Setting the Context
Supporting older Canadians to age in their place of choice depends on having access to appropriate care services when and where they need them. Over the last decade, there has been a significant re-orientation of health care delivery from institutional settings, like hospitals and nursing homes, toward more home and community-based settings (see Figure 4)[1].
A poll conducted by Ipsos Reid on behalf of the Royal Bank of Canada (RBC) on Canadians and retirement revealed that 88% of retired older adults reported wanting to stay at home.[1] Despite this, there is a general recognition that the home and community care needs of older Canadians are inadequately met.
One survey found that approximately 919,000 (3.3%) of Canadians over the age of 18 were receiving formal home care services in the preceding 12 months, with 433,000 reporting having perceived unmet needs.[2]
The above estimated number of Canadians receiving formal home care services figures may also be an underestimate, given that a number of Canadians who could benefit from the support of government-funded home care services may not even know how best to access them or choose not to access whatever is available because they don’t feel it would adequately meet their needs.
Furthermore, it has been demonstrated that there are still many older Canadians who are prematurely institutionalized in nursing homes due to challenges in accessing even basic home and community care supports or other more general appropriate support services. Indeed, the lack of adequate home and community care services that can support individuals’ activities of daily living (ADLs) is not only a strong predictor of institutionalization, but also an extremely strong predictor of overall utilization of health care services for older adults.[3],[4],[5] Across Canada there have been varied approaches to bridging the unmet needs gap to support older Canadians’ health and ADL needs in their homes. One of the latest promising approaches to address access to care issues is the development of models of care leveraging community paramedics, especially in more rural and remote communities (See Case Study 2[6],[7],[8]).
The population of older Canadians is growing, and many are living far longer and with more complex and often inter-related health, social, and functional issues than in previous generations. Meeting the rapidly growing need for home and community care services is becoming increasingly challenging. Additionally, the growing need for more robust home and community care services must be understood relative to the need for institutional-based care, such as assisted living, acute and long-term care services.
Case Study 2. Innovative Approaches to Home and Community Care with Community Paramedicine
While waiting for placement in a nursing home, some older adults make frequent contact with the health care system and have high rates of emergency department use. As a result, in the rural town of Deep River, Ontario, the County of Renfrew Paramedic Service launched a unique community paramedicine program with funding from the Champlain Local Health Integration Network (LHIN) to support older adults who are eligible for or awaiting a nursing home placement to stay in their own homes longer. Through this cost-effective program, paramedics in association with other community partners, developed a system to provide 24-hour flexible and proactive supportive and enhanced home-based primary and community care services to these older adults – with impressive results. The program reduced overall emergency department and hospital utilization and improved the health status of individuals such that it delayed or even completely avoided admissions to the local nursing home. This paramedicine program is not the first or last of its kind, with a growing number of similar initiatives being developed across the country.
Figure 4. Conceptual Framework Supporting Future Long-Term Care Provision in Care in Canada [9]
Avoiding inappropriate nursing home admissions and inappropriate stays in acute care settings amongst older Canadians has become a significant policy and health services research focus across Canada. It is estimated that 14% (7,500) acute care hospital beds per day in Canada are being occupied by individuals identified as alternative level of care (ALC) patients – referring to individuals who no longer require the intensity of care services where they are located.[10] The vast majority of ALC patients are older Canadians who are ready to be discharged from hospitals but for whom no appropriate home and community support or nursing home services are available. [11] Current estimates predict that freeing acute care resources through providing more appropriate levels of care for older Canadians could result in $2.3 billion in annual savings for use elsewhere in the health care system.[12] Several examples of program and policy interventions targeting ALC issues are emerging throughout Canada. For example, Ontario’s Home First policies, which were subsequently adopted in a number of other parts of the country, aim to, “identify individuals at high risk for institutionalization in order to provide adequate supports to enable successful transitions back to one’s home or for people to remain in their homes in the first place”.[13] Within the first two years of its Home First initiatives, Ontario saw its overall supply of nursing home beds decline by 2.7% amongst its fastest growing segment of the population aged 75 years and over. At the same time, demand for nursing homes declined 6.9%, while the placement rate into nursing home beds had declined 26% amongst Ontarians 75 years and over.[14]
While understanding the interface of services across the continuum of care is complex, legislative factors further complicate realizing the potential role of home and community care, and nursing home services in reducing ALC days. The Canada Health Act specifically focuses on the provision of hospital and physician services and does not address the universal provision of home, community, and nursing home care including the provision of palliative care. Thus, policies must be strengthened to ensure their regulation, organization, and funding can meet the needs of older Canadians.
