealthCareFundingandRevenueGeneration,A Sustainable Health System for Alberta(AlbertaHealthandWellness:October2002),accessedMarch4,2013,http://www.health.alberta.ca/documents/Sustainable-system-2002.pdf.

9 AuditorGeneralAlberta,Report of the Auditor General on Seniors Care and Programs,(OfficeofAuditorGeneral:May2005),accessedMarch4,2013,http://www.oag.ab.ca/files/oag/OAG_Seniors_2005.pdf.

10 Honourable Iris Evans and Honourable Yvonne Fritz, Ministers’ Statement: Auditor Gener-al’s Report on the Government of Alberta’s Seniors Core Services and Programs(GovernmentofAlberta:May9,2005),accessedMarch5,2013,http://www.continuingcarewatch.com/ABMinis-tersStatementonAGReport.pdf.

11 MLATaskForceonContinuingCareHealthServiceandAccommodationStandards,Achieving Excellence in Continuing Care(GovernmentofAlberta:November2005),accessedMarch6,2013,http://www.health.alberta.ca/documents/Continuing-Care-Report-2005.pdf.

12 AlbertaSeniorsandCommunitySupports,Supportive Living Framework(GovernmentofAl-berta:March2007),10,accessedMarch17,2013,http://web.archive.org/web/20110103000024/http://www.seniors.alberta.ca/continuingcare/system/standardsframework.pdf.

13 AlbertaHealthandWellness,Continuing Care Strategy, 19.

14 AlbertaHealthandWellness,Continuing Care Strategy,19.

15 AlbertaSeniorsandCommunitySupports,Supportive Living Framework,10.

16 AlbertaHealthServices,Admission Guidelines for Publicly Funded Continuing Care Living Options(GovernmentofAlberta:April15,2010),accessedMarch13,2013,http://www.alberta-healthservices.ca/Seniors/if-sen-living-option-guidelines.pdf.

17SupportiveLivingAccommodationLicensingAct,S.A.,ch.S-23.5,(2009).

Endnotes

53

http://www.cma.ca/index.php?ci_id=206148&la_id=1

http://www.cma.ca/index.php?ci_id=206148&la_id=1

http://www.health.alberta.ca/documents/Healthy-Aging-Overview-1999.pdf

http://www.assembly.ab.ca/lao/library/egovdocs/alpm/2001/132279.pdf

http://www.health.alberta.ca/documents/Sustainable-system-2002.pdf

http://www.health.alberta.ca/documents/Sustainable-system-2002.pdf

http://www.oag.ab.ca/files/oag/OAG_Seniors_2005.pdf

http://www.oag.ab.ca/files/oag/OAG_Seniors_2005.pdf

http://www.continuingcarewatch.com/ABMinistersStatementonAGReport.pdf

http://www.continuingcarewatch.com/ABMinistersStatementonAGReport.pdf

http://www.health.alberta.ca/documents/Continuing-Care-Report-2005.pdf

http://web.archive.org/web/20110103000024/http:/www.seniors.alberta.ca/continuingcare/system/standardsframework.pdf

http://web.archive.org/web/20110103000024/http:/www.seniors.alberta.ca/continuingcare/system/standardsframework.pdf

http://www.albertahealthservices.ca/Seniors/if-sen-living-option-guidelines.pdf

http://www.albertahealthservices.ca/Seniors/if-sen-living-option-guidelines.pdf


18 AlbertaHealthCommunications,Continuing Care Health Service Standards (GovernmentofAlberta:July2008,amendedMarch5,2013),accessedMarch13,2013,http://www.health.alberta.ca/documents/Continuing-Care-Standards-2008.pdf.

19 AlbertaHealth,“AccommodationStandards,FormsandPublications,”http://www.health.alberta.ca/services/continuing-care-forms.html (accessed April 2, 2013).

