30 Nov 2020 New Respectfully Submitted Elder Care Policy Report
ARPA Canada’s newest Respectfully Submitted Elder Care Report has just been released! You can read the text of the report below or view, download, and/or print a pdf of the policy report here.
In 2016, Canada’s senior population (those aged 65+) exceeded the number of children (under the age of 15) for the first time in history.[i] By 2025, the proportion of seniors in the Canadian population is expected to double from where it was in 2015.[ii] Canada has had a fertility rate lower than replacement rate for over 40 years and deaths could exceed births by 2030. Canada is aging.
As aging Canadians ourselves, we should each have a vested interest in how elder care is done in Canada. Do we really respect our elders and care for them in a way we ourselves would want to be cared for in old age? God calls us to honour our fathers and mothers, to respect our elders, and to care for the vulnerable elderly among us.[iii] We have a growing opportunity and responsibility to live up to this calling in how we provide elder care, both now and in the future.
Elder care in Canada needs improvement. This report focuses on senior Canadians who need some assistance with the tasks of daily living and can no longer live independently. We call for greater family and community investment in elder care, for prioritizing home-based care, and for considering purpose and meaning when determining how to provide long-term care. The policy recommendations we conclude with would support these priorities at the federal, provincial and municipal levels.
Family first: The role of family and community in elder care
Ideally, family should care for their aging elders at home for as long as possible, and remain active participants in care if they enter a long-term care facility. Cultural and economic changes of the past century, though beneficial in many ways, may make home care by family more difficult. Fewer stay-at-home parents, delayed childbearing, fewer children, and longer life expectancies for seniors means families may need to balance two jobs, child care, and elder care responsibilities simultaneously.[iv] We also live in a more transient society, where many people leave the community they were raised in and so do not reside near elder family members.
Regardless, family should be on the frontline of care for elders. The biblical command to honour one’s father and mother extends into their care in old age. The New Testament church, for example, was instructed that family had first responsibility for caring for widows, as a way for children and grandchildren to “make some return to their parents” (1 Timothy 5:4). Jesus also condemned those who made pious claims of doing good while abandoning the proper care of their parents (Mark 7:9-13). Family commitment to elder care may require sacrifices of time, finances, or career, but it is to be encouraged and promoted as the right response to the call to honour our parents.
Enabling family to be more active in the care of their elderly family members can be done through education, rigorous community supports and social connections, and financial support that recognizes the valuable role of informal caregivers.
Education, first of all, would help family members gain confidence in the skills needed to safely care for a family member at home.[v] Affordable, specialized courses or workshops should be available through local caregiver groups, possibly in partnership with institutions that offer continuing education so that community members wishing to learn basic home care techniques are able to do so. Training should include skills like how to administer medications, how to transfer someone from a wheelchair to a bed, and how to help with bathroom needs. These programs should be developed in partnership with relevant experts such as care aides or pharmacists to ensure accuracy and helpfulness.[vi]
Public respite help is essential to ensure family caregivers are supported and able to provide successful home-based care. Unpaid/informal caregivers bear a high burden of stress and expectation – in British Columbia, for example, a third report significant distress and burnout.[vii] Promoting home-based care means also promoting and expanding safe options for back-up care to help these caregivers manage. In some places, long-term care homes offer day programs where families can drop off their elderly family member for activities, a meal, and a tub bath if necessary. There are also respite beds in some care homes reserved for short-term use, providing a safe place for a senior whose caregiver needs a break. Respite hours can also be used in the family caregiver’s home, where a qualified person goes to the home and spends a few hours with the person needing care while the family caregiver runs errands or goes visiting. Church groups, neighbourhood associations, or other religious, cultural, or community associations should expand these respite services. With support from the civil government, these programs can be made widely available across Canada in the relatively short amount of time these urgent services are needed.
Caregiver Associations and support groups should be priorities at the provincial and municipal levels. These groups are a great source of connection and encouragement, and can serve as a conduit for educating and equipping caregivers while assessing for and supporting through caregiver burnout.[viii]
If institutional long-term care home placement is necessary, family involvement must remain a priority. Staff rightly remain professional caregivers, while family and community should satisfy emotional, social, and spiritual needs. This holistic approach to the well-being of the elder person in care must be maintained at all times.