Table 9 summarizes descriptions of income-based home care services, public expenditure on home care, as well as proportion of individuals over 85 years of age in nursing homes and the number of nursing home beds by province/territory. Unexpectedly, increases in the proportion of public spending for home and community care do not always correspond with lower rates of nursing home placement. For example, while provinces such as Prince Edward Island spend a very low proportion on home and community care and have the highest rates of nursing home placements, other provinces (e.g. Newfoundland and Labrador) spend a higher proportion on home and community care yet still have higher than average rates of nursing home placement. These figures demonstrate the importance of understanding context in health system capacity planning.
While there are many capacity challenges, the unmet palliative and end-of-life care needs of Canadians run across the continuum of care with respect to home, community, and institutional-based services. Palliative, hospice, and end-of-life care can be understood as services which, “aim to relieve suffering and improve the quality of living and dying”.[15] The Canadian Hospice Palliative Care Association cite that, “only 16-30% of Canadians who die currently have access to or receive specialist hospice palliative and end-of-life care services”.[16] Beyond helping individuals to die with dignity and in less discomfort, evidence for the provision and accessibility of palliative care services – be they delivered in the home or in an institutional setting – suggests there are significant overall systemic cost savings that could be realized for the health, social and community care systems by providing these services.[17]
With the advent of the unanimous ruling in 2015 by the Supreme Court of Canada that individuals have the right to a provider-assisted death also known as Medical Assistance in Dying (MAID)[18], end-of-life care service provision must be reimagined. Future research must be directed toward understanding resource allocation and the systemic implications of providing universal coverage for MAID, as universal coverage and access towards palliative do not exist across Canada, especially in many rural and remote areas. Currently, research shows that physician-assisted death could save between $34.7 million and $138.8 million annually in Canada, which exceeds the estimated $1.5–$14.8 million in direct costs associated with its implementation.[19]
Exploring how to leverage knowledge and evidence from other jurisdictions where physician-assisted death has been available for some time (e.g. the Netherlands, Belgium, Luxembourg and various U.S. States) may also go some way to inform how to better plan and support the provision and right balance of MAID and palliative care.
Across all levels of health care service delivery, access to appropriate and high-quality care for older Canadians not only directly impacts the quality of life of individuals, it can also deliver significantly improved patient and system outcomes and costs.
Table 9. Income-based Home Care Service Delivery Models in Canada & Nursing Home Use by Province/Territory (2011)
Province/Territory |
Description of Income-Based Model of Funding where In Place[20] |
Public Expenditure on Home Care ($ millions), percentage of total HEALTH CARE SPENDING as of 2012[20] |
Proportion of population over 85 yrs in NURSING HOMES by province (male %, female %)[22] |
Total number of publicly funded NursinG HOME beds by province (N)[23] |
British Columbia |
Home support is income tested with the exception of two weeks post-acute home support or palliative care. |
$721, 4.5% |
(10.6, 17.3) |
24,616 |
Alberta |
Assessed professional case management, professional health, personal care and caregiver support services are provided without charge. A consistent provincial process and fee schedule is under development to determine client charges for home and community support services. |
$402, 2.4% |
(13.1
, 19.7) |
14,654 |
Saskatchewan |
For meals, homemaking and home maintenance, fees are charged (according to income testing) to clients after their first 10 units of service in a month. Subsequent units of service are charged based on client’s adjusted monthly income. |
– |
(14.7, 21.5) |
8,944 |
Manitoba |
– |
$290, 5.8% |
(14.5, 24.6) |
9,833 |
Ontario |
– |
$1,988, 4.4% |
(14.3, 24.4) |
75,958 |
Quebec |
– | $1,407, 5.4% | – |
46,091 |
New Brunswick |
Income testing for long-term supportive and residential care services according to net income. Client contribution required based on income testing for home support services through Social Development. |
$187, 6.4% |
(15.8, 24.1) |
4,391 |
Nova Scotia |
Has no fees for clients whose net income falls within or below the designated Home Care Nova Scotia client income category or who are in receipt of income-tested government benefits (e.g., Guaranteed Income Supplement, Income Assistance, Family Benefits). No fees charged for nursing services or personal care services provided by RNs or Licensed Practical Nurses or for physician services provided through Medical Services Insurance. |
$196, 5% |
(10.4, 20.9) |
5,986 |
Prince Edward Island |
– |
$13, 2.3% |
(21.3, 32.8) |
978 |
Newfoundland |