20 Ibid.

21 TherearealsosomeirregularitiesinfeesderivingfromdifferencesinpracticesamongAlberta’sformerregionalhealthauthorities,whichwereeliminatedin2008.Forinstance,intheChinookhealthregion,residentsinstudioDSLsuitesarechargedbetween$125to$250lesspermonththantheregulatedrate(Personalphonecall,ExecutiveDirectoroftheAlbertaContinuingCareAssociation,November27,2012).ItshouldbenotedthatAlbertansofsufficientfinancialmeansmayaccessanylevelofsupportivelivingbyabsorbingallassociatedcosts.Insupportiveliving,ratesforaccommodationandcarearesetbytheoperator,andcanvarywidelyamongfacilities.

22 AlbertaHealthServices,Annual Report: 2011-2012,(GovernmentofAlberta:March2012),64.

23 CanadianInstituteforHealthInformation,Alternate Level of Care in Canada(CIHI:January14,2009),18,accessedApril3,2013,https://secure.cihi.ca/free_products/ALC_AIB_FINAL.pdf.

24 Alberta Health Services reports on the number of individuals in either acute or sub-acute careawaitingplacementincontinuingcare.Betweenlate2010andearly2013,thatnumberhasvariedbetween471and600.Overthesameperiod,between907and1150individualswerewaitinginthecommunity.However,wewereunabletodeterminehowmanyoftheseindividualswereinneedofeldercareservices.AlbertaHealthServices,Q2 Performance Report 2012/2013,(AHS:December13,2012),62-63. 25 Alberta Health, Supportive Living Guide (Government of Alberta: August 2013), 7, accessed September 3, 2013, http://www.health.alberta.ca/documents/CC-Supportive-Liv-ing-Guide-2013.pdf

26 StatisticsCanada,Population Projections for Canada, Provinces and Territories(MinisterofIndustry:June2010),catalogueno.91-520,accessedFebruary5,2013,http://www.statcan.gc.ca/pub/91-520-x/91-520-x2010001-eng.pdf.

27 JohnGeddes,“TheHealthCareTimeBomb,”Maclean’s, April12,2010.

28 BrentJ.SkinnerandMarkRovere,Canada’s Medicare Bubble: Is Government Health Spending Sustainable without User-based Funding?(FraserInstitute:April2011).

29 CanadaDepartmentofFinance,“EconomicandFiscalImplicationsofCanada’sAgingPopula-tion,”https://www.fin.gc.ca/afc/faq/eficap-rebvpc-eng.asp(accessedFebruary5,2013).

30 RobertG.Evans,“EconomicMythsandPoliticalRealities,”inMedicare: Facts, Myths, Prob-lems, Promise,ed.BruceCampbellandGregMarchildon(Toronto:JamesLorimer&CompanyLtd,2007),113-155.

31 MarcLee,How Sustainable is Medicare? (CanadianCentreforPolicyAlternatives:2007),15-16;Evans,“EconomicMyths,”140;CanadianInstituteforHealthInformation,Health Care Cost Drivers: The Facts(CIHI:November3,2011),12,accessedFebruary6,2013,https://secure.cihi.ca/free_products/health_care_cost_drivers_the_facts_en.pdf.

32 SharonCarstairsandWilbertJosephKeon,Canada’s Aging Population: Seizing the Opportu-nity,(TheSenateofCanada:April2009),63;M.L.Barer,R.G.Evans,andC.Hertzman,“Ava-lancheorGlacier?HealthCareandtheDemographicRhetoric,”Canadian Journal on Aging14,no.2(1995):193-224;NeenaL.ChappellandMarcusJ.Hollander,“AnEvidence-BasedPolicyPrescriptionforanAgingPopulation,”Healthcare Papers11,no.1(2011):8-18;F.T.Dentonand

