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EldercareOn the Auction Block
Alberta families pay the price
By
Wendy Armstrong
The Alberta Chapter
Consumers' Association of Canada
September 2002
Updated December 2002
The Alberta Chapter of the Consumers' Association of Canada is a provincially
incorporated non-profit consumer watchdog group. It is committed to enhancing the
quality of life for Alberta families by providing information, skills and strategies;
analysing consumer problems; championing the rights of consumers and citizens to fair
and honest dealing; and uniting consumers to ensure fairness in the marketplace. Funds
are raised through memberships, donations, and project grants.
If you wish to support the work of the Alberta Consumers' Association, please send
your donations or $25 for a membership to CAC Alberta, P. O. Box 11171, Edmonton,
AB. T5J 0P1. See membership application form at the back of report.
Eldercare On the Auction Block is available by contacting the CAC Alberta Office.
Copies of other investigative reports on health restructuring Taking Stock 1996, and
Canada's Canary in the Mine Shaft (2000) are also available for a nominal fee.
Box 11171 Edmonton, Alberta, T5J 3K4
Telephone (780) 428-3270
Fax (780) 425-9578
E-mail: cacab@ecn.ab.ca
About the author
Wendy Armstrong is a researcher, policy analyst and advocate. She recently completed
an investigation into long term care and eldercare for the Alberta Chapter. She can be
reached at wlarmstr@telusplanet.net.
Table of Contents
Executive summary
1
Introduction
4
Long term care in Alberta before 1990
5
Mixed messages behind changes in the 1990s
6
Disappearing care and coverage
6
Decoding the jargon and concepts disguising the changes
9
The promise of new public models of residential care
12
The many faces of Assisted Living: Alberta's new reality
14
Consumer protection in new markets for care
20
False assumptions challenged by the evidence
20
Conclusion
25
Recommendations 26
Endnotes
27
Appendix: Insights
29
Selected bibliography
32
Executive Summary
Since the 1990s, dramatic changes to Alberta's long term care sector have
unfolded with little media notice. Confusing jargon, mixed messages, lack of data, and
widespread differences among the province's 17 regional health authorities have
disguised much of the restructuring. Yet the changes have not gone unnoticed by
families. Today, more and more adult children and elderly spouses are finding
themselves trapped in the bewildering grip of Alberta's heavily privatized LTC
environment. What they find is rarely what they expect - or need.
In 2002 the Alberta Chapter of the Consumers' Association of Canada decided to
investigate these changes. Our research found that both residential and in-home care for
the elderly have become costly and inaccessible arenas for many people. Quality is
often grim, staffing levels are marginal. The promise of innovative models of care has
been largely eclipsed by limited access and decreasing coverage of the costs associated with
care. Many families now face an untenable choice: either give up a salary to care for a
loved one at home, or spend savings and assets to purchase private services. Indeed, so
much of the burden and cost of care has been offloaded to families that the Long Term
Care Association of Alberta is quietly advising people to purchase private LTC
insurance to protect their income and assets.
If this sounds like American-style health care, it is. And just as the
administrative costs of the U.S. system are much more expensive than Canada's, Alberta
is now spending more money managing an increasingly fragmented LTC sector, leaving
less money for actual care. Between 1997/1998 and 1999/2000, the actual money spent
on administration by regional health authorities increased by 15.2 percent - more than
for any other identified category except research and education.*
Background
Alberta began cutting public coverage of LTC in the early 1990s, first in the
name of deficit reduction, then in the name of tax cuts to encourage business to fill the
void. Construction of new nursing homes and auxiliary hospitals ceased. Between 1988
and 1998, acute care hospital beds dropped from over 14,000 to 6,300. Existing LTC
beds were used to deal with the acute care shortage; as a result traditional LTC clientele
were turned away and many terminally ill cancer patients found themselves paying per
diem charges. Long-promised home supports never materialized.
The reduction in public LTC options created a large gap between what was
needed and what was available to Alberta seniors. This gap, in turn, created immense
opportunities for real estate investors. Developers imported a new retirement housing
concept from the United States called "Assisted Living." These complexes bore little
resemblance to the Assisted Living model pioneered in Oregon in the late1980s.
Originally, Assisted Living was a progressive approach to caring for seniors and other
persons with limited abilities. The model called for a home-like setting that gave
residents control over their private space and enabled them to maintain their capacity
for self-care. The program could also include a basic package of meals, housekeeping,
and help with personal care; it could also offer the option to add on extra services.
* See End-note 25
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In Alberta today, the term Assisted Living usually refers to multi-unit
apartments with varying amounts of on-site personal supports and care - all available
for a hefty price. The original vision has been co-opted by commercial interests.
Residents are often vulnerable due to their physical and cognitive limitations, yet the
province says it has no responsibilities for licensing, tracking, or monitoring these
facilities.
Faced with a severe shortage of public LTC beds, some Alberta health
authorities are resorting to a new hybrid model, often referred to as "Designated
Assisted Living". The health authority contracts with housing owner/operators for
access to living units; the contract also covers access to 24-hour personal care, provided
by the operator. Seniors placed in these units are responsible for the largely unregulated
price of their lodging, food, utilities, and many other support expenses. Designated
Assisted Living is part of Alberta's overall strategy of unbundling and offloading the
costs normally associated with long term care.
Key concepts behind the changes
The alterations to Alberta's LTC environment were based on several key inter-
related concepts
· Distinguishing between "core" and "complementary" services: Theoretically,
this distinction would enable the public healthcare system to save money by limiting
the number of services it covers (i.e., core services). Clinics, hospitals, and nursing
homes would then be free to earn extra income by selling related services or
products at unregulated prices (i.e., complementary services).
· Separating "health" from "housing:" Alberta has gradually limited its LTC
funding obligation to a very narrow range of direct healthcare services, while
withdrawing from support costs such as housing, meals, housekeeping,
maintenance, utilities, and so on.
· The level playing field: This means making seniors in LTC facilities bear the same
costs as seniors at home. In other words, if a senior in their own home pays for
drugs, personal care, medical devices, incontinence supplies, housing, meals, and
other costs of living, they would also pay for these in a LTC setting. In reality, level
playing field means dragging public coverage of residential care down to the ever-
declining level of home care.
· Unbundling services: Unbundling is the process used to operationalize the concepts
above. The more a service can be broken down into its component parts, the more
opportunities for reducing the basic healthcare package, contracting out services,
and offloading costs to individuals and families. Not only can healthcare be
unbundled from housing, but housing and support services can be atomized and
unbundled further.
A number of false assumptions, unsupported by the evidence, regarding the merits
of pursuing these policies have also fuelled many changes. These include perceptions
about the wealth of seniors and their adult children, the affordability of private care and
private insurance, and the costs to society from pursuing these strategies.
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Conclusion and Recommendations
Alberta families are increasingly trapped in a high-priced LTC market with few real
choices. Worse still, the battered public sector has adopted many of the expensive
habits of risk-adverse private insurers, driving up the costs of administration and
leaving less money for care. Since failure to address this situation will have grave
ramifications for Alberta families, employers and communities, the Consumers'
Association recommends that the province of Alberta:
· Restore and expand universal public coverage for long term care supports, regardless
of the setting. Ensuring timely and affordable access to a wide range of quality
public LTC services is an essential step Alberta can take to enhance the
determinants of health among the elderly and their families.
· End the unbundling of services. Efforts should be made to re-integrate services,
functions, organizations, and payments. Not only will this benefit individuals and
families in need, it will also reduce administrative costs and maximize opportunities
for wholesale purchasing.
· Ensure full disclosure about LTC services. Albertans have a right to open and
complete information about availability and eligibility requirements for LTC
services and about the costs and obligations of agencies and operators supplying
services. Without this information, Alberta families and communities cannot make
responsible choices or hold suppliers and plan administrators accountable.
