Canada’s long-term care facilities need an overhaul. Non-profits could be the bridge to a better system.

In spite of the horrors of Canada’s long-term care (LTC) system during the COVID-19 pandemic, the wait list for people hoping to live in Yee Hong Geriatric Care’s facilities is still 4,000 names deep.

Dr. San Ng, CEO of the large non-profit facility focused on Asian seniors in the Greater Toronto Area, says the facility did rather well during the pandemic. According to statistics compiled by Nora Loreto, an independent researcher, Yee Hong has suffered just five COVID-related resident deaths since the start of the pandemic. “People come to Yee Hong and actually live longer than the average age of other long-term care organizations,” Ng told Future of Good.

The median wait time for LTC facilities in Ontario is anywhere from 90 days for Ontarians coming from a hospital to 159 days for those arriving from home living, according to Ontario government health data (although individual health regions vary quite widely. In Waterloo-Wellington, health advocacy groups found the median wait time for long-term care is over five years). 

Ng says the average wait time for Lee Hong is between 2.5 to 4 years. That’s a testimony to Yee Hong’s dedication during the pandemic, she says — in not allowing staff to work across multiple companies, requiring COVID-19 vaccinations, and proactively donning PPE in the early days of the pandemic — but it also shows just how desperate Canadians are for good-quality long-term care overall.  

As a whole, Canada’s LTC system did an abysmal job of protecting its residents and staff from COVID-19, a conclusion denied by every LTC organization Future of Good spoke to for this story but borne out by data from independent researchers, governments, and regulators.  

More than 80 percent of Canadians who died of COVID-19 in the first three months of the pandemic were LTC residents, according to the Canadian Institute for Health Information (CIHI). Only about 18 percent of all Canadian COVID infections occurred among LTC residents, but, in the early months of the pandemic, Canada’s proportion of LTC deaths to the rest of the population was more than double the OECD average. It eclipsed LTC death rates as a percentage of overall COVID fatalities in Germany (34 percent), Portugal (25 percent), the U.S. (31 percent), the Netherlands (15 percent), Hungary (7 percent), and Norway (58 percent). After the first year of the pandemic, the CIHI estimated 14,000 residents, connected family members, and LTC workers had died of the virus.

The death toll, as well as horrific accounts of conditions inside some LTCs, prompted some Canadian politicians to demand a complete overhaul of the LTC system. A few even called for for-profit operators to be taken over by the government because of the particularly high death rates seen in their facilities. But the fact is that there is little difference between non-profit and for-profit LTCs when it comes to the types of services they provide or the populations they assist, although international research has found non-profits tend to have better care outcomes.

Clearly, the current LTC system isn’t sufficient — but an overhaul that cuts out non-profit or for-profit LTCs entirely may not be possible in the short term. Canada’s population is entering an ageing boom and demand for LTC beds will skyrocket in the coming years. In order to accommodate everyone who will need a bed, LTC professional associations, an LTC operator, and healthcare experts say the sector needs a lot more funding for LTC infrastructure and better training for staff to enter this crucial field.

Public vs. private

One of NDP Leader Jagmeet Singh’s boldest moments during the recent federal election campaign was when he promised to nationalize Revera Retirement, a for-profit LTC company with one of the highest death rates among LTC operations in Canada while standing outside its headquarters in Mississauga. “My team and I will take profit out, pay long-term care workers a living wage and guarantee quality care for seniors,” he told onlookers at the August rally, according to the Mississauga News.

Much of the election campaign’s coverage of fixing the LTC system rested on the question of whether to bring the 29 percent of LTC facilities run by for-profit companies in Canada under public control. The framing of the discussion, however, hid the fact that for-profit and non-profit LTCs — which comprise about 23 percent of Canada’s LTC facilities — share a lot of similarities. Both serve similar populations — seniors unable to live in retirement homes, those with chronic illnesses, and disabled people. They’re both held to the same regulatory standards. And they also equally benefit from government funding. 

“In most provinces, the government funds long-term care facilities the exact same whether they are public, private not-for-profit, or private for-profit,” says Chris Parsons, provincial coordinator of the Nova Scotia Health Coalition and a former LTC dietary aide. “The private long-term care industry in Canada is entirely supported by public money.”

However, non-profits and for-profits do have some differences in care quality and outcomes. “Long-term care research, in Canada and internationally, has strongly pointed to a link between for-profit long-term care and inferior care quality,” wrote Kristen Pue, a postdoctoral fellow in philanthropy and non-profit studies at Carleton University, in an email to Future of Good. “Nonprofit and government LTC is generally associated with higher quality, although we know less about nonprofit long-term care specifically.”