54

http://www.health.alberta.ca/documents/Continuing-Care-Standards-2008.pdf

http://www.health.alberta.ca/documents/Continuing-Care-Standards-2008.pdf

http://www.health.alberta.ca/services/continuing-care-forms.html

http://www.health.alberta.ca/services/continuing-care-forms.html

https://secure.cihi.ca/free_products/ALC_AIB_FINAL.pdf

http://www.health.alberta.ca/documents/CC-Supportive-Living-Guide-2013.pdf

http://www.health.alberta.ca/documents/CC-Supportive-Living-Guide-2013.pdf

http://www.statcan.gc.ca/pub/91-520-x/91-520-x2010001-eng.pdf

http://www.statcan.gc.ca/pub/91-520-x/91-520-x2010001-eng.pdf

https://www.fin.gc.ca/afc/faq/eficap-rebvpc-eng.asp

https://secure.cihi.ca/free_products/health_care_cost_drivers_the_facts_en.pdf

https://secure.cihi.ca/free_products/health_care_cost_drivers_the_facts_en.pdf


B.G.Spencer,“PopulationAginganditsEconomicCosts:ASurveyoftheIssuesandEvidence,”Canadian Journal on Aging19no.S1(2000):1-31;HughMackenzieandMichaelRachlis,The Sustainability of Medicare(CanadianFederationofNursesUnion:2010).

33 MackenzieandRachlis,Sustainability of Medicare,34.

34 Evans,“EconomicMyths,”139.

35 WendyArmstrong,Eldercare – On the Auction Block: Alberta Families Pay the Price (Consum-ers’AssociationofCanada-AlbertaChapter:September2002),5.

36 Ibid.,7.

37 AleckOstry,Change and Continuity in Canada’s Health Care System(ChaPress:2006),ascitedinIreneJansenandJaniceMurphy,Residential Long-Term Care in Canada: Our Vision for Better Senior’s Care(CanadianUnionofPublicEmployees:October2009)24. 38 MarcyCohen,JeremyTate,andJenniferBaumbusch,An Uncertain Future for Seniors: BC’s Restructuring of Home and Community Health Care, 2001-2008 (Canadian Centre for Policy Alter-natives:April2009),22.

39 JansenandMurphy,Our Vision for Better Senior’s Care,25.

40 ItshouldbenotedthattheHFRCdidnotverifycompliancewithallbasicstandards,suchasminimumcarehoursinlongtermcarefacilities.Nordiditreviewresidentrecordsinamannerthatwouldmakeitpossibletoconnectcarequalitytohealthoutcomes.Rather,theCommitteeoperatedprimarilyintermsoftheirownimpressionsofthefacility,combinedwiththefeedbackfromresidents,friendsandfamily,andstaff-memberswhoareableandwillingtocommunicatewiththem.Despitethesesignificantlimitations,thereportsoftheHFRCofferedawindowontheexperiences of Albertans that is not otherwise available.

41 HealthFacilitiesReviewCommittee,Routine Review – Summary of Findings, Northcott Care Centre (GovernmentofAlberta:February2,2012).

42HealthFacilitiesReviewCommittee,Routine Review – Summary of Findings, Venta Care Centre (GovernmentofAlberta:February6-7,2012).

43 Ibid.

44 Ibid.

45 HealthFacilitiesReviewCommittee,Routine Review – Summary of Findings, Mount Royal Care Centre,(GovernmentofAlberta:January19,2012).

46HealthFacilitiesReviewCommittee,Routine Review – Summary of Findings, Carewest Garrison Green,(GovernmentofAlberta:August24-25,2011).

47HealthFacilitiesReviewCommittee,Routine Review – Summary of Findings, Our Lady of the Rosary Hospital(GovernmentofAlberta:August16,2011).

48HealthFacilitiesReviewCommittee,Routine Review – Summary of Findings, The Good Samari-tan Stony Plain Care Centre (GovernmentofAlberta:July20-21,2011).

49 HealthFacilitiesReviewCommittee,Summary of Findings, Venta Care Centre.

50 HealthFacilitiesReviewCommittee,Summary of Findings, Carewest Garrison Green.

51 HealthFacilitiesReviewCommittee,Routine Review – Summary of Findings, Valleyview Con-

55


tinuing Care Centre(GovernmentofAlberta:January25,2012).


53HealthFacilitiesReviewCommittee,Routine Review – Summary of Findings, Wing Kei Care Centre(GovernmentofAlberta:February13,2012).


55 HealthFacilitiesReviewCommittee,Routine Review – Summary of Findings, Stettler Hospital,(GovernmentofAlberta:September27-28,2011).