No income testing for those requiring professional health services or short-term acute home support but applies a financial assessment for long-term home support services. |
$136, 5.6% |
(22.5, 33.3) |
2,747 |
Northwest Territories |
– |
$4.6, 1.6% |
– |
– |
NunavutTerritory |
– |
$7.8, 2.8% | – |
– |
Yukon Territory |
– |
$4.5, 2.2% | – |
– |
In the 2015 iteration of this report, it was recommended that the federal government use the CHT agreement as a vehicle for incentivising targeted plans for health services provision in the areas of home, community, and palliative care. It was also recommended the federal, provincial, and territorial governments work together to set national standards, targets, and benchmarks with comparable and meaningful measures that can clearly illustrate progress.
In Budget 2017, the federal government announced $6 billion over 10 years to support the expanded provision of home care services across the provinces and territories tied to the CHT. As part of this plan, governments agreed to develop common performance indicators and mechanisms for annual reporting to citizens, as well as a detailed plan on how the funds will be spent, over and above existing programs.[24] As such, the Federal/Provincial/Territorial health ministers have since endorsed a set of indicators for measuring access to home and community care recommended by the Canadian Institute for Health Information (CIHI) and were to begin public reporting on those that are available beginning in 2019-2020.[25] In November 2019, CIHI released its first report on initial results for three indicators, including the indicator on hospital stay extension due to untimely access to home care.[26] The results showed that between 2017 to 2018, 1 in 12 hospital patients in Canada had to stay in hospital until home care services or supports were ready. The median length of extended stay for patients discharged to home care was seven days. However, there was a large variation in length of stay between each territory and province depending on the availability of home services and supports, ranging from 3 days in Manitoba to 24 days in the Northwest Territories.
One criticism of the current investments in the expansion of home and community care occurring across the provinces and territories is the apparent focus around supporting hospitals in managing ALC patients while neglecting to focus on the active development of more preventative models of home and community-based care.[27]
What Are the Issues?
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A Lack of Access to Support Services for Individuals’ Activities of Daily Living (ADLs) Negatively Impacts Health, Causes Additional Stress for Family and Friends, and Has Systemic Cost Implications
While health care services are extremely important, evidence suggests that older adults who have inadequate access to home and community care supports for activities of daily living (ADLs) – such as personal care, cooking, cleaning, and transportation – ultimately end up requiring more health care resources.[28] Much of this care is provided by family members, friends, unpaid caregivers, and lower paid and less regulated health care providers like personal support workers or health care aides.For families and friends of older Canadians, meeting needs that are under-supported by local home and community care providers can lead to increased caregiver burden, stress and anxiety. Furthermore, unmet needs can present significant out-of-pocket costs to friends and family. For example, the Canadian Hospice and Palliative Care Association estimate that 25% of palliative care costs associated with providing care in the home are covered by family members.[29] The NIA’s recent report The Future Co$t of Long-Term Care in Canada also estimated that about 75% of total home care hours are currently being met by unpaid caregivers, and the demand for potential unpaid caregivers will grow by 43% from 2019 to 2050.[30]
Negative outcomes associated with unmet care needs have far reaching effects. Most immediately, individuals with unmet home care needs are more likely to experience injuries (specifically increased risk of falls), depression, reduced morale, lower self-reposted health status, feelings of decreased control, smaller social networks and an inability to prepare food. It has been also well-documented that having unmet needs and having to depend on others for one’s ADLs have been associated with more doctor visits, greater numbers of emergency department visits, hospital admissions, ALC days, institutionalization, overall morbidity and mortality, and premature death.[31],[32],[33],[34],[35],[36] For certain age-related illnesses such as dementia, the effects of unmet care needs increase the likelihood of an individual’s premature placement into a nursing home, and earlier death.[37]
Understanding that supports for daily living are just as important as more clinically-oriented forms of home care will be important in considering the current and future provision of home care services. Furthermore, understanding the need to support families and caregivers in order to alleviate caregiver burden whenever possible, will increase the chances that a person will be able to continue ageing in place.