· License, regulate, and monitor supportive housing and Assisted Living settings. At a
minimum, supportive housing and Assisted Living operators should be licensed
regardless of their ownership status. Formal and informal complaint and appeal
mechanisms need to be visible and effective, and community groups should be
supported to take an active role in acting as advocates.
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Introduction
In the 1990s the province of Alberta undertook dramatic changes to the
organization and funding of the public healthcare system. During the same period the
Alberta Chapter of the Consumers' Association of Canada (CAC) played a pivotal role
in monitoring the impact of those changes. The association recently turned its attention
to the long term care needs of elderly people whose ability to care for themselves and
live independently has been compromised by deteriorating health. This paper covers the
highlights of our research. While our focus was primarily on services for the elderly and
their families, most of our findings are also relevant to younger Albertans with chronic
care needs.
Why is long term care a consumer issue? Simply because the direct and indirect
costs of ill health can have such an unparalleled impact on the sustainability and
financial, emotional, and physical health of families and communities. In particular,
individuals and families of those requiring long term care (LTC) face enormous stress,
suffering, and potentially ruinous expense in the absence of appropriate and affordable
care options.
Our research shows that residential LTC in Alberta has become a very costly
and ofttimes inaccessible arena for many people. Many families have been left with an
untenable choice: give up a family income to care for a loved one, or purchase needed
care in new U.S. style Assisted Living facilities - at U.S. prices. Individuals and
families requiring LTC services are unclear about what, exactly, is available - especially
from the province's new residential care models. The public system is rapidly
"unbundling" services, which greatly fragments and reduces the scope of public
coverage. At the same time, health authorities are spending more money administering
an increasingly disintegrated and privatized system, and less money funding and
delivering health services.
To help make sense of the situation, this paper looks at:
· Step-by-step changes in the 1990s that shifted the cost and burden of care to
individuals and families.
· The promise and the reality of changes in long term care, notably Assisted
Living.
· The false assumptions driving many of these changes, including the role of
the marketplace and the cost benefits of private-pay health care.
To begin, though, a brief description of some research challenges.
Missing data: Accessing data is a real challenge in Alberta. When the province delegated
responsibilities to 17 appointed regional health authorities (1995) and moved to
population-based funding (1997-98), provincial data regarding numbers and categories
almost disappeared. Lack of relevant and comparable data is a frequent theme in reports
of the Alberta Auditor General. It has also limited the reliability of Canadian Institute
for Health Information studies and created obstacles for academic-based researchers.
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Confusing language: The language used in long term care reforms is often unclear. How
the language is used is sometimes deceptive. Much is implied, but little is revealed.
Concepts are complex and nomenclature is constantly changing. There are widespread
regional variations and no official definitions. Comforting phrases such as "aging in
place" and "taking care to the patient instead of the patient to the care" often have very
different connotations than people expect. This paper attempts to disentangle the
language and shed light on some of the mixed messages, hidden meanings, and broad
themes surrounding healthcare reform in Alberta.
Long term care in Alberta before 1990
Before 1990, the province had three main options for seniors' residential care,
two within the public healthcare sector and one in the housing sector:
Auxiliary hospitals were created in 1959 as a lower-cost alternative to acute
care hospitals for patients requiring lengthy convalescence, rehabilitation, or
permanent custodial care. Although part of the hospital system, elderly residents
in permanent care were charged a token per diem in relation to the standard
federal pension income, based on the rationale that these facilities replaced the
resident's primary residence.
Nursing homes were brought into the system in 1964 to provide a somewhat
lower level of care than auxiliary hospitals. Operators of private enterprise
facilities, charitable homes, and new publicly owned homes were given access
to public dollars, subject to regulations and standards. From 1967 to 1976 the
province restricted the growth of private enterprise nursing homes, particularly
by large out-of-province chains, due to concerns that the profit motive might
adversely affect the quality of care and reduce opportunities for more integrated
and cost-effective services.1
Public lodges, established in 1959, were a mode of publicly subsidized
supportive housing outside the healthcare sector. Unique to Alberta, these public
lodges were created to provide safe housing, nutritious meals, social
opportunities, and minimal protective oversight by non-medical staff for
independent but frail elderly people with minor health problems and limited
incomes. Without such supports, these individuals were seen to be at risk for
health breakdowns and hospitalization. Public lodges are run by community-
based, non-profit foundations that also control entry; funding from resident
rents, the province, and municipalities.
Alberta's LTC landscape before 1990 also included a small number of private
homes that would take in seniors in rural settings, and smaller number of more
expensive private lodges, primarily in large urban centres. A public home care program
was established in 1978 to provide nursing and homemaking services to seniors in their
homes and lodges.
Some planned changes to this traditional long term care environment were
already in the wind in 1988, but it wasn't until the early 1990s that these changes began
to be implemented.
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Mixed messages behind changes in the 1990s
In the 1990s, dramatic changes unfolded in Alberta's long term care sector,
accompanied by equally dramatic changes to the acute care sector. These changes were
often "sold" to Albertans via several key messages that can be found in provincial
government documents and media reports. The Alberta public was asked to support
these changes because:
· Home Care and community programs are positive alternatives to institutional
care.
· Increased reliance on families and friends is better for seniors (and at most a
minor inconvenience). It is also a low-cost alternative to public care.
· Seniors will have better choices about where and how their needs are met.
· Services will be client focused, and seniors will be treated with respect and
dignity.
· The government is taking "aggressive steps to prevent two-tiered healthcare."2
Yet these positive themes, often embraced by the public, were frequently
accompanied by other messages that suggested quite a different story. These parallel
messages stressed individual and family responsibility and the value of private markets.
Albertans were repeatedly told that:
· Individuals and families are primarily responsible for their own health, with
implied responsibility for the burden and costs of care.
· Consumers of continuing care services are well informed and capable of
managing their own care. They also have more income and show an increased
willing to pay.
· The buying and selling or private healthcare will stimulate the economy.
· Markets will regulate themselves for price and quality, so there is no need to
interfere.
· The public can no longer afford to provide services to a growing number of
seniors.
· Rising healthcare costs are due to abuse or inappropriate use, particularly by
seniors.
As can be seen, these are two very different sets of messages with two very
different sets of expectations. Unfortunately, the clearest trend in Alberta is towards
reducing public coverage and encouraging new unregulated private-pay markets.
Disappearing care and coverage
The changes to Alberta's health system have been profound. For example, the number
of acute care hospital beds dropped from over 14,000 in 1988 to 6,300 in 1998.3 Many
hospitals were closed or reclassified. Some were sold at fire-sale prices to private
investors who would later contract with regions to provide desperately needed services.
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Between 1989 and 1993, auxiliary hospitals and nursing homes were merged under one
umbrella, despite significant differences in their original ownership and purpose. They
were first labelled "long term care facilities" and then "continuing care centres." At the
same time construction of new beds was halted and a new assessment process restricted
access to high-needs residents only.
In 1993 the Conservatives were
... construction of new beds was
re-elected under a new leader. Ralph
halted, and access was restricted to
Klein's government acted quickly on
what they saw as their new mandate:
high-needs residents only ...
deregulation, delegation, and increased
reliance on private markets. The
province sold off public assets and downsized public programs, first in the name of
deficit reduction and later in the name of tax reductions to encourage private investors.
Dramatic cuts were made to the health budget. Newly appointed regional health
authorities were made responsible for both the provision of healthcare services and the
health of the population in their area. Front-line staffing in LTC settings reportedly
dropped in half.4 Resident accommodation fees were increased, and the increase was
sent to the Alberta Treasury to help pay off the deficit. Home care programs were
overwhelmed by acute care demands after previous age restrictions were lifted in
1990/91 and hospital downsizing began in earnest in 1994.