Social connection and a sense of belonging are crucial at any age. Older adults often face a shrinking social network as their mobility decreases, friends die, and they let go of roles that brought them into contact with others, such as work and volunteer opportunities. Around 25% of senior men and 40% of senior women – 1.4 million Canadians – report feeling lonely. This is a national epidemic of loneliness.[ix]
Isolation and loneliness can contribute to depression, cognitive decline, high blood pressure, and other health problems.[x] In recent years, multiple studies found that “loneliness may be the most potent threat to survival and longevity… In short, loneliness kills people.”[xi] Isolation and loneliness should be a key focus in any policy around elder care. Human beings are designed for relationship and connection.
Family cannot always fill the need for social connection for older adults. Many older adults prefer to be around people of their own age, abilities, and interests. Faith, cultural, or hobby-based groups that foster connection for citizens in their senior years (book clubs, Bible studies, garden sharing programs, walking groups, dining clubs, quilting groups, birdwatching groups, etc.) have positive results: studies show that people who belong to these types of community groups are less likely to become ill and recover more quickly from illness or surgery. Social group involvement was also found to reduce risk of depression by almost 25 percent.[xii] This shows the importance of social connection for our elders, a connection that is easier to maintain when aging at home in a familiar community. It also shows the necessity for community services designed for seniors, such as access to transportation that facilitates involvement in these groups.
Ensuring financial support for family members caring for an elderly relative will enable people to provide extended care on a full-time basis. Public policy can support this family-first approach to care by improving financial benefits to allow payment to the family caregiver(s). Recognizing the understandable time limitations of work leave benefits, tax credits for families caring for an elderly relative in their home would help in this regard. A doctor’s signed confirmation can confirm the level of care needed as well as a family member’s primary caregiver status, qualifying them for the credit. Current compassionate care benefits and family caregiver benefits extend for up to 35 weeks at just over half of a person’s full wage, with limitations for maximum payments.[xiii] This time-limited support does not account for the multiple years of care some older adults require.
Increasing and extending financial support options for families willing to care for their elders would strengthen the foundational building block of the family and help seniors wishing to stay in their communities. It would also relieve staffing and bed shortages in long-term care facilities and could significantly reduce the financial cost to the civil government.
Aging at home
Canadians overwhelmingly wish to age at home.[xiv] This is reflected in the fact that more than 90% of Canadian seniors live in their own home or a family member’s home, and most do not enter long-term care facilities until it is absolutely necessary.[xv] Aging at home allows and encourages the voluntary sector, particularly families, religious groups, and other social organizations, to play a larger role in elder care. Enabling seniors to “age in place” also enhances relationship continuity and familiarity with one’s environment. Ensuring Canadians can age at home for as long as possible respects their wishes, and community planning and programs should promote it.
In 2006, the World Health Organization developed the Global Age-Friendly Cities project, which identified eight key domains where communities can become more age-friendly. Canada is already doing excellent work on some of these domains.[xvi] For example, many cities now offer free or subsidized public transport for older people, and senior-friendly recreation centres, shopping, and community amenities. Well-lit, well-maintained sidewalks and more automatic doors also help. However, some of these areas have not increased in line with our aging population. HandyDart services, for example, which provide transportation to those unable to drive or needing specialized vehicles to accommodate wheelchairs or walkers, are often overwhelmed and end up setting high standards of qualification. This restricts access for many who could benefit. Services like these connect our elders with grocery shopping, doctor appointments, and other community services that maintain the level of independence and flexibility they desire. They should be reviewed across Canada and expanded where needed.
Provincial and municipal governments should focus on developing their cities and towns as age-friendly communities. This “inclusive design” prioritizes modifications like ramps at entrances, automatic doors on all public buildings, elevators in multi-level buildings, audible crosswalk sounds and optional extra time to cross, benches at bus stops, well-lit sidewalks, high contrast and large print signage, and sloped sidewalk ramps for walkers, scooters and wheelchairs to leave the sidewalk.[xvii] Such modifications accommodate the diversity of abilities in our communities and will benefit all of us at some point in our lives.
Consider Japan, which the United Nations calls a “super-aged” society. As of 2015, more than 25% of the population was over 65, and more than 30,000 reach the age of 100 every year.[xviii] Japan anticipated its demographic shift. In an effort to promote community care and age-friendly communities, Japan restricted the development of institutionalized care facilities and focused on community modifications such as large-print bus schedules, reading glasses on store counters, buttons allowing extra time at crosswalks, and generalized training workshops in dementia care.[xix] By doing so, Japan encouraged and equipped local communities to become senior-friendly.