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Canada is Facing Significant and Unprecedented Workforce Challenges to Delivering Care
Human resources are a particularly challenging issue when it comes to the delivery of care for older adults in Canada. This includes both the paid and unpaid workforce. Specifically, attracting and retaining care providers for older Canadian is a well-documented challenge.[38] According to a survey by the BC Care Providers Association, 71% of continuing care sector respondents identified recruitment to be extremely challenging and 74% believed that retention was very or extremely challenging. [39] A recent in-depth series examining the future of long-term care in Canada identifies the following challenges around the paid workforce: turnover/retention/recruitment; job satisfaction; poor working conditions, including understaffing and violence; training; and, compensation.[40]
The role of unpaid caregivers is also key: CIHI reports that 98% of older adults receiving publicly funded care also had one or more unpaid caregivers involved in their care.[41] Recall that ‘unpaid caregivers’ (and ‘caregivers’) refer to individuals who provide care to another person primarily because a personal relationship exists while paid ‘care providers’ refer to those who provide care due to a financial relationship (see Box 1 in Evidence Brief #1 for full definitions).[42] According to the Government of Canada, there are approximately 6.1 million Canadians (35% of employed Canadians) working and balancing caregiving duties.[43] Despite high and increasing rates of labour participation amongst women in Canada, women still take on a larger share of caregiving duties. It is estimated that 54% of Canadians caregivers are women and have reported spending 20 hours or more per week providing care, while men average less than one hour per week [44] (Read more about this in Evidence Brief #12 and #13).
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Poor Financing of Long-Term Care Results from Unsustainable Funding and Inappropriate Funding Rules
Across Canada, there is an increased demand for services while capacity and resources remain limited. Governments are balancing many challenges including escalating costs due to increased acuity of clients, increasing public expectations for home care services, ensuring equitable services across jurisdictions and geography, and maintaining the supportive/preventive elements of home care and community services within current cost-cutting environments.[45] A lack of resources and funding to address these challenges put the sustainability of the system as a whole at risk.[46] One area of interest when looking at the financing of care is funding models for delivery of care. In Canada, the delivery of health, social, and community care services has traditionally been through non-means-tested universal programs.[47] Given that the current care being made available is often not adequate to meet current or future demand, a review of the appropriateness of current funding models would be beneficial.[48]
Inappropriate funding rules are also an area of interest when looking at sustainable funding for the provision of care. Currently, funding rules do not appropriately align with the requirements of care provision.[49] For example, according to the Registered Nurses Association (RNAO), if a resident is incontinent, funding is provided for the care and the supplies, but not provided for the staff hours required to implement more appropriate practices, such as prompted toileting at regular intervals to reduce the frequency of incontinence.[50] The RNAO also argues that the current funding rules disincentivize improved patient outcomes as nursing home, in some case, may be financially penalized for delivering improved patient outcomes.[51]
Evidence-Informed Policy Options
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Enable Evidence-Informed Person-Centered Systems of Home, Community, and Nursing Home Care
Enabling evidence-informed person-centered systems of care will require meeting the needs of both care recipients and their unpaid caregivers. Care models need to be more flexible, adaptable, coordinated and inclusive of the needs of older adults and their unpaid caregivers.[52] Utilizing the concept of ageing in place requires the use of a person-centered lens and the recognition that care must be uniquely centered around the individual. The WHO highlights that for some, ageing in place may mean staying in the same home, but for others it may mean moving to a safer or adapted home where care is available; however, the focus should always remain on the older adult and what is right for them.[53] Caregivers’ needs should also be recognized on an individual basis. Therefore, governments should commit to a foundational principle of ensuring that home, community, and nursing home systems of long-term care prioritize the needs and preferences of both caregivers and care recipients.[54]
-
Support System Sustainability Through New Financing Arrangements and a Strong Workforce
