How Can We Improve Long-Term Care?

Ontario’s long-term care system is failing seniors argues a leading researcher.

As you or your parents or relatives advance in age, develop illnesses, and can no longer live independently, you are likely to begin considering a move to a long-term care home. In delving into this system for the first time, you are probably going to be surprised at how it’s run, who’s behind it most of the time, and who really benefits.

Pat Armstrong is a distinguished research professor of sociology at York University. Her work focuses on social policy, women, work, health, and social services. She is the principal investigator of two recent studies that included a comprehensive survey of best practices in long-term residential care in several countries.

She argues Ontario’s current model that sees large private corporations pocketing profits from running long-term care homes is doing seniors and their families a disservice.

Retirement, nursing, and long-term care homes

First, it’s important to be sure of exactly what type of home we’re talking about.

Retirement homes are residential facilities geared towards independent people who want access to care or support when or if they need it. 

Nursing homes are different because they provide 24-hour care and medical assistance. In Ontario, nursing homes are called long-term care homes. 

Note, however, that long-term care homes are so full that many people choose retirement homes even though they need 24-hour care.

The history of long-term care in Ontario

After World War II, Ontario expanded public healthcare. There was a significant focus on hospitals, and many different types existed. These included psychiatric, acute care, general, chronic care, and rehabilitation hospitals.

Because there was such a significant focus on hospitals, people who needed 24-hour care would go there rather than to a long-term care facility. 

Ontario’s long-term care homes back in the old days followed a model closer to today’s retirement homes. They provided support for daily living but, for the most part, lacked medical care.

These long-term care homes had three ownership models: privately owned by a for-profit business entity; privately owned by a not-for-profit organization; and publicly owned. 

For-profit homes were often small, family-owned facilities. In contrast, private not-for-profit homes were owned by religious organizations or community groups, and municipalities owned public homes.

These three ownership models are very similar to how long-term care homes are owned today. The main difference is how for-profit homes are run.

For-profit homes have shifted from small, family-owned facilities to being owned by large corporations. 

This shift took place in the 1990s when the Harris government put government-subsidized homes up for bidding in a process favouring large corporations with more resources.

Today, Ontario has the largest proportion of for-profit long-term care homes than anywhere else in Canada: out of 627 homes, 57% are for-profit.

Why did the corporation-owned for-profit model emerge?

The justifications offered for this model include:

• Increased efficiency.
• Increased competition leads to choice and higher quality of care.
• The private sector has more money to invest in long-term care homes.

However, Armstrong says that there is no evidence that the private sector is more efficient than the public sector in this area. 

“Efficiency” is also the wrong way to measure the quality of care because that is not the goal of the service.

 “This isn’t making widgets or even cars; this is caring for people,” she says.

The argument that competition brings choice and better quality care doesn’t hold up. Because homes are so full, competition isn’t even a consideration.

“We have so few beds in our long-term care homes that people don’t have a choice,” Armstrong notes. “I was talking to someone the other day that said they applied two years ago to go into long-term care. They were determined to be eligible, and they just got a phone call. [They were] offered to go into one of the homes that had the worst record during the pandemic, the highest death rate, and the most COVID cases. This isn’t consumer choice.”

There is also no money being saved by the government in contracting corporations to build new long-term care homes rather than paying upfront, Armstrong says. 

She compares it to a mortgage on a home, but you don’t even own the house once the mortgage has been paid off.

“So it saves the government no money,” Armstrong says. “We have seen no improvement in quality. In fact, we’ve seen the reverse, we have seen no improvement in choice because the government hasn’t expanded the number of beds and when we look at what people choose […] they’re way more likely to choose a municipal home, a public home, then they are to choose a for-profit home.”

How are long-term care homes funded?

All long-term care homes, even for-profit ones, are funded in part by the provincial government. All residents have to pay accommodation fees whether the home is public or private. The province covers healthcare costs.

Set amounts of money are also provided for things like food and staffing, but it’s supposed to be sent back if the money isn’t spent.

So how do for-profit homes make so much money? These homes usually have lower staffing levels and pay their staff less money. However, Armstrong is still unsure how such a significant profit is possible.

“You can make some money on accommodation and other services, but it’s still somewhat of a mystery to me how their profits can be as high as they are,” she says.

Regulations in long-term care

One of Armstrong’s studies looked at scandals in long-term care homes in Norway, Sweden, Germany, the United Kingdom, the United States, and Canada. The researchers found that most scandals took place in for-profit homes, which are more common in the United States, Canada, and the United Kingdom.

The most common response to scandals was to introduce more regulations. 

“When we were doing our research in the United States, they said the nursing homes are more regulated than the nuclear industry —  in part because there’s been more disasters in them,” Armstrong notes.

For the most part, these regulations only target staff rather than the owners of homes. Armstrong says that the real problem in these homes is not the team’s actions but that there are not enough staff in the first place. 

Staffing is the most significant expense for a corporation, so for-profit homes tend to operate with less staff and less care.

Another problem with the system is that regulations also need to be enforced. If inspections don’t take place and there are no consequences for not meeting regulations, there is no point in having rules in the first place, Armstrong argues.

In Ontario, inspections of long-term care homes have been dramatically reduced and are primarily done in response to complaints. There are also not enough consequences if regulations aren’t met, Armstrong points out.

Why isn’t the for-profit model ideal?

One of the most significant issues in for-profit homes is inadequate staffing. 

Paying fewer staff benefits a corporation, but it is harmful to residents when there is insufficient care staff. It also hurts staff by increasing their workload so that they cannot provide the best standard of care.

Many staff in long-term care homes are only part-time, which is less than ideal. 

“The majority of personal support workers in Ontario only have part-time jobs,” Armstrong says. “That’s just not good enough. If you think of care as requiring continuity so that the person who’s looking after you knows you, knows what you need, knows what can really irritate you and what doesn’t, then you need full-time employment for people, and of course, those people who do the jobs need full-time employment too.”

COVID-19 deaths have also been much higher in for-profit homes than in not-for-profits or municipally owned homes because of the lower standard of care, Armstrong argues.

Can we make the for-profit system work for Canadians?

Armstrong says it will take more than just minor tweaks: “I think in terms of Ontario, we can not renew their contracts. […] I’m talking about a progress movement towards moving away from [for-profit long-term care homes].”

She says that to reach this goal, the system must make it more challenging to make a profit off of long-term care by ensuring that all money and funding available will go towards providing the best care possible.

Armstrong says that there are no for-profit long-term care models that work worldwide, and she does not see the quality of care improving unless we make changes to move away from this model.

“It’s not that the municipal homes are perfect, nor are the not-for-profits; they’re certainly not perfect,” she says. “And there’s a lot of room for improvement in all of the homes, but […] it seems to me that we don’t have any real justification for spending public money to pay for profit as opposed to paying for care.”

BIO

Pat Armstrong is a distinguished research professor of sociology at York University. She was the principal investigator of two recent studies: Re-imagining Long-term Residential Care: An international study of promising practices, and Healthy Ageing in Residential Places. Armstrong also serves on the technical committee developing proposals for long-term care standards for the Health Standards Organization and is a member of the Congregate Care Settings Group, the Canadian Health Coalition, and the Members Council of the Canadian Centre for Policy Alternatives. 

For more information about her work go to: York University