In 1993 both the provincial and federal governments cut all grants for new
subsidized seniors' housing. A year later, the province did away with several benefit
programs for seniors that had helped maintain their disposable income and purchasing
power. Eliminated were free health premiums and about $1,200 per year in rental or
property tax supplements to help in Alberta's expensive housing market. Generous
dental and vision benefits were substantially reduced and, ultimately, eliminated in
2002. Drug benefits decreased. In their place the province introduced a limited, income-
tested Seniors Income Benefit Program.
Another significant event was the release of Alberta's 12 Public/Private
Principles, a little-known document that emerged from the province's dispute with
Ottawa over facility fees at private clinics. In this 1994 document, the province asserted
two important principles: 1) an increased role for the private sector inside and outside
the public healthcare system, and 2) the right of Albertans to purchase healthcare
services "above their assessed need."
Taking Stock: Early evidence of the impacts
As the province rolled out changes, an array of problems surfaced throughout
the system. Elderly patients were given
little chance to recover in hospital; they
The results of our research were
were quickly shuffled off to LTC
settings or their relatives were simply
shocking. Funding for services
told to pick them up and take them
had not followed patients into their
home. Acute care hospitals began
communities ...
downloading new types of patients into
LTC facilities. In-home care was limited. Families of individuals dying of cancer were
dismayed to suddenly find themselves responsible for accommodation fees in LTC
facilities or for substantial out-of-pocket expenses for care and supplies at home.5
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Patients recovering from surgery or medical treatment were increasingly admitted to
new sub-acute and rehabilitation beds in traditional long term care facilities.
In 1995/96 the Consumers' Association decided to investigate the impact of
these changes. We had initially championed many of the government's proposed
healthcare reforms; now we wanted to determine exactly what was happening. The
association established a toll-free number, did numerous interviews, documented
people's actual experiences, and investigated many identified issues. We wanted to test
the theory of reform against its practice.
The results of our research were shocking. Funding for services had not followed
patients into their communities and home-based care. In fact, significant unanticipated
costs had been shifted to patients and their families, including:
· major new expenses for drugs or drug co-payments, equipment, supplies, and
transportation to healthcare professionals relating to in-home care.
· major direct and indirect costs to family members who took time off work to
provide oversight and care; and
· patients being pushed into high-priced private-pay markets to purchase care
For example, patients with total hip replacements found themselves suddenly
discharged from the hospital 3 to 5 days after surgery (compared with 10 to 14 days in
previous years). Many individuals were unable to manage getting in and out of chairs,
dress or undress, and prepare can meals. Fearful of going home alone or to a frail and
elderly spouse, some patients would purchase a few extra days of convalescent care
from a private nursing home for $100 or more per day.
The association also found that many expenses had been shifted to employer-
sponsored benefit plans. Rather than providing full coverage to Albertans for
community health services (formerly available in hospitals), the province would often
only pay if the individual lacked a private benefit plan that could be convinced to pay.
Individuals were also expected to pay substantial user fees based on their income and
perceived ability to pay.
There were, in short, major gaps in public plan coverage and access to care. The
Consumers' Association documented these and other findings in a report entitled Taking
Stock
By the mid 1990s, deteriorating access to long term care beds, due to both the
influx of new types of patients and overall population growth, led to excruciatingly long
waits for placement in some regions and
... real estate investors and private
no choice among facilities for all
practical purposes.6 Meanwhile, real
lodge operators were jumping into
estate investors and private lodge
the vacuum with a new and
operators were jumping into the vacuum
expensive private-pay model
with a new and expensive private-pay
model imported from the U.S., which
imported from the U.S.
they loosely termed "Assisted Living".
The Auditor General of Alberta finally sounded an alarm about the lack of LTC
beds in his Annual Report. The 1999 Broda report, from a government advisory
committee on long term care, simply reaffirmed the province's strategy of downloading
traditional clientele into other settings and leaving families on their own.7
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Due to the newly discovered uses for long term care beds as acute care beds, the
province authorized the construction of 1,319 new nursing home beds. The government
provided 25% of the capital funding, compelling health authorities to go into long term
partnerships with the private sector to raise the majority of the money.
In order to understand some of the implications of the Broda report, it is
important to decode the concepts used to advance Alberta policy directions in the last
decade.
Decoding the jargon and concepts disguising the changes
Several key concepts have surfaced in Alberta's healthcare environment,
concepts that play a significant role in how LTC issues are debated and acted upon,
especially in the area of new public models of residential long term care called
Supportive and Assisted Living.
Distinguishing between "core" and "complementary" services: The division of
healthcare services into core and complementary categories emerged in the early 1990s.
The theory behind core and complementary is that the public healthcare system will
save money by limiting the number of services it pays for either in whole or in part (i.e.,
core services). Clinics, hospitals, doctors, and nursing homes will be free to earn extra
income by selling related services or products at unregulated prices (i.e.,
complementary services).8
Take the example of laundry services in a publicly funded nursing home. Bed
linen is laundered at no additional cost to the resident - it's a core service; but personal
laundry must be paid for privately - it's a complementary service. If a resident wants to
wear their own clothes (a recognized factor in maintaining health and well being), he or
she is going to pay extra, and the price isn't regulated (about $25-$40 a month).
Basing access to care on "assessed need": Another concept from the early 1990s
was that access to all publicly funded LTC beds or in-home care would be based on
"assessed need" (i.e., assessed by a health professional from the health region, using a
formal criteria). Most people don't realize that "assessed need" isn't what a person
actually needs but refers only to the particular and often narrow range of supplies and
services available through the regional health authority (RHA). In other words, an
individual's assessed need is limited by what the regional home care program, for
example, offers. The available services are more meagre than most people anticipate.
Assessed need has other problems too. Information about formal criteria and
available services is not made public; in fact, wrestling this information from an RHA is
almost impossible. Many seniors with disabilities are unaware of what they may be
eligible for, in theory and in practice; even public lodge operators whose residents rely
on home care programs talk about being perplexed.
Originally conceived as a process to ensure safety, fairness, and appropriateness
based on professional judgment, "assessed need" is now often used to hide politically
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9
embarrassing shortfalls, or undisclosed changes in the terms and conditions of public
coverage.9
Separating "health" from "housing": In Alberta legislation, the per diem
accommodation fees paid by residents in LTC facilities are acknowledged as a partial
payment (co-payment) to cover the entire basket of room, board, and care services. In
1994, however, Alberta used an internal policy directive to move towards a different
interpretation of this legislation. Today the per diem fee is construed as one that should
eventually cover all costs of accommodation, including most of the costs of
constructing and operating the facility.
This move was the beginning
of a significant philosophical
The separation was designed to limit
separation, designed to limit the
the funding obligations of the
funding obligations of the province
province to a very narrow range of
to a very narrow range of direct
healthcare services, with no
direct healthcare services, with no
obligation for support services such
obligation for accommodation, meals,
as accommodation, meals,
housekeeping, maintenance, utilities,
housekeeping, maintenance, utilities,
and so on. (These support costs are
and so on.
often called "hotel costs.") People
may find it difficult to grasp the concept of separating the costs of services provided by
healthcare personnel- be it wielding a scalpel or a washcloth from the costs of the
goods used to provide care or a special environment in which the service is provided.
These elements seem inextricably linked. For example, most people would consider the
meal provided by a worker to a LTC resident who cannot shop, prepare food, or eat
without assistance to be part of their "care."10 In fact, that meal is often deemed a
housing cost in Alberta today.
The separation of healthcare from support and housing is an established trend.
The shift to full personal responsibility for these costs is not yet evident in traditional
facilities but is quite marked in Alberta's new models of residential care known
collectively as supportive living.11
The level playing field argument: The most important new idea to grasp is the
concept of the "level playing
field," which gained momentum in
In other words, if you paid at home for
the 1999 Broda Report.
drugs, personal care, medical devices,
In the 1990s one argument
supplies, housing, meals, and other
for moving care from hospitals to
costs of living, you should also pay for
people's homes was that it would
be substantially cheaper for the
these in a nursing home.
public system because the "hotel
costs" would be transferred to the individual. Today, the level playing field means
making individuals in LTC facilities bear the same costs as individuals in their own
home, all in the name of fairness. The Broda Report put it this way: If goods and
services were wholly or partially uninsured by the public plan in a senior's home, the
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10
same goods and services should be uninsured in all settings. In other words, if you pay
at home for drugs, personal care, medical devices, supplies, housing, meals, and other
costs of living, you should also pay for these in an auxiliary hospital or nursing home.