The home, community, and nursing home systems of long-term care do not currently meet the needs of Canadians who wish to age in place. As it stands, a recent NIA report that examined the current and future costs of long-term care in Canada using microsimulation methods projected that costs of long-term care could rise from $22 billion in 2019 to at least $71 billion by 2050. [55] Unpaid care caregivers will need to increase their efforts by 40% to keep up with care needs, as the number of seniors needing support is projected to grow by 120% by 2050.[56]
Strengthening the workforce tasked with the care of older adults will therefore require addressing the issue of paid and unpaid caregivers (see Evidence Brief #13 and #14 for recommendations on unpaid caregivers). In relation to care providers, the government should consider improving immigration policies to enable recruitment and retention of international care providers to increase capacity in the system.[57]
Despite significant investments in the provision of home, community, nursing home, and palliative care services, it is thought that more spending may be required to achieve growth and build capacity in the sector to support a health care system that works for Canadians.[58] To further support system sustainability, it is recommended that all levels of government come together with stakeholders to strengthen the financing of home, community, nursing home, and palliative care services to enable care that is preventative and supportive.[59]
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Leverage Technology to Improve Delivery of Long-Term Care
Technological solutions can also play a role in supporting the overall sustainability of healthcare systems. However, the research around them also stresses that new technology must be co-designed with care providers and care recipients to improve its overall effectiveness, efficiency and intended outcomes.[60] Canada has invested in tele-homecare programs to allow providers such as nurses or paramedics to monitor patients living with chronic health conditions such as congestive heart failure and chronic obstructive pulmonary disease[61], in addition to other telemedicine networks that connect patients to providers virtually, such as the Ontario Telemedicine Network[62]. There are also a growing number of technologies that can address functional challenges to enable more independent living for older adults, such as apps that help individuals monitor and manage chronic conditions and motion sensors that can detect falls[63]. Assistive technologies are important to support care transitions and assist in a person’s ability to perform their daily activities in a way that also improves their function, safety, independence, participation and social inclusion. In times when visitors were not being allowed to visit residents in care home settings, such as during the COVID-19 pandemic, technology such as video-conferencing became one key way to assist residents in staying connected to their families.
Equitable access to assistive technologies across Canada remains an issue, as different definitions for assistive technologies exist across provinces and territories, leading to confusion in eligibility and funding.[64] A standardized definition for assistive technologies in legislation, policies and programs across Canada will allow for increased awareness of what is available and what is covered within each jurisdiction.[65]
Governments can fund further research and development into technologies to enable older adult at increased risk of losing their independence to live at home. In addition, jurisdictions can develop an integrated approach to include assistive technologies as a part of the solutions available in home and community care settings, such as adapting government procurement strategies with larger buying power to allow for scale, spread, and reduction in costs for home and community care.
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Support Alternative Care Models to Allow Aging in the Community
The COVID-19 pandemic has highlighted an increased need for alternatives to LTC or nursing homes as the primary means of supporting older adults. Several alternative LTC models have been well-researched. The United States’ Program for All-Inclusive Care of the Elderly (PACE) is one such example that was first developed in San Francisco and has since spread to more than 133 organizations across the 31 U.S. States.[66] This model allows older adults to remain living in their home or in an assisted living environment while care is provided through an adult day health centre that consists of an interdisciplinary team (e.g. driver, dietician, physiotherapist, nurse) as well as in-home services as required.[67] The PACE model has reduced future LTC home placement and enabled more older adults to live in their own communities for less overall costs despite experiencing increased cognitive and overall impairment.[68]
Future LTC policies in Canada should encompass alternative models of care to facilitate a shift from expensive institutionalized care towards more cost-effective home and community-based models of support for older adults that require more intensive care.
References
[1] For the purposes of this brief, we’re considering the paid activities referred to in Figure 4. See Unpaid Caregivers brief for unpaid home and community care information.