When aging at home is no longer possible, people need assisted living or long-term care. This type of care is under intense stress and scrutiny in Canada. Elder care has become an industry rife with misunderstandings regarding reporting, funding, and standards of care. This report looks at the goals of long-term care, the staffing crisis facing long-term care, and the need for choice in long-term care. The recommendations here apply across all long-term care facilities, whether government run, for-profit, or non-profit.
An institution, or a place of purpose?
Too often the main goal of long-term care seems to be resident safety/risk mitigation rather than resident satisfaction. Rules and patterns are established for the supposed safety of the residents, from limitations on foods to restrictions on visitors. At their worst, care homes are akin to prisons, requiring people to room with strangers, bathe and dress when told, eat what is provided, and use the bathroom when allowed. Care homes are also often designed to appeal to middle-aged people looking for a safe place for their elderly parents. The hotel-like lobbies, brochures about activities, and advertised safety features may be focused more on them than the would-be residents.
We should aim to reduce the institutionalization of elder care and to better serve the needs and desires of the dependent elderly. Keren Brown Wilson, a pioneer of assisted living in the 1980s, said, “We want safety and security for our loved ones, and freedom and autonomy for ourselves. …Why don’t we want the same things for them that we do for ourselves?”[xx] Long-term care should be designed to leave freedom for, and facilitate what, makes life meaningful to each unique resident. We should do everything we can to make long-term care homes feel like home, a place where a person belongs and can maintain social connections both within and outside the home.
Instilling a proper appreciation and respect for our elders also necessarily includes relationship, and so we believe assisted living should never be “out of sight, out of mind.” Some have suggested incorporating senior residences into shopping developments or university complexes,[xxi] while others have integrated day care directly into long-term care facilities.[xxii] Provincial governments should commission a study or pilot project to look at the efficacy and satisfaction rates with such homes to determine whether long-term care homes should pursue such programs to stay connected with the communities they serve. These types of programs may also help to reduce ageist stigma.
Staffing needs in long-term care
Staffing is a critical issue in long-term care homes. As the desire to age at home grows and programs for aging at home improve and become more widespread, there has been a corresponding increase in the level of care required in long-term care homes. Reductions in hospital capacity have also led to more high-needs patients being transferred to long-term care homes.
As a result, long-term care facilities are increasingly high-needs environments, with many patients having multiple co-morbid conditions.[xxiii] Many facilities are not equipped in terms of staffing, training, or design for this shift to a more complex level of care. In Ontario, for example, 90% of care home residents have some cognitive impairment, more than 80% need help with daily tasks such as getting out of bed and eating, and more than 60% have 10 or more prescription medications that need managing.[xxiv]
Adequate staffing is essential for high quality care. Staff should be well-trained and well-paid to lower turnover rates and resulting inconsistencies in caregiving. Full-time positions should be prioritized to minimize staff moving between care homes and to improve continuity of care. Minimum staffing ratios in care homes should be set as part of government requirements for operating a care home, with flexibility based on levels of care needs and family care integration.
Adding family care-givers as essential workers and encouraging their active engagement in care could alleviate some staffing pressure. Nathan Stall, a geriatric physician, says family caregivers play an essential role in the geriatric health system, and their involvement in care reduces mortality.[xxv] Family members are not just visitors: they are a “shadow workforce” in the geriatric care sector and their absence was sorely missed during COVID-19 restrictions.[xxvi] Stall says family caregivers are fully capable of learning and following the protective measures necessary to prevent the spread of infection. Allowing them to do so would benefit both residents and staff immensely.
Recognizing that family is not always willing or able to be involved, care homes should have a plan to actively solicit volunteers and visitors from the community. The care homes should have clearly laid out opportunities and expectations for those volunteers, and should offer basic free training.
Future staffing also needs to be considered, as workers in elder care are themselves aging – in 2016, 1 in 5 female Registered Nurses were 55 or older, compared to 1 in 10 in 1996.[xxvii] The Ontario Long-Term Care Association (OLTCA) reports that 50% of long-term care nurses in the province are near retirement age.[xxviii] There is nowhere near an equal replacement rate of young nurses entering the profession and, as the population continues to age, staffing shortages will be a problem in both home care and long-term care facilities.[xxix] The OLTCA suggests reducing Registered Nurse staffing requirements, and instead permitting Personal Support Workers and Registered Practical Nurses to do more.[xxx] This reduction in required training could be balanced by regular physician visits to care homes to check-in with patients and provide urgent care when needed, reducing the need for trips to an emergency room.