Consider the example of intravenous therapy. In 1992/93 Alberta introduced an
optional home intravenous program (the treatment had previously been restricted to in-
patient settings). People had to pay 25 percent of equipment and supply costs and the
first $5,000 of drugs (deductible) if they didn't have a private plan. Today, in-patient
treatment is often not an option due to facility downsizing. Many patients are forced
either to use the costly in-home option or to make frequent trips to outpatient
departments for free therapy. But some hospitals and regions have been charging for
this treatment based on the argument that it isn't fair that outpatients don't pay while
people at home do.12
In reality, "level playing field" means dragging public coverage of residential
care down to the low level of home care (while continuing to shrink home care
programs). Alberta's position is a complete reversal of the more progressive idea of
expanding public coverage of services in community-based settings.
Unbundling services: Unbundling is the process used to operationalize many of the
concepts described above. The more a service can be broken down into its component
parts, the more opportunities for reducing the basic healthcare package and offloading
costs. Not only can healthcare be unbundled from housing, but housing and support
services can also be atomized and unbundled further.
The components of continuing care services are now being subdivided into:
· access to information;
· professional case coordination and clinical services;
· personal care;
· technical supports (equipment, medication, transportation);
· residential supports (basic independence and enhanced independence); and
· housing (including capital and operating expenses).
Most of us think of care as a comprehensive whole. To use a metaphor, when
someone buys a car, they expect it will come with tires, steering wheel, brake fluid,
engine, doors, seats, etc. They can generally assume the car will be delivered in a
complete and functional condition. People expect the same of residential care. An
elderly person in a residential care facility needs ongoing case coordination (health
monitoring). Perhaps they need clinical services such as dressings, and some personal
care such as guidance with bathing, feeding, or incontinence care. They might need
equipment, medications, or transportation to medical appointments, and residential
supports such as meals, housekeeping, and laundry. Or they may require help with using
a telephone, managing their pain or forgetfulness, their immobility and their fears.
Some may require help with money management or someone to advocate on their
behalf.
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In the past, most of these services were inseparable parts of the healthcare basket.
Today, they are being broken up and shunted into different boxes. Until recently,
guiding a senior who was confused or having difficulty taking his or her medication
would have been classified as a health professional service. Now it may be classified as
a personal care service or an independence support provided by a housing operator.
The classification of services and products determines the personnel who arrange
the service, provide the service, and bill for it at month's end. These divisions enable the
costs of care to be shifted, bit-by-bit. For example, care aides have largely taken over
responsibility for hands-on personal care for LTC clients. This development enabled
health authorities to separate the tasks of personal care from the tasks of professional
nursing, which in turn facilitated the contracting out of personal care to private
agencies.
The unbundling trend also smoothed the way for the Broda Report's
recommendation that people pay for all
or part of their personal care (especially
Although promoted as a means of
LTC clients). The rationale for this step
enhancing consumer choice,
is slippery: because people are normally
unbundling is little more than a
responsible for their personal hygiene
throughout their life, they should pay for
consumer nightmare.
their hygiene as they age (ignoring the
fact they may be unable to do so due to a medical condition). This idea is supported by
RHAs; personal care may well be the next service that Albertans are expected to pay for
out of pocket.
Although promoted as a means of enhancing consumer choice, unbundling - and
rebundling with higher overall costs for the same basket of services - is little more than
a consumer nightmare, financially and emotionally. The practice has allowed the
province to continually erode coverage and transfer costs to individuals and families.
Unbundling also drives up administrative costs significantly and compounds the
complexity of evaluating services at a time when individuals and families are already
overwhelmed.
A clear sign of the times comes from the Alberta Long Term Care Association.
This trade association of traditional facility operators is quietly advising callers to
consider purchasing. private LTC insurance to protect themselves, their income, and
their assets.13
The news out of Alberta in the 1990s, however, was not all frightening. The last
decade was also a period of innovation.
The promise of new public models of residential care
In the early 1990s, inspired by local and international research on aging, some
public and not-for-profit LTC operators began seeking new and better approaches
within Alberta's public system. After much lobbying, and with help of federal project
money, they were able to pilot and evaluate three new models. These new approaches
yielded many valuable ideas about alternatives to old-style facility care, yet their
benefits were counterbalanced by the problem of unbundling "health" from "housing"
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12
costs and the chasm between "core" and "complementary" services. The three pilots
were:
· An Assisted Living residence in which 30 persons with limited nursing and
care needs lived in a home-like setting that provided some health, recreation,
and social services; with opportunities to purchase extra meals or
housekeeping, and a commitment to aging in place.
· A dementia facility in which 36 persons with mid-stage Alzheimer's dementia
were provided holistic care in a specially designed more home-like facility.
· Adult family living programs in which elderly persons lived in homes owned
and operated by unrelated individual(s) who provided them with room and
board; the owner/operators were paid for designated services.
The goal of these new models of care was to provide safe, compassionate, and
caring environments; to keep residents connected to others and their past life; to create a
home-like residence; and to reduce the medicalization of care so residents could
maintain a sense of self and quality of life. An important criterion was that programs be
client-focused and based on caring partnerships among staff, operators, and family
members.
Between 1995 and 1998 the pilots were studied by a team of researchers from
the University of Alberta, led by Dr. Norah Keating and Dr. Janet Fast of the
Department of Human Ecology. The EPICC study sought to 1) describe the care giving
partnerships in each setting, 2) determine the kind and amount of care/services provided
by each partner; and 3) explore the
attitudes of paid and unpaid partners
The partnerships appeared to be
towards the delivery of these services.
enhancing the well-being of
To accomplish this, the researchers
created a time-use tool to measure care
residents
activities such as enhancing well-being
(emotional and social contacts), care management, financial management,
transportation, shopping, housework, personal care, and skilled care.14
Overall, the EPICC study found a generally high level of satisfaction regarding
quality of care. Many benefits were identified, and the partnerships appeared to be
enhancing the well-being of residents. But the researchers also raised serious concerns
about the demands on family and on staff, particularly where aging-in-place policies
were involved.
Amount of care provided by family and staff: Researchers found that family
members provided, on average, about 40 hours of direct services to residents per month
(mainly enhancing care and transportation). Staff members spent about 100 hours per
resident per month in direct services, although this varied substantially among the three
models.
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Pilot models of care
Hours of care per resident per month
Staff
Family
Adult family living
152
32
Dementia care
93
34
Assisted Living
45
50
Source: EPICC
As the chart shows, Assisted Living can be a substantial load for family
members. The EPICC researchers were particularly concerned that, if a senior hadn't
purchased up to the next level of care in the Assisted Living setting, their relatives were
forced to shop for groceries, make meals, and do extra housekeeping in addition to their
ongoing social and emotional support. Family members reported feeling stressed,
exhausted, and unable to take breaks or holidays. Researchers also expressed alarm over
the social and economic well-being of the largely part-time staff and the sustainability
of adult family living operators without additional resources. In Alberta, residents of
adult family living homes are not eligible for public day programs or related
transportation costs, leading to significant demands on individual operators.
The evaluation team's findings culminated in several valuable recommendations
to improve the identified problems while keeping the benefits of these models. But by
the time their report was released in 1998, the privatization die had been cast. The
EPICC recommendations were ignored. Instead, the province and regional health
authorities used the introduction of variations of these pilots to shift costs to residents
and families, other government departments and municipalities.