[1] Ipsos Reid. (2013). RBC Retirement Myths and Realities Poll 2013(Rep.). Retrieved May 13, 2019, from Royal Bank of Canada website: http://www.rbc.com/newsroom/_assets-custom/pdf/1024-13-myths-poll.pdf
[2] Gilmour, H. (2018). Unmet home care needs in Canada. Statistics Canada, Health Reports, 29(11), 3-11. Retrieved from: https://www150.statcan.gc.ca/n1/pub/82-003-x/2018011/article/00002-eng.pdf
[3] Levesque, L. et al. (2004). Unmet needs for health and community-based services for the elderly aged 75 years and over. Canadian Health Services Research Foundation. Available at: http://www.cfhi-fcass.ca/Migrated/PDF/ResearchReports/OGC/levesque_e.pdf
[4] Dawson, M., Lentzner, H., Dwason Weeks, J. (2001). Unmet needs for personal assistance with activities of daily living among older adults. The Gerontologist. 41(1), pp. 82-8.
[5] Sands, L. et al. (2006). Rates of acute care admissions for frail older people living with met versus unmet activities of daily living needs. Journal of the American Geriatrics Society. 54(2), pp. 339-44.
[6] Nolan, M et al. (2012). Year in Review 2011-2012. Emergency Medical Services Chiefs of Canada. 57-68.
[7] County of Renfrew Emergency Medical Services. (2012). Community Paramedicine Briefing Note. Submission to Dr. Sinha, September 11, 2012.
[8] Matthew S. Leyenaar, Ryan Strum, Mashiat Haque, Michael Nolan, and Samir K. Sinha on behalf of the Ontario Community Paramedicine Steering Committee. (2019). 2019 Report on the Status Of Community Paramedicine In Ontario. Available at: www.ontariocpsecretariat.ca
[9] National Institute on Ageing (2019). Enabling the Future Provision of Long-Term Care in Canada. Toronto, ON: National Institute on Ageing White Paper.
[10] Sutherland, J. M., & Crump, R. T. (2013). Alternative Level of Care: Canada’s Hospital Beds, the Evidence and Options. Healthcare Policy,9(1). doi: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3999549/pdf/policy-09-026.pdf
[11] Sutherland, J. & Crump, R. (2011). Exploring alternative level of care (ALC) and the role of funding policies: An evolving evidence based for Canada. Canadian Health Services Research Foundation. Available at: http://www.cfhi-fcass.ca/sf-docs/default-source/commissioned-research-reports/0666-HC-Report-SUTHERLAND_final.pdf?sfvrsn=0
[12] Simpson, C., Caissie, M., & Velji, K. (2015). Canada needs a national seniors’ strategy. Retrieved January 23, 2019, from https://www.thestar.com/opinion/commentary/2015/01/29/canada-needs-a-national-seniors-strategy.html
[13] CIHI. (2012). Seniors and alternate level of care: Building on our knowledge. Available at: https://secure.cihi.ca/free_products/ALC_AIB_EN.pdf
[14] Sinha, S. (2012). Living longer, living well. Available at: http://www.health.gov.on.ca/en/common/ministry/publications/reports/seniors_strategy/
[15] Levesque, L. et al. (2004). Unmet needs for health and community-based services for the elderly aged 75 years and over. Canadian Health Services Research Foundation. Available at: http://www.cfhi-fcass.ca/Migrated/PDF/ ResearchReports/OGC/levesque_e.pdf
[16] Canadian Hospice Palliative Care Association. (2014). CHPCA fact sheet – hospice palliative care in Canada. Available at: http://www.chpca.net/projects-and-advocacy/hpcfirst.aspx
[17] Hodgson, C. (2012). Cost-effectiveness of palliative care: A review of the literature. Available at: http://hpcintegration.ca/resources/discussion-papers/economic-review.aspx
[18] Government of Canada. (2020). Medical Assistance in Dying. Available at: https://www.canada.ca/en/health-canada/services/medical-assistance-dying.html
[19] Trachtenberg, A.J. & Mann, B. (2017). Cost analysis of medical assistance in dying in Canada
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[20] Sinha, S. (2012). Living longer, living well. Available at: http://www.health.gov.on.ca/en/common/ministry/publications/reports/seniors_strategy/
[21] Canadian Home Care Association. (2013). Portraits of home care in Canada. Available at: http://www.cdnhomecare.ca/content.php?doc=274.