56HealthFacilitiesReviewCommittee,Routine Review – Summary of Findings, Brooks Health Centre(GovernmentofAlberta:May19-20,2011).

57HealthFacilitiesReviewCommittee,Routine Review – Summary of Findings, Edmonton Gener-al Continuing Care(GovernmentofAlberta:October20-21,2010).

58HealthFacilitiesReviewCommittee,Routine Review – Summary of Findings, Capital Care Dickinsfield (GovernmentofAlberta:October31-November1,2011).

59 HealthFacilitiesReviewCommittee,Routine Review – Summary of Findings, Extendicare Michener Hill (GovernmentofAlberta:October26-27,2011).

60 HealthFacilitiesReviewCommittee,Summary of Findings, Valleyview Continuing Care.

61HealthFacilitiesReviewCommittee,Routine Review – Summary of Findings, Stettler Hospital and Care Centre (GovernmentofAlberta:September27-28,2011).

62 Ibid.

63HealthFacilitiesReviewCommittee,Routine Review – Summary of Findings, Bow View Manor (GovernmentofAlberta:May18-19,2011).

64 GovernmentofAlbertaLongTermCarePolicyAdvisoryCommittee,Healthy Aging: New Direc-tions for Care, Part One: Overview,22.

65 RuthDuncan,“FrontLineView,”Calgary Herald,December9,2012.

66 Foradiscussionofstaffinglevelsneededtosupportminimalorqualitycare,see:C.Harringtonetal.,“ExpertsRecommendMinimumNurseStaffingStandardsforNursingFacilitiesintheUnit-edStates,”Gerontologist40(2000):5-16;A.KramerandR.Fish,Appropriateness of Minimum Nurse Staffing Ratios in Nursing Homes: Report to Congress: Phase II Final: Volume I (Centers for MedicareandMedicaidServices:December24,2001),1-26.

67HealthFacilitiesReviewCommittee,Routine Review – Summary of Findings, Vegreville Care Centre (GovernmentofAlberta:August24,2010).

68HealthFacilitiesReviewCommittee,Routine Review – Summary of Findings, Good Samaritan South Ridge Village (GovernmentofAlberta:November29,2010).

69HealthFacilitiesReviewCommittee,Routine Review – Summary of Findings, Edith Cavell Care Centre(GovernmentofAlberta:July13-14,2011).

70 P.ArmstrongandT.Daly,‘There are not enough hands.’ Conditions in Ontario’s Long-Term Care Facilities(CanadianUnionofPublicEmployees:2004);M.Ross,A.Carswell,andW.Dalziel,“StaffBurnoutinLong-TermCareFacilities,”Geriatrics Today5,3(2002):132–135;N.ChappellandM.Novak,“CaringforInstitutionalizedElders:StressAmongNursingAssistants,”Journal of Applied

56


Gerontology13(1992):299–315.

71 HealthFacilitiesReviewCommittee,Summary of Findings, Good Samaritan South Ridge Village.

72 J.E.Bosticketal.,“SystematicReviewofStudiesofStaffingandQualityinNursingHomes,”Journal of the American Medical Directors Association7,no.6(2006):366-376;MarcyCohen,Caring for BC’s Aging Population: Improving Health Care for All (Canadian Centre for Policy Alter-natives:July2012,24).


74 Albert Banerjeeetal.,“Out of Control”: Violence against Personal Support Workers in Long-Term Care(YorkUniversityandCarletonUniversity:2008);AlbertBannerjeeetal.,“StructuralViolenceinLong-Term,ResidentialCareforOlderPeople:ComparingCanadaandScandinavia,” Social Science and Medicine74,3(2012):390-98.

75HealthFacilitiesReviewCommittee,Routine Review – Summary of Findings, Elk Point Health Care Centre(GovernmentofAlberta:May5,2011).