Today the pilot models would be classified under the broad heading of
supportive housing, which is one of three streams in Alberta's constantly evolving new
LTC paradigm (the other two being individual homes and traditional LTC facilities). In
this paradigm, Assisted Living represents the high-service end of the supportive housing
stream. But, like the U.S., Assisted Living has branched off in many different
directions in Alberta.
The many faces of Assisted Living: Alberta's new reality
Assisted Living refers to several different phenomena in Alberta. It can be:
· a philosophical approach to care
· a marketing tool for real estate agents - and buyer beware!
· new unregulated private nursing homes with "a la carte" care
· a cost-avoidance plan of the Alberta government
Let's take a closer look at these different faces of Assisted Living.
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The original philosophy: The term "Assisted Living" refers to a model or care that
recognizes the importance of caregiver approach and environment in enhancing the
quality of life for people who are frail, disabled, or cognitively impaired. Developed in
Oregon 15 years ago, it is based on six principles: choice, dignity, privacy of person and
space, independence, individuality, and a homelike atmosphere. Assisted Living
embodies the concepts of managed risk and bounded choices. For example, if a senior is
unsteady on their feet, they will be supported by handrails, a barrier-free environment
and someone watching from a distance rather than by chemical and physical restraints,
even though they may be at risk for falling - if that is their agreed upon choice. The first
public pilot evaluated by EPICC was based on this philosophical approach.
A marketing tool for real estate agents: Today the term "Assisted Living" is
liberally used by real estate agents selling condominium and adult-living complexes.
Originally the housing model of Assisted Living was as a form of supportive housing
for independent seniors, largely built by churches and pension funds. These residences
relieved seniors of home-maintenance responsibilities and gave them the opportunity to
live in a secure building with neighbours of the same age and interests, while enjoying
planned social activities and recreation. Some residences had optional dining room
meals, housekeeping, a tuck shop, regular bus service, and beauty salons.
The contemporary market for so-called Assisted Living is a minefield of
misleading advertising. Essentially, the term is being applied to residences that were
formerly billed as "barrier free" or "adult living with amenities" or "on-site
restaurant/dining room service." Very little by way of care or monitoring may be
offered. Some for-profit operators promise a lot and deliver very little. For example, a
highly promoted 24-hour security and health monitoring service may simply entail
being handed a business card to call and order a private lifeline service.
Unregulated nursing homes with ą la carte menus: These private lodges and
retirement complexes offer a combination of safe and secure housing, hotel-type
services such as regular meals and housekeeping, and nursing care (provided by
personal care aides) - all for a hefty price. They are promoted as a residential option that
falls somewhere between independent living and nursing home care.
Seniors can buy their own unit as a life lease, or they can be renters. For
example, rents in one Edmonton complex go from $1,595 to $3,195 per month (2002).
The facilities sell a range of services. Some have dining rooms only (no "room
service"); others have 20- bed locked dementia units. Hotel-type services and personal
care are purchased in separate units or in tiered packages, over and above basic housing
costs. For example, one private facility charges:
Lunch (daily):
$196 per month
Dinner (daily):
$279 per month
Incontinence care:
$150 per month
Night checks:
$100 per month
Medication assistance:
$150 per month.
Assistance getting out of bed, dressed, bathed, or taken to meals is usually
charged in 15- minute increments at $15-$28 per hour.
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Profits flow to owners/investors from rents and from the sale of support and
nursing services. In Alberta major players include the Reichmann family with their 70
percent ownership in Central Park Lodge Inc. and CPL Long Term Care Real
Investment Trust. The field is dominated by real estate investors who usually contract
out the management of on-site services. Several international and U.S. operators are
eyeing the Canadian market, particularly for joint ventures with large Canadian
developers.15 Insurance companies are also investing. An advertisement in the
Edmonton Journal in early 2002 invited potential investors to a seminar on how they
could make a 20 percent return on Assisted Living condominiums.16 The number of
private units that bill themselves as Assisted Living is constantly climbing in Alberta,
mainly in large urban areas. In 1990 Calgary had 400 such units; by 2001 there were
2,300 with another 2,000 in the planning stage.
Despite the high monthly costs, it isn't just rich people who live in these
complexes. The crisis in access to public LTC facilities means that many middle-class
seniors are forced to spend down their savings and cash in their assets to purchase the
care they need. When they run out of funds, they are forced to move on. Desperate
families will pay as much as $4,000 per month, or more, to place their parent in a
private complex while awaiting a public LTC bed.
Private Retirement Living Complex
Life Lease (purchase)
Edmonton 2002
Bundled:
Homemaking Service
$150 month
(morning light housekeeping,
bed making including weekly linen change, tidy counter,
dishwashing, one load of personal laundry a week)
Unbundled:
Weekly vacuum
$20
month
Laundry (one load per week)
$30
month
Health services:
Medication administration assistance
$150
month
24-hour emergency monitoring
$40
month
(if call not emergency, an additional
$10
month
Daily telemonitoring
$30
month
Blood pressure check
Weekly $20
Monthly $
5
Blood sugar monitoring
$ 3 per check
Companion services
$15/hour
Meal escort service
$150
month
Bathing $20
bath
Incontinent management (resident supplies product)
$150
month
Support stockings assistance
$100
month
Foot care
$20
month
Daily lunch
$177 $196 month
Daily dinner
$252 $279 month
Another private lodge (on rental basis) offers night checks ($100/month); help with support stockings ($100/month);
oxygen management ($152/month); and services as listed above. The package deals for more dependent residents and
dementia care cost $650 and $850 (respectively) on top of monthly rents from $1,595 to $3,150 (excluding meals and other
amenities)
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16
The chart entitled "Private Retirement Living Complex, Life Lease" shows the
costs associated with some privately paid Assisted Living arrangements.
A cost-avoidance plan via "Designated Assisted Living": This last version of
Assisted Living was indirectly documented in the 1999 Broda Report. Researchers from
a consulting group identified opportunities for $145 million in savings (cost avoidance)
for the province, essentially by shifting LTC candidates into settings where they bear
more costs.
One particular method comes in the form of Designated Assisted Living (DAL).
This is a hybrid model that appears to falls somewhere between the first public pilot of
Assisted Living and the fully private pay commercial model. Here's how it works. A
health authority contracts with private or nonprofit operators to control entry to a
number of units in a lodge or housing complex; the contract also involves a basket of
services including 24-hour access to personal care (up to $1,500 per month in Calgary,
2002).
Candidates are then placed in these units through the region's entry process - that
is, if the person is able and willing to pay the "housing" and support costs set by the
operator. Any additional care must be approved by a representative of the health
authority. The catch is that the candidate must also be able to absorb additional
expenses that would normally covered in traditional long term care settings. This
includes co-payments for drugs and drug packaging, aides to daily living supplies,
transportation, special equipment, and the package of "hotel" services such as meals and
housekeeping. Usually, the more dependent the patient, the greater the need for
supplies. While Regions reportedly try to find spaces for $900 to $1400 dollars, rents
are not geared to income. In 2001 Calgary had 165 Designated Assisted Living spaces
and Edmonton had 81.
The chart entitled "Designated Assisted Living Unit / Breakdown of Payment
Responsibilities" demonstrates how the various components of care have been
unbundled and shifted so that clients residents pay the same costs as they would
in their own home (e.g. rent, drugs, bed linens, housekeeping, meals, building
costs, etc.) The chart, taken from a request for proposals by Calgary's RHA in
2001, represents the high end of public support and care in Alberta today.
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17
Designated Assisted Living Unit
Breakdown of Responsibility for Payment
Calgary Regional Health Authority, 2001
Resident payment responsibilities
RHA payment responsibilities
Accommodation charges
· Direct care support (i.e., personal care)
· Rent
· RN consultant on call
· Utilities (client space only)
· LPN on site 24 hours per day
· Cleaning (client space only)
· Therapeutic recreational staff
· Communal furnishings
· Coordination of support services
· Building maintenance costs (inc. capital
· Care supplies
expense)*
· Arranging transportation
· Meals (3) plus snacks
· Administering contract
· Linen laundry
· Social/recreational activities
· Administration of accommodation.