Choice in Long-Term Care
Much has been written on public versus private long-term care systems, and whether there is a need for a government-controlled approach to institutionalized elder care. The evidence does not support a definitive stance exclusively in support of either government-run facilities or for-profit or non-profit care homes. What is clear is that a national top-down approach would unhelpfully limit choice in long-term care.
Governments have an important role in ensuring that the means are available to care for our elders, and that certain standards are met. But it is important that this role respects the rights of older adults to choose the type of care they receive, and respects the efforts of private sectors to provide this care. The civil government should not interfere in privately-run care homes, whether non-profit or for-profit, beyond the necessary safety and standard of care regulations.
Public policy should enable a variety of elder care options to flourish. Canadians should be able to choose a home where they feel safe, valued, and cared for, and where their beliefs are respected. While all homes providing elder care should be held to a high standard of care, they should never be penalized for holding to religious standards that forbid, for example, assisted suicide or euthanasia. There are many senior citizens who prefer that type of home, and many staff who prefer that work environment.
Cultural and religious diversity should be expected and promoted, also in institutionalized long-term care settings.[xxxi] Anecdotal evidence suggests that “[r]esidents living in an ethnic-specific home likely also benefit from having a sense of cultural safety and familiarity.”[xxxii] Whether these are private homes or public homes that find ways to reach out to different cultural and faith communities on behalf of their residents, this focus on individual and cultural values can ease the transition to long-term care and enhance the recognition of residents as people with unique personal stories and identities.
Many elders suffer physical, emotional and financial abuse or neglect from caregivers or other community members. A full discussion of elder abuse is beyond the scope of this report, but must not be ignored. Thankfully, public officials are aware of this issue, and are rightly committed to using the criminal justice system to investigate allegations and pursue charges in cases of elder abuse.[xxxiii]
One area of potential abuse that has not received enough attention, however, is the result of shutting visitors out of care homes. During COVID-19 restrictions, many family members were blocked from accessing their loved one – some of whom had been involved in daily care, such as feeding or personal hygiene. This restriction caused great emotional distress to many, and sadly also physical distress to some whose care suffered without the help of their family member. There were stories of horrifying neglect in the midst of the COVID crisis.[xxxiv]
Keeping care home doors open to designated family members should be a priority not only for the emotional well-being of residents, but also as a means of accountability and a safeguard against abuse in these facilities. Having this “shadow workforce” of family members, as discussed above, may also relieve pressures on care home staff, reducing stress that may lead to physical or emotional abuse or neglect of long-term care residents.
It is our hope that excellent community care programs, adequate staffing in long-term care homes, and formal training and public support for unpaid caregivers will reduce stress and frustration that may lead caregivers to act in abusive or neglectful ways. Promoting the integration of elders in their communities can also positively impact how we view caregiving, which will help us develop high expectations of care and excellent long-term care environments.
Our population is aging. Canadians are living longer, healthier lives than ever before. That is reason for thankfulness. It is also reason to recognize our responsibility toward those who raised us.
Aging can rob us of what we hold most dear – friendships, physical abilities, work, home, possessions, even independence. We are all aging, and we need to work together now to build a societal system of elder care that goes beyond maintenance to meaningfulness. As image bearers of God, we are created for his purpose and sustained for as many days and years as that purpose requires. Elder care should focus on honouring our aging population and affirming their inherent human dignity.
With this in mind, we respectfully submit policy recommendations with a focus on ensuring that older Canadians are heard, supported, and cared for in a holistic and compassionate way, from the community to the care home. We recognize the tremendous variety of needs and the wide cultural and religious diversity of older Canadians, resulting in the need for a variety of policy responses and collaboration between civil government, community groups, and family units. Elder care at its best will be a collaborative partnership between public and private sector services, with a focus on valuing and respecting our elders and building a system of elder care that they and we can look forward to growing old in. Through this, we can build on our reputation in Canada as one of the best places in the world to grow old.
All levels of government must respect and support the value of choice in long-term care, particularly care homes that meet the unique spiritual and cultural needs of particular citizens. Ensure strong conscience protection rights for private care homes to operate in line with their religious and cultural commitments and heritage.