[22] McGregor, M. & Ronald, L. (2011). Residential long-term care for Canadian seniors: Nonprofit, for-profit does it matter?. IRPP Study. Available at: http://irpp.org/wp-content/uploads/assets/research/faces-of-aging/residential-long-term-care-for-canadas-seniors/IRPP-Study-no1.pdf
[23] McGregor, M. & Ronald, L. (2011). Residential long-term care for Canadian seniors: Nonprofit, for-profit does it matter?. IRPP Study. Available at: http://irpp.org/wp-content/uploads/assets/research/faces-of-aging/residential-long-term-care-for-canadas-seniors/IRPP-Study-no1.pdf
[24] Government of Canada. (2017). Building a Strong Middle Class: Budget 2017. Retrieved February 14, 2019, from https://www.budget.gc.ca/2017/docs/plan/budget-2017-en.pdf
[25] Canadian Institute for Health Information. (2018). Shared Health Priorities. Retrieved from: https://www.cihi.ca/en/shared-health-priorities#indicator
[26] Canadian Institute for Health Information. (2019). Common Challenges, Shared Priorities: Measuring Access to Home and Community Care and to Mental Health and Addictions Services in Canada. Available at: https://secure.cihi.ca/free_products/shp-companion-report-en-1.pdf
[27] National Institute on Ageing. (2019). Enabling the Future Provision of Long-Term Care in Canada. Toronto, ON: National Institute on Ageing White Paper.
[28] Levesque, L. et al. (2004). Unmet needs for health and community-based services for the elderly aged 75 years and over. Canadian Health Services Research Foundation. Available at: http://www.cfhi-fcass.ca/Migrated/PDF/ResearchReports/OGC/levesque_e.pdf
[29] Canadian Hospice Palliative Care Association. (2014). CHPCA fact sheet – hospice palliative care in Canada. Available at: http://www.chpca.net/projects-and-advocacy/hpcfirst.aspx
[30] MacDonald, B.J., Wolfson, M., and Hirdes, J. (2019). The Future Co$t of Long-Term Care in Canada. National Institute on Ageing, Ryerson University
[31] Levesque, L. et al. (2004). Unmet needs for health and community-based services for the elderly aged 75 years and over. Canadian Health Services Research Foundation. Available at: http://www.cfhi-fcass.ca/Migrated/PDF/ResearchReports/OGC/levesque_e.pdf
[32] Sands, L. et al. (2006). Rates of acute care admissions for frail older people living with met versus unmet activities of daily living needs. Journal of the American Geriatrics Society. 54(2), pp. 339-44.
[33] Millan-Calenti, J. et al. (2010). Prevalence of functional disability in activities of daily living (ADL), instrumental activities of daily living (IADL) and associated factors, as predictors of morbidity and mortality. Archives of Gerontology and Geriatrics. 50(3), pp. 306-10.
[34] Hoover, M. & Rotermann, M. (2012) Seniors’ use of and unmet needs for home care, 2009. Statistics Canada Health Reports. 23(4) pp. 3-8. Available at: http://www.statcan.gc.ca/pub/82-003-x/2012004/article/11760-eng.htm
[35] Levesque, L. et al. (2004). Unmet needs for health and community-based services for the elderly aged 75 years and over. Canadian Health Services Research Foundation. Available at: http://www.cfhi-fcass.ca/Migrated/PDF/ResearchReports/OGC/levesque_e.pdf
[36] CIHI. (2012). Seniors and alternate level of care: Building on our knowledge. Available at: https://secure.cihi.ca/free_products/ALC_AIB_EN.pdf
[37] Gaugler, J., Kane, R., Kane, R., Newcomer, R. (2005). Unmet care needs and key outcomes in dementia. Journal of the American Geriatrics Society, 53(12), pp. 2098-2105.
[38] CALTC. (2018). Long Overdue: Improving Seniors Care in Canada. Retrieved from: https://caltc.ca/wordpress/wp-content/uploads/2018/11/CALTC-budget-submission-ONLINE.pdf
[39] BC Care Providers Association. (2018). The Perfect Storm: A Health Human Resources Crisis in Seniors Care. Retrieved from: https://bccare.ca/wp-content/uploads/2018/04/The-Perfect-Storm_BCC3-2018-Report-FINAL.pdf
[40] National Institute on Ageing. (2019). Enabling the Future Provision of Long-Term Care in Canada. Toronto, ON: National Institute on Ageing White Paper.
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