Additional resident responsibilities
Provided by RHA Home Care
· Personal expenses
· Professional case management
· Personal laundry
· Professional care (e.g., RN and Rehab.)
· Personal toiletries
· Supplying linens
· Telephone/cable in room
· Drugs (co-pay Blue Cross)
· Client room furnishings
· Social expenses
· Transportation costs
· Personal insurance
Other Partners
· Equipment (including special beds): co-payment
with Alberta Aids to Daily Living program
(AADL)
· Drugs: co-payment with Blue Cross (if senior)
AISH
· Ambulance: co-payment with Blue Cross
*The capital expense cost is new. In the past many LTC facilities were built with public money; today,
privately constructed facilities pass their costs on to residents.
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18
Operators are also free to sell additional services (see "Additional services" chart
below) such as care from a Registered Nurse or personal care aide, special diets, and
room service.
Additional services for purchase at a Designated Assisted Living unit (2001)
Personal Services
Professional Health Services
· Laundry or linen services
· Registered Nurse
· Charges for second individual in suite
· Other (specify)
· Furnished suite
· Therapeutic massage
· Pet care
· Wheelchair or personal device maintenance
Meal and Food Services
· Handyman services
· Additional housekeeping
· Special diets
· Transportation
· Room service
· Special recreation & special events
· Private dining room
· Craft supplies
· Visitor meals
· Additional meals
Care Services
· Packages
· Companion Services
· Respite/Short Stay
Source: Calgary RHA Request for Proposals
Many disabled elderly people simply cannot afford the housing and personal
costs associated with these designated units. And while the RHAs' official statement is
that no one is denied access to an appropriate setting due to lack of money, they
privately admit quite another story:
"The plan was to let the market set the price and the province would top up the
people who couldn't pay," said one contact, "but [the province] seems to have
forgotten the last part."
A stock of subsidized, affordable housing is desperately needed for low income
seniors, yet Alberta faces chronic shortages. Under tremendous pressure, the RHAs
have resorted to a two-pronged strategy: 1) using provincial social housing monies to
build new Designated Assisted Living units to be run by non-profit organizations, and
2) trying to gain control over the public lodges to turn them into Assisted Living stock.
Control over lodges, however, means squeezing out independent seniors who require
only social supports, and would thus create a new gap.17
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Consumer protection in new markets for care
Alberta has been starving public LTC facilities and home care, causing dramatic
declines in quality and access, and leaving seniors and families with few places to turn.
Desperate people are being forced to pay any price to get the care they need, whether
through home care agencies, private lodges, or private Assisted Living developments.
Yet these Assisted Living complexes and other new models of supportive living
used to replace traditional nursing home care operate for the most part, in a regulatory
void. They are not licensed, tracked, or monitored except for the obligations/
monitoring imposed through RHA contracts. Given the terrible track record of the
province and the RHAs in monitoring and enforcing quality standards in regular nursing
homes, even this minimal oversight may not provide a lot of comfort.18 Neither private
pay facilities nor the housing/support services provided to assisted living clients outside
an RHA contract are subject to the Protection of Persons in Care Act.
A senior's choice of housing is limited by the regional placement process and by their
ability to pay - in other words, little choice for low or middle-income seniors. Any
increases in publicly funded health
services, which may be essential to
Assisted Living could easily regress
prevent a person's loss of function, are
to the state of yesterday's
restricted by the availability of an off-
site regional case coordinator who
unregulated and often exploitive
may be unfamiliar with the client.
private care homes.
Definite limits exist regarding "aging
in place". Residents and families may need to purchase substantial extra care for even
temporary episodes of illness, or else face dislocation. Why? Because the minimal
staffing levels and skill mix within these complexes make it difficult to provide
significantly more support or two person transfers when required.
The promise of Assisted Living is in offering seniors the chance to maintain their
independence in a personal domestic setting while receiving the care, social contacts,
and attention they need. The original model was a dignified and responsive care option
for individuals with chronic or declining conditions. But with Alberta's pattern of
privatization and abandonment of the progressive public model, Assisted Living could
easily regress to the state of yesterday's unregulated and often exploitive private care
homes.
False assumptions challenged by the evidence
Alberta's long term care sector has been pushed and pulled by powerful and ofttimes
competing forces over the years. Many measures have gone unchallenged due to the
complex and camouflaged nature of the changes. Our research also revealed several
widely promoted rationales used to justify new measures. When we examined the
evidence, however, the justification for these claims simply did not exist. Let's take a
closer look at three of these widely accepted, but completely false assumptions or
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20
myths, in fact and the realities facing the next generation if we continue to allow these
rationales to go unchallenged.
Myth #1: Today's seniors and their families are sophisticated
consumers, willing and able to spend more for their care
Few Canadians can be called sophisticated consumers of LTC services.
According to interviews with seniors' housing agencies, the savvy consumer of care
housing doesn't exist. Residential care is not something people purchase repeatedly in
their lives. The need for LTC services
The factors that matter most, such
usually arises due to a major personal
crisis such as a stroke, or the death or ill
as quality of staff or integrity of the
health of a care giving spouse. Families
operator, are not readily visible or
are often desperate. Evaluating complex
quantifiable.
service options is difficult and time-
consuming, even with experience. The
factors that matter most, such as quality of staff or integrity of the operator, are not
readily visible or quantifiable.
Purchasing healthcare services is even more daunting. Most residents are well
into their 80s, and the incidence of cognitive problems related to dementia climbs
significantly after age 85. How does anyone make a sound judgement about whether to
buy a regular blood pressure check, particularly if an operator or nurse suggests they
might benefit?
Essentially, the elderly must now buy their way into a housing situation to get
the care they need, or have it paid, at least partially, by the public plan. But unlike at a
hotel, seniors cannot just book themselves in because authorization is required from a
health authority. Nor can they easily walk out, even from private-pay facilities: a
change in residence can have a profound effect on the well-being of seniors with
dementia, limited mobility, and shrinking social contacts.
According to a document from one RHA, seniors in need of care housing " have
experienced health deterioration, and as such can no longer be supported in
environments that are too demanding of their existing physical, psychological, social
and emotional abilities." This certainly does not sound like a sophisticated consumer to
us. Many relatively well residents in private pay facilities are even reluctant to complain
when things go wrong for fear of being asked to leave.
Not necessarily wealthy: It is also a misconception that most people over age 65 are
well to do. The median income of seniors in Alberta in 1997 was just over $1,400 per
month.19 The failure of private markets to provide affordable and appropriate rental
housing for even independent seniors means that money from the sale of the family
home can quickly disappear. Cuts to benefit programs and rising expenses have left
many middle-class parents and grandparents struggling to hang on to their lifestyle; the
situation of low-income families can be even worse. Loss of projected investment
income is another problem for some middle-class households. Grown children are
expected to fill the gap by either giving or buying care, yet are themselves often
struggling to raise families. Many are only one pay cheque away from serious financial
Eldercare On the Auction Block
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21
problems. In the so-called land of plenty, Alberta families have the highest median debt
load in Canada.20
Myth #2: Shifting the burden of care to families is costless to
society
In fact, shifting the burden of care turns out to be substantially more expensive
in personal, familial, and societal terms. Direct and indirect costs are borne by many
parties: the recipients of care, informal family caregivers and their children and spouses,
employers, and society at large.
The documented emotional
The repercussions for spouses and
costs to seniors include guilt, loss of
control, anger, and loneliness.
children can also be significant:
Loneliness because family caregivers
strained family ties due to forfeited
often have little time or energy left
income, lost family time, disrupted
over to provide important emotional
and social supports when they are
schedules, loss of privacy, and
exhausted from the myriad tasks and
deterioration of marital relationships
responsibilities of hands-on care.
