Originally published at Ottawa Citizen
Most Ontarians can be excused for confusing retirement homes with long-term care homes, since they both house older adults with care needs. The similarities are numerous: Both provide care to seniors, are regulated by government with regard to care, and have roughly equivalent numbers of homes and residents across the province.
While some retirement homes focus on more independent seniors who require less care, others have stepped up their offerings in assisted living and dementia care – some even in palliative care – to become direct substitutes for long-term care homes.
In fact, so similar are the issues and challenges facing the two groups that they hold an annual joint conference called “Together We Care.” It’s Canada’s largest gathering of long-term care and retirement home professionals and it took place recently in Toronto. I made a point of attending, having recently finished a doctoral dissertation that compares services in the two sectors.
Despite the similarities, a major difference between the sectors remains government funding. LTC homes receive funding from the Ministry of Health and Long-term Care of about $3,500 per month for each resident’s nursing, therapies and food. Retirement home residents, on the other hand, cover their care costs principally out of their own pockets. In both settings, the cost of accommodation or rent, as distinct from care, is generally the responsibility of the resident, though some LTC residents are eligible for subsidies based on income.
I listened with interest as both Premier Kathleen Wynne and Health and Long-Term Care Minister Helena Jaczek addressed the plenary session by recounting recent budget pledges directed at the long-term care sector, including 30,000 new beds over the next 10 years and a target of four hours of daily care per long-term resident. But the elephants in the room were the hundreds of representatives from the retirement home sector, who did not figure into any of this new funding.
How does this apparent inequity continue to exist between residents in the two sectors? Part of the reason lies in the regulatory structure. Though the Retirement Homes Act and its regulations prescribe standards for security, safety and care that resemble those for long-term care homes, retirement homes are under the jurisdiction of a different ministry, the Ministry of Seniors Affairs, which does not have the financial resources of the Ministry of Health and Long-Term Care.
In addition, numerous myths about retirement homes persist. One is that retirement home residents “choose” the private pay route and therefore the care costs that come with it. With respect, no one chooses to pay for care that is otherwise funded for others, any more than one would ask to pay their own hospital bill in Ontario. More correctly, retirement home residents choose a particular domicile and begrudgingly pay the care costs that come with it.
The reality in Ontario is that many seniors enter or remain in a retirement home by default. The wait list of people assessed as eligible for long-term care beds – those requiring 24-hour care or monitoring – currently numbers 34,000 and all must find an alternative in the meantime.
No one chooses to pay for care that is otherwise funded for others, any more than one would ask to pay their own hospital bill in Ontario.
Another myth is that retirement home living is the expensive luxury of the affluent. But analysis shows that the average cost of high acuity care and accommodation in a retirement home in Ontario is competitive with that in a long-term care room of equivalent size. It is only after factoring in the government subsidy that the long-term care alternative becomes about half the cost of the retirement home room.
Some will argue that retirement home residents can always call on the resources of publicly funded home care, but recent research indicates that such access is constrained. A 2017 study conducted in the Hamilton-Niagara area showed retirement home residents received significantly fewer hours of publicly funded home care than those in private homes, despite having higher care needs.
Let’s recognize that Ontario has a two-tier system for seniors’ residential care. By itself, this is not problematic. After all, many European countries whose health care systems are ranked well above ours run parallel public-pay and private-pay systems. The real problem for Ontario may be the lack of any means testing with respect to the care portion of our residential care. Long-term care residents receive the same funding for care, regardless of how wealthy they are, and retirement home residents pay the full cost of their care regardless of how poor they are. Without an adequate means test based on assets or income, the determination of who pays for care is based not on need, but on who is best able to navigate the system.
There are many ways to address the inequity for retirement home residents who currently pay for high levels of care. Some of the more promising ones being discussed involve self-directed care, where the person – not the institution – is afforded a budget for care based on their assessed need. Individuals can take their funding “voucher” to an eligible care provider instead of waiting for care dollars to trickle down to them.
As Jaczek noted, the population of Ontarians over 90 is set to quadruple by 2040. With this will come growth in demand for seniors’ care services. Problems regarding care funding will also compound without clear policies to address equity of access to public dollars.