In an academic paper published in March by Pue and two other academics in Canadian Public Policy, the co-authors constructed a model to predict how many LTC residents alone would have died under a totally for-profit and totally non-profit system. Nearly 4,000 residents had died of COVID-19 at the time in Ontario, but only 2,822 would have perished under a completely non-profit system— or 4,977 under a completely for-profit sector. By contrast, their paper found only 1,348 residents would have died if all LTC facilities had been government-run. “So even though the predicted deaths are highest in for-profit long-term care facilities, non-profits also fare badly compared to government,” Pue and her colleagues later wrote in The Conversation. 

There’s also the profit motive. While LTC associations say for-profits are just as devoted to their staff as non-profits and that profits in care homes aren’t that high to begin with, the former is responsible for generating value for shareholders whereas non-profits are supposed to reinvest in their operations. Profits are seen by some critics as the motive, rather than a bonus, of for-profit long-term care. 

Ng says there are common perceptions about the differences between for-profit and non-profit facilities “that aren’t validated through data.” But some LTC leaders believe for-profit and non-profit LTC facilities, as well as public-run ones, can work together. They share many of the same problems: inadequate infrastructure, a lack of qualified staff, and long waitlists.

Donna Duncan, CEO of the Ontario Long Term Care Association — which represents non-profit, for-profit, and municipally-funded providers across the province — says care operators are trying to solve these problems, rather than talk about divisive issues like the nationalization of long-term care. “Let’s look at what we’re doing to ensure we’re focused on outcomes and safety and quality care,” Duncan told Future of Good in an interview. “And let’s also work together to reimagine what care for seniors looks like.”

The aging boom

Getting LTC right in Canada is absolutely vital in the coming years, as Canada — like many Global North countries — faces a sharp rise in retired seniors. According to an RBC Economics report, the proportion of provincial healthcare spending on senior care is expected to jump from 45 percent to 55 percent over the next decade. The proportion of working-age Canadians to seniors and young people was 2.3 to 1 in 2010. By 2030, it’ll be closer to 1.7. Adjusting will require a seismic shift in Canada’s economic strategies — and its support for the LTC system.

As it stands, Canada’s LTC system isn’t prepared. According to the Canadian Institute for Health Information, there were 2,076 LTC care homes coast-to-coast-to-coast as of March 2021 with just over 198,000 available beds — for a population of 6.8 million Canadians over the age of 65. Not all of them will necessarily move into LTC facilities, even as they age, but the shortfall is still alarming to the LTC sector. “We don’t have enough long-term care beds to meet the growing demand as we move forward,” says Michele Lowe, executive director of the Nursing Homes of Nova Scotia Association.

Ng says many long-term facilities that are currently in operation were built years ago with very little in the way of updates. “We’re not building LTC facilities fast enough,” she explains. “We’re not redeveloping them fast enough, and we’re not keeping pace with other sectors that also deliver services.” Ng also pointed out the lack of equity between pay rates in the LTC sector versus other healthcare fields. (Even before the pandemic, the personal support workers who form the backbone of LTC staff were known to be poorly paid, inadequately trained, and subject to physically demanding working conditions.)

Mike Klassen, vice-president of public affairs for the B.C. Care Providers Association, says getting more money into the sector is “absolutely vital” to brace for the coming wave of seniors needing care. “Twenty years ago, the average age of someone entering a care home might be in their late 70s,” he says. “The average age in British Columbia today is between 85 and 87, and people are living longer. They’re living at home longer. When they arrive at a care home, it’s usually because they’ve been in a hospital for a while.”

Seniors who do arrive in an LTC often have conditions such as dementia, or they’re living with illnesses that require constant care. But Klassen and other LTC association representatives say they don’t just want facilities to treat people as patients. They want facility staff who know their residents by their name, their background, their family members, their favourite foods. Juggling that personalized level of care with the heavy load Canada’s LTC system won’t be easy, but Klassen is optimistic. “In spite of the fact the sector is obviously going to get a lot larger in Canada, I want it to be so much more focused on people,” Klassen says, “and I think that’s within our grasp.

Patching up the system

Over the past 18 months, Duncan says, LTC facilities of all kinds have come together to help one another through the pandemic. Before her interview with Future of Good, she had taken part in a meeting on just that. “Our larger members were sharing with their smaller non-profit members about what they’re doing with mandatory vaccines,” she says. “Everybody’s been helping each other and we’re all in this together. We’re all serving the same types of residents. We’re all trying to navigate the same issues. At our core, we are all mission-driven.”

Establishing a national standard of care for Canada’s LTC system is something operator associations, nurses, and healthcare advocates tend to agree on, as is boosting infrastructure funding to build or maintain facilities. Then there are alternative models of care. Denmark’s system provides in-home care, as well as LTC facilities to those who require them, under a system where national and local governments cover 90 percent of the cost. Hundreds of elder care villages – mostly non-profits – across North America, Europe, and the United States allow seniors to live in their own homes while receiving elder care.

“We do think that, in the long run, the whole system should be public,” Parsons says. “But we also recognize that right now there are not-for-profit facilities that do incredible work and that are important parts of communities. They should continue to operate with more funding and better support and should be slowly integrated back into the public system.”

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