Ironically, while a new emphasis on
"client-centred care" is often used as a policy rationale to increase reliance on informal
caregivers, studies suggest that elders themselves prefer formal paid caregivers.
For family members, the stress of constant caregiving often leads to emotional,
financial, and health breakdowns. Out-of-pocket expenses are considerable, such as
purchasing domestic services (yardwork, meals, babysitting) in order to "buy time," or
purchasing private care. There are also the costs of lost work time, income, and future
pension benefits if adult children are obliged to leave the work force. Some of these
caregivers are destined to become the next generation of poor elderly. A U.S. study
found that a so-called "career" of care giving costs an average of $656,000 in lost
wages, pensions, and social security benefits, not to mention negative health impacts.21
.
The repercussions for spouses and children of informal caregivers can also be
significant: strained family ties due to forfeited income, lost family time, disrupted
schedules, loss of privacy, and deterioration of marital relationships. 22 According to the
University of Alberta Population Research Laboratory Surveys, there has been a major
jump in the number of Albertans providing home or personal health support to a family
member. The number of Albertans providing such care jumped from 31 percent in 1998
to 43 percent in 1999 and 46 percent in 2001. A significant proportion of these
caregivers- 16 percent of women respondents and 11 percent of men- indicated that
providing this support was a major disruption in their lives.
Employers of caregivers pay the price too. Family caregivers come in late, leave
early, drop back to part-time, turn down promotions, choose early retirement, or give up
work entirely. The 1997 MetLife Study of Employer Costs for Working Caregivers in
the U.S. estimated that accommodations for working caregivers cost U.S. employers
between $11.4 and $29 billion dollars per year in lost productivity not including the
related healthcare costs to employer benefit plans. Ipsos-Reid's 2002 Canadian survey
of employees with benefit plans found that about one third of respondents were taking
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22
care of elderly family members to some degree, making it difficult for them to balance
work and family responsibilities.23
Society at large also pays a price in lost tax revenues, higher poverty rates,
family bankruptcies, and additional healthcare costs. In the U.S. over 500,000
bankruptcies per year are associated with healthcare costs, often LTC expenses. When a
family unit loses its ability to be self-sustaining, social services must try to pick up the
pieces. This is yet another reason why universal public health plans makes so much
sense - paid for by the taxes of people who are well and working, so they have
something to fall back on it when they are unwell.
Myth #3: Private pay markets and commercial suppliers will lead to
lower prices for care and health plan coverage, and better value for
money.
No evidence exists that increased reliance on private payment and commercial
suppliers ensures better care or value for money. In fact, a substantial and growing body
of evidence proves the opposite. Real competition, affordable prices, and quality
controls are difficult to achieve in commercially driven health or care housing markets
precisely due to the nature of the need, the high stakes, and the limited ability of
someone to walk away to another supplier under the circumstances. Normal market
forces do not exist. If the price of a bath doubles after someone moves in, are they going
to shop for a bath elsewhere or change their whole social environment?
Private health insurance might be the poorest regulated consumer product in
Canada. Policies for LTC insurance (residential and in-home care) first appeared in this
country in 1995. The "market" is full of restrictions, financial and otherwise. Pre-
existing conditions drive up premiums or preclude coverage. One policy we examined
cost about $2,400 per year for an individual 50 years old (if approved for coverage); at
age 60, premiums rose to over $7,000, depending on a number of variables. Lifetime
maximums are in place. Shopping for health insurance may have even more pitfalls than
shopping for Assisted Living.
Alberta's skyrocketing administrative costs: Relying on private insurance and
multiple payers also adds enormous administrative costs. Prodigious amounts of time
are spent evaluating risk and payment, determining eligibility and premiums, approving
and processing claims, deciding who pays and how much, and selling policies. This fact
helps explain an extremely important observation we made about Alberta's healthcare
system. We had posed the question, "Why is Alberta's spending on healthcare at a
record per capita high given the extensive off-loading of costs and reduction of
benefits?" Here's what we found.
Actual money spent on administration
Intentionally or not, Alberta has
created a high-priced American
increased by 15.2% - more than for
system of healthcare with
any other identified category except
widespread fragmentation of payers,
research and education
providers, managers, and suppliers.
In fact, the public healthcare system in Alberta, particularly for continuing care
services, appears to have adopted all the features of the private insurer, multiple-payer
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23
model that make U.S. healthcare spending the highest in the world. Why the high price?
Significant new administrative costs.24
For example, the administrative costs of Alberta's RHAs rose from 5.6 to 6.2
percent of their total expenditures between 1997/1998 and 1999/2000. In contrast,
spending on community and home based care only increased from 5.4 to 5.7 percent
and spending on continuing care facilities dropped from 15.6 to 13.6 percent. Actual
money spent on administration increased by 15.2% - more than for any other identified
category except research and education.25
Comparisons to the U.S. healthcare system, where insurance companies run
bureaucratized Health Maintenance Organizations (HMOs), are also striking. Staff in
Alberta's 17 regional health authorities are
spending ever-increasing amounts of time,
Billing clerks are displacing RNs
energy, and money determining eligibility,
evaluating, assessing, documenting, approving, coordinating, itemizing, billing,
collecting, and arranging forever tinier unbundled units of care from multiple agencies-
instead of delivering services. They are also constantly looking for someone else to pay.
For instance, RNs are expected to fulfill the "cost-saving" role of denying care. (Alberta
may be spending from $500-$1,000 to deny a bath assist). Using a regional care
coordinator to evaluate and approve incremental units of care, rather than an on-site
coordinator, also raises expenses.
In other words, many measures implemented in the name of saving money
actually drive up costs.26 Billing clerks are displacing RNs. The similarities to the
claims adjudication process in the private insurance field are remarkable.
Wholesale savings abandoned for retail profits: Increased reliance on commercial
suppliers and contracting-out also drives up costs. Historically, when private insurers in
the U.S. first entered the managed care
business (originally the domain of
The province seems to have
non-profits), they immediately bought
forgotten the enormous benefits of
up existing public and non-profit
hospitals and home care businesses to
wholesale prices, bulk purchasing,
bring their suppliers in-house in the
and internal flexibility - the original
name of cost savings. Alberta headed
model of the Canadian healthcare
in the opposite direction. The
system
provision of services has swung from
in-house wholesale prices to retail
pricing. The province seems to have forgotten the enormous benefits of wholesale
prices, bulk purchasing, and internal flexibility - the original model of the Canadian
healthcare system.
Consider this example. People who need tube feeding for nutritional purposes
usually purchase their monthly supplies from a retail pharmacy, paying about $400 per
month for supplements alone. If a regional health authority purchases these supplies in
bulk, the price drops to $100 per month. When Edmonton created such a public service
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24
for individuals, retail pharmacists tried to scuttle the program out of concern for lost
profits.
The rationale for creating regional management bodies was to increase the
integration of healthcare services and reduce costs. Yet it appears that the entire
continuing care system in Alberta has dis-integrated over the past decade, and both
public and private costs are rapidly rising. Instead of moving ahead, Alberta is actually
going backwards.
Conclusion
Policy makers across Canada are spending more and more time talking about
how the determinants of health can improve the well-being of Canadians and hence
reduce the pressures on medicare. In fact, the theme of keeping people healthy to avoid
demands on the public system was a key feature of the Alberta Premier's Advisory
Council on Health report, also called the Mazankowski Report (2001).
"Determinants of health" refers to factors known to have a powerful impact on
the health and well-being of people within a society. The determinants include having a
reliable and adequate income to purchase both the necessities and some pleasures of
life; a decent place to live; and opportunities for social interactions. Other determinants
involve having some control and choices in one's life, some personal privacy; and
adequate nutrition, rest, and exercise. For those needing care and their informal
caregivers, the constant strain of coping with scarce resources and juggling obligations
are known to have a detrimental effect on their health, their use of health services, and
their relationships with family members and employers. Undoubtedly, a significant
determinant of health is access to a reliable network of LTC services that foster the
wellness and sustainability of families.