76 Suchsituationshavebeendescribedasinstancesof‘structuralviolence.’SeeBanerjeeetal.,“StructuralViolenceinLong-Term,ResidentialCare.” 77 ExtendicareRealEstateInvestmentTrust,2011 Annual Information Form (Extendicare REIT: March30,2011),51,accessedJune24,2013http://www.extendicare.com/uploads/public/51/docs/AIF_2011_Final.pdf

78 J.M.Murphy,Residential Care Quality: A Review of the Literature on Nurse and Personal Care Staffing and Quality of Care,(NursingDirectorate,BCMinistryofHealth:November2006),ac-cessedMay5,2013,http://www.health.gov.bc.ca/library/publications/year/2006/residential-care-quality-a-review-of-the-literature-on-nurse-and-personal-care-staffing-and-quality-of-care.pdf.

79 ThebenchmarkforqualitycareisbasedonC.Harringtonetal.,“ExpertsRecommendMini-mumNurseStaffingStandardsforNursingFacilitiesintheUnitedStates,”andJohnSchnelleetal.,“RelationshipofNursingHomeStaffingtoQualityofCare,”Health Services Research39,no.2(2004):225-250.ThebenchmarkforminimalqualitycareisbasedonA.KramerandR.Fish,“Re-lationshipbetweenNurseStaffingLevelsandtheQualityofNursingHomeCare.”

80M.P.Hillmeretal.,“NursingHomeProfitStatusandQualityofCare:IsThereAnyEvidenceofanAssociation?”Medical Care Research and Review62,no.2(2005):139-166.

81VikramR.Comondoreetal.,“QualityofCareinFor-ProfitandNot-For-ProfitNursingHomes:SystematicReviewandMeta-Analysis,”British Medical Journal339(2009):b2732.

82 W.Berta,A.Laporte,andV.Valdamanis,“ObservationsonInstitutionalLongTermCareinOntario:1996-2002,”Canadian Journal on Aging24(2005):71-84.

83 MargaretJ.McGregoretal.,“StaffingLevelsinNot-For-ProfitandFor-ProfitLong-TermCareFacilities:DoesTypeofOwnershipMatter?”Canadian Medical Association Journal172,5(2005):645-649. 84 MargaretJ.McGregoretal,“CareOutcomesinLong-TermCareFacilitiesinBritishColumbia,Canada:Doesownershipmatter?”Medical Care44(2006):929-35;E.ShapiroandR.B.Tate,“MonitoringtheOutcomesofQualityofCareinNursingHomesUsingAdministrativeData,”Canadian Journal of Aging14(1995):755-68;KimberlyN.McGrailetal.,“For-ProfitVersusNot-For-ProfitDeliveryofLong-TermCare,”Canadian Medical Association JournalSupplement176(2007):57-58.Seealso:MargaretJ.McGregorandLisaA.Ronald,“ResidentialLong-TermCareforCanadianSeniors:Non-Profit,For-Profit,orDoesitMatter?”IRPPStudyNo.14,January2011.

57

http://www.extendicare.com/uploads/public/51/docs/AIF_2011_Final.pdf

http://www.extendicare.com/uploads/public/51/docs/AIF_2011_Final.pdf

http://www.health.gov.bc.ca/library/publications/year/2006/residential-care-quality-a-review-of-the-literature-on-nurse-and-personal-care-staffing-and-quality-of-care.pdf

http://www.health.gov.bc.ca/library/publications/year/2006/residential-care-quality-a-review-of-the-literature-on-nurse-and-personal-care-staffing-and-quality-of-care.pdf


85 HospitalEmployeesUnion,Quality of Care in BC’s Residential Care Facilities: A Submission to the Office of the Ombudsman on Senior’s Care(HEU:January12,2009),accessedApril15,2013,http://www.heu.org/sites/default/files/uploads/2010%20seniors/HEU%20submission%20to%20Ombudsperson.pdf.

86 C.Harringtonetal.,“DoesInvestorOwnershipofNursingHomesCompromisetheQualityofCare?”American Journal of Public Health91(2001):1452-5.

87 MargaretJ.McGregoretal,“DoesTypeofOwnershipMatter?”

88 Academic researchers have found that quality elder care requires 1.15 hours of directed care byRNsperresident,perday.SeeC.Harringtonetal.,“MinimumNurseStaffingStandards.”