Provincial governments should designate close family caregivers as essential workers, ensuring they maintain access to visiting their loved ones in care even during times of crisis. (See, for example, Ontario’s proposed “More Than a Visitor Act (Caregiving in Congregate Care Settings), 2020)
In consultation with care homes and those they serve, provincial governments should develop, implement, and enforce minimum staffing requirements for long-term care homes. These staffing requirements should:
- prioritize full-time positions
- ensure access and training for family caregivers
- recognize the excellent work done by Registered Practical Nurses and personal support workers/care aides, and
- decrease requirements for on-staff Registered Nurses.
Provincial governments should:
- commission a study or run pilot projects across their provinces to examine the effectiveness of multi-use facilities that incorporate long-term elder care with pre-school or daycare services, music programs, or sport clubs in reducing loneliness and increasing life satisfaction of older adults in care.
- commission a study evaluating access to modified transportation options, such as HandyDart or community volunteer organizations that provide driving services. Determine whether additional needs could be met by expanding these efforts.
With a view to supporting home-based and family care:
- Federal government should:
- expand tax credits for unpaid family caregivers
- introduce a home-improvement credit for renovations to the home in order to accommodate home-care for a parent (e.g. installing ramps, chair lifts in stair-wells, walk-in showers, etc.)
- Provincial governments should
- expand programs for community respite support such as day programs for the elderly, short-term bed availability in care homes, and in-home care in the caregiver’s absence;
- develop workshops or Continuing Education courses on basic home care such as wheelchair transfers, mouth care, foot care, administering medication, etc. and offer these through existing provincial Caregivers Associations or Continuing Education programs; and
- subsidize equipment costs to enable staying at home longer (eg: wheelchairs, accessible vehicles, hospital beds).
- Municipal governments should ensure local senior centres/clinics and caregiver support groups have up-to-date lists of local support services available for older Canadians.
[iii] Exodus 20:12, Leviticus 19:32, Proverbs 16:31; 20:29; 23:22, Mark 7:9-13, Ephesians 6:2-3, 1 Timothy 5:3-8.
[iv] Bookman, A. & Kimbrel, D. (2011). Families and elder care in the twenty-first century. The Future of Children, 21(2).
[v] See, for example, “More training for unpaid caregivers needed, says support group.”
[x] Sutin, A. R., Stephan, Y., Luchetti, M., Terracciano, A. (2018) Loneliness and Risk of Dementia. The Journals of Gerontology: Series B, 112.
[xi] Bzdok, D. & Dunbar, R.I.M. (2020). The Neurobiology of Social Distance. Trends in Cognitive Sciences.pp 1-2.
[xv] Garner, R., Tanuseputro, P., Manuel, D. G. & Sanmartin, C. (2018) Transitions to Long-Term and Residential Care Among Older Canadians.
[xviii] Arai, H., Ouchi, Y., Toba, K., Endo, T., Shimokado, K., Tsubota, K., Matsu, S., Mori, H., Yumura, W., Yokode, M., Rakugim H. & Oshima, S. (2015). Japan as the front-runner of super-aged societies: Perspectives from medicine and medical care in Japan. Geriatrics and Gerontology International, 15(6).
[xix] Hsieh, P., Wang, S., Chen, C., Wake, J., Yeh, C. (2016). Community Integrated Support Center: The Experience of Hachioji, Tokyo, Japan. Hu Li Za Zhi, 63 (5).
[xx] As quoted in Gawande, Atul. (2014). Being Mortal: Medicine and what matters in the end.
[xxii] Lau, A. (2015). When a preschool is located in a nursing home, magic happens, from Washington Post. See also Abma, S. (2018). ‘They give us life!’: Seniors get boost from weekly playdates, from CBC News.
[xxiii] Ng, R., Lane, N., Tanuseputro, P., Mojaverian, N., Talarico, R., Wodchis, W. P., Bronskill, S. E., & Hsu, A. T. (2020). Increasing complexity of new nursing home residents in Ontario, Canada: A serial cross-sectional study. Journal of American Geriatrics Society, 68(6).
[xxv] Bogart, N. (2020). Family caregivers should be on frontlines if ‘willing and able’ from CTV news.
[xxxi] Sue Cragg Consulting and the CLRI Program (2017). Supporting cultural diversity in long-term care.
[xxxiv] Brewster, M. & Kapelos, V. (May 26, 2020): Military alleges horrific conditions, abuse in pandemic-hit nursing homes and Malek, J. (2020): Military Report on Long-Term Care Homes Reveals Long-Known Truths.
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