89 C. Harringtonetal.,“MinimumNurseStaffingStandards.”

90 Pat Armstrong and Hugh Armstrong, “Women, Privatization and Health Care Reform: The Ontario Case,” in Exposing Privatization: Women and Health Care in Canada (Aurora: Garamond Press, 2001).

91 AlbertaUnionofProvincialEmployees,“HardistyStaffRatifiesFirstAgreement,StrikeEnds,”http://www.aupe.org/news/hardisty-staff-ratifies-first-agreement-strike-ends/(accessed August 1,2013).

92 AlbertaUnionofProvincialEmployees,“CollectiveAgreementRatifiedatDevonshire,”http://www.aupe.org/news/collective-agreement-ratified-at-devonshire/(accessedAugust15,2013).

93 CanadianUnionofPublicEmployees,“CUPEWinsPublicSectorRatesatPrivateNursingFacility,”http://alberta.cupe.ca/Alberta-Health-Emplo/wins-public-sector-rates-private (accessed March5,2013).

94 AlbertaUnionofProvincialEmployees,“LongestLabourDisputeinAUPEHistoryFinallyComestoanEnd,”http://www.aupe.org/news/longest-labour-dispute-in-aupe-history-finally-comes-to-end/(accessedApril15,2013).

95 AlbertaHealthServices,Activity Based Funding of Long-Term Care User Summary (AHS: Au-gust2,2011),13,accessedMarch23,2013,http://web.archive.org/web/20130320002651/http://www.albertahealthservices.ca/hp/if-hp-in-ltc-user-summary.pdf. 96 AlbertaContinuingCareAssociation,Labour and Funding Issues Jeopardize Seniors Care,July4,2012,accessedFebruary15,2013,http://www.ab-cca.ca/acca-news-releases.

97 GovernmentofAlberta,Supportive Living Guide,10. 98 AuditorGeneralofAlberta,Report of the Auditor General on Seniors Care and Programs – Frequently Asked Questions (FAQs),(OfficeoftheAuditorGeneral:May2005),2,accessedApril17,2013,http://www.oag.ab.ca/files/oag/OAG_Seniors_2005_FAQ.pdf

99 HealthFacilitiesReviewCommittee,Summary of Findings, Capital Care Dickinsfield.

100 HealthFacilitiesReviewCommittee,Summary of Findings, Edith Cavell Care Centre.

101 Ibid.

102 HealthFacilitiesReviewCommittee,Routine Review – Summary of Findings, Barrhead Con-tinuing Care,(GovernmentofAlberta:April28,2010).


58

http://www.heu.org/sites/default/files/uploads/2010 seniors/HEU submission to Ombudsperson.pdf

http://www.heu.org/sites/default/files/uploads/2010 seniors/HEU submission to Ombudsperson.pdf

http://www.aupe.org/news/hardisty-staff-ratifies-first-agreement-strike-ends/

http://www.aupe.org/news/collective-agreement-ratified-at-devonshire/

http://www.aupe.org/news/collective-agreement-ratified-at-devonshire/

http://alberta.cupe.ca/Alberta-Health-Emplo/wins-public-sector-rates-private

http://www.aupe.org/news/longest-labour-dispute-in-aupe-history-finally-comes-to-end/

http://www.aupe.org/news/longest-labour-dispute-in-aupe-history-finally-comes-to-end/

http://web.archive.org/web/20130320002651/http:/www.albertahealthservices.ca/hp/if-hp-in-ltc-user-summary.pdf

http://web.archive.org/web/20130320002651/http:/www.albertahealthservices.ca/hp/if-hp-in-ltc-user-summary.pdf

http://www.ab-cca.ca/acca-news-releases

http://www.oag.ab.ca/files/oag/OAG_Seniors_2005_FAQ.pdf


104 Ibid.

105OfficeoftheInspectorGeneral,Inappropriate Payments to Skilled Nursing Facilities Cost Medicare More Than a Billion Dollars in 2009 (United States Department of Health and Human Services:November2012).

106 JanetE.Fast,DeannaL.Williamson,andNorahC.Keating,“TheHiddenCostsofInformalElderCare,”Journal of Family and Economic Issues20,3(1999):304.

107 DonnaVogel,MichaelRachlis,andNancyPollak,Without Foundation: How Medicare is Undermined by Gaps and Privatization in Community and Continuing Care,(CanadianCentreforPolicyAlternatives:November2000),44.

108 Fastetal.,“HiddenCosts”,322.

109 Ibid.,303.

110 Ibid.,306.

111 PatArmstrong,“UnpaidHealthCare:AnindicatorofEquity,”Pan American Health Organiza-tion,n.d.,18-19.

112 Ibid.,21-22.

113 Authors’calculations.DataretrievedfromAccommodationStandardsandLicensing,www.asalreporting.gov.ab.ca(accessedFebruary2013). 114 “AnonymousDonorsRevealed:NumberedCompaniesGave$191,000toToryLeadership,”Edmonton Journal,March16,2012.

115 Author’scalculationsbasedonTreasuryBoardandEnterprise,Blue Book: General Revue Fund, Details of Grants, Supplies, Services, Tangible Capital Assets and Other Payments, by Payee,(GovernmentofAlberta:2006to2011).

116 CanadaDepartmentofFinance,“Backgrounder:TheRapidGrowthof‘IncomeTrusts,’”http://www.fin.gc.ca/n10/data/10-125_1-eng.asp(accessedMarch13,2013),3.

117 ExtendicareRealEstateInvestmentTrust,2011 Annual Report(ExtendicareREIT:n.d.),99,ac-cessedApril14,2013, http://www.extendicare.com/uploads/public/51/docs/EXE_AR11_full%20for%20SEDAR.pdf

118 TheSenateStandingCommitteeonSocialAffairs,ScienceandTechnology,The Health of Canadians – The Federal Role(TheSenateofCanada:October2002).

119 ExtendicareRedevelopmentServices,“AboutUs,”http://www.extendicareredevelopment.com/paul_tuttle.htm#(accessedApril4,2012).

120 Returnoninvestmentwascalculatedas(Totalrevenues–Totalexpenses)/TotalExpenses.

121 Author’s Calculations. Data retrieved from ForeCastChart.com, “S&P 500 Stock Market Index Historical Graph,” http://www.forecast-chart.com/historical-sp-500.html(accessedMay6,2013).

122 W. Berta,A.Laporte,andV.Valdamanis.,“InstitutionalLongTermCareinOntario.”

123 K.ShannonandC.VanReenen,“PACE(ProgramofAll-InclusiveCarefortheElderly):Innova-tiveCarefortheFrailElderly,”Health Progress79(1998):41-5.

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124 AlbertaHealthServices,“CHOICE,”http://www.albertahealthservices.ca/services.asp?pid=-service&rid=1001469(accessedMarch15,2013).

125 WendyArmstrong,“BriefingMemoRe:CHOICEProgramsinAlberta,”November27,2006.

126 AlbertaHealthServices,Becoming the Best: Alberta’s 5-Year Health Action Plan(GovernmentofAlberta:November2010),15,accessedMay13,2013,http://www.health.alberta.ca/documents/Becoming-the-Best-2010.pdf.

127 AlbertaHealthServices,CHOICE – Comprehensive Home Option of Integrated Care for the Elderly, Program Information,(GovernmentofAlberta:2011-12),2.

128 PinnellBeaulneAssociatesLtd,CHOICE Evaluation Project: Evaluation Summary Final Report (PinnelBeaulneAssociates:November26,1998);AlbertaHealthServices,“SeniorsHaveChoice,”http://www.albertahealthservices.ca/1362.asp(accessedFebruary2,2013).

129 AlbertaUrbanMunicipalitiesAssociation,Mayors’ Caucus Request for Decision: Lodge Programme Funding and Modernization,(AUMA:June14,2012),2,accessedApril9,2013,http://www.auma.ca/working/digitalAssets/65/65335_RFD_Attachment_4.pdf.

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