Although the Mazankowski
Report paid lip service to keeping
Undoubtedly, a significant
people healthy, it nevertheless
determinant of health is access to a
recommended offloading more
reliable network of LTC services
responsibilities to individuals and
families, unbundling more goods and
that foster the wellness and
services, increasing use of commercial
sustainability of families.
suppliers, and greater reliance on
private-pay care options. According to the Advisory Council, such strategies are
necessary to ensure the sustainability of the public healthcare system and plan coverage.
Yet the Consumer Association's research reveals that these very strategies are at
the root of devastating changes to Alberta's LTC sector since the 1990s. The costs of
care have been offloaded to individuals and families. Services have been unbundled and
fragmented in destructive ways. Both residential care and home care have witnessed the
concentrated growth of profit-oriented suppliers. Families have been railroaded into
new private-pay markets due to decreased public access and quality.
Rather than fortifying the public system, Alberta's strategies have compromised
the sustainability of the public system. Excessive fragmentation of LTC services has
driven up administrative costs, leaving fewer dollars for actual care. It has also driven
Eldercare On the Auction Block
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25
up the private costs of care. If trends continue, it is possible that in some not-too-distant
future the only services covered by the public plan may be the claims adjudication
process by regional care coordinators, clinical services by professionals, and Medicaid-
style provisions for the truly destitute.
In the early 1990s Alberta was not alone in altering its approach to healthcare
and eldercare supports; the federal government and other provincial governments have
also been guilty of shifting the burden and costs of care. If provincial and federal policy
makers are truly committed to sustaining families and communities by improving the
determinants of health, regressive policies that shift the burden of care and costs and
drive up prices must be reversed. With families scattered across many provinces, this is
clearly a national problem.
Recommendations
· Restore and expand universal public coverage for long term care supports, regardless
of the setting. Ensuring timely and affordable access to a wide range of quality
public LTC services is an essential step Alberta can take to enhance the
determinants of health among the elderly and their families.
· End the unbundling of services. Efforts should be made to re-integrate services,
functions, organizations, and payments. Not only will this benefit individuals and
families in need, it will also reduce administrative costs and maximize opportunities
for wholesale purchasing.
· Ensure full disclosure about LTC services. Albertans have a right to open and
complete information about availability and eligibility requirements for LTC
services and about the costs and obligations of agencies and operators supplying
services. Without this information, Alberta families and communities cannot make
responsible choices or hold suppliers and plan administrators accountable.
· License, regulate, and monitor supportive housing and Assisted Living settings. At a
minimum, supportive housing and Assisted Living operators should be licensed
regardless of their ownership status. Formal and informal complaint and appeal
mechanisms need to be visible and effective, and community groups should be
supported to take an active role in acting as advocates.
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Endnotes
1 Ministerial Briefing Memo to the Hon. Neil Crawford, 1973, Selected Minutes of Nursing Home
Committee Meetings, 1970s, Alberta Health Library.
2 Advertisement by the Government of Alberta, National Post, September 9, 2001
3 Alberta Health Annual Report, 1988, and the Canada Health Act Annual Report, 1988-1999.
4 Based on interviews with managers and front-line staff.
5 In 1995 a palliative care doctor in Edmonton advised a Committee of the Alberta Medical Association
that "in 1992-93, 85% of patients who died of cancer in Alberta, died in acute care hospitals. In 1995-96,
it is expected that 70% of patients who die from cancer will die at home or in a long term care facility."
(Taking Stock, Alberta Consumers' Association, 1996).
6 In fact, in order to get "placed", families must go on an urgent waiting list and take the first bed
available. While later transfers from within the system are an option, the trauma of readjustment means
many don't bother.
7 The Broda Report's official title is Healthy Aging: New Directions for Care. It was the report of the
Long Term Care Policy Advisory Committee issued in November 1999. This committee was struck in
1997; its research was commissioned in 1998 and included a review by KPMG.
8 This split was heavily promoted by commercial operators as a means for them to provide a lower
contracted price to the public plan while maintaining profit margins and patient access to valued (or
marketed) services. Canada's Canary in the Mine Shaft, Alberta Consumers' Association, 2000.
9 Frustrated families and outreach agencies complain that requests for information are met with a
response that the individual "will receive whatever they need to meet their assessed need." Yet when
services or placement is obtained, it often doesn't meet their needs at all. Numerous families have
reported their unhappiness with what appears to be a commonly assessed need for all LTC residents: one
bath per week.
10 This separation also means that, although resident fees continue to rise, the money cannot be used to
increase the level of hands-on caregiving.
11 This strategy is not unfamiliar to the Alberta government; it reflects the province's position on facility
fees charged by private cataract clinics until 1996. Since the first clinic opened in 1980, the province
maintained a position that its only obligation was to fund the doctor's professional fee, not the operating
costs of the facility. This left patients to cover the full operating costs and any profit desired by operators,
over and above what the surgeon billed to the public plan. (The Consumer Experience with Cataract
Surgery and Private Clinics in Alberta: Canada's Canary in the Mine Shaft, Consumers' Association of
Canada, 2002).
12 A 1998 consultant's report to Alberta Health on the status of intravenous treatments went so far as to
suggest that regions and hospitals that do not charge outpatients are misinterpreting stated restrictions in
both the Alberta Hospitals Act and the Canada Health Act. The report argues that such charges are only
restricted if the service is exclusively provided in a hospital setting out of necessity. C.A. MacDonald
and Associates, The Provision of Publicly Funded Drugs in Community Settings, Alberta Health,
February 1998.
13 Interview in 2002 with Dianne Mirosh, executive director of the Long Term Care Association of
Alberta.
14 EPICC, the acronym for Evaluating Programs of Innovative Continuing Care, was an interdisciplinary
research project conducted between 1995-1998. Dr. Norah Keating, of the Department of Human
Ecology, University of Alberta, was principal investigator. The research was funded by Health Canada,
Eldercare On the Auction Block
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27
National Health Research and Development Program (NHRDP), through the Seniors' Independence
Research Program (SIRP) and the research arm of Canada's Drug Strategy (CDS).
15 Globe and Mail, "Seniors housing crisis predicted: Developers unprepared for boom: analyst," undated
clipping, circa 2001, and Malcom, K., The Financial Post, "Seniors market pumps up: companies are
scrambling to amass nursing home empires and cash in on growing number of golden oldies," undated
clipping, 2002.
16 Whitehorn Lodge, Assisted Living Condominiums promotional package, 2002.
17 The loss of safe, affordable housing for independent seniors would be no small matter. The academic
research is overwhelming: living alone on tea and toast is no way for an independent senior to stay
healthy. If someone has inadequate income, inappropriate housing, no social contact, and difficulty
buying groceries, a healthcare disaster is not far down the road. As well, the municipalities that provide
substantial grants to public lodges, which are considered low- income housing, also question their
taxpayers dollars being used for traditional nursing home clients.
18 Documented in a publication called "The Shame of Canada's Nursing Homes" by a Calgary based
organization called Families Allied to Influence Responsible Eldercare (FAIRE), and supported by
feedback from another grassroots organization in central Alberta called Families Protecting Patients.
19 Alberta for All Ages: Directions for the Future: Alberta Community Development, June 2000.
20 Vanier Institute of the Family website.
21 1999 MetLife Juggling Act Study. Recent research suggests that mental or emotional strain
experienced by the caregiver is an independent risk factor for mortality, particularly among elderly
spousal caregivers of people with Alzheimer disease. Schulz, F. & Beach, S. (11999) Caregiving as a
Risk Factor for Mortality: the Caregiver Health Effects Study. Journal of American Medical Association,
282 923), 2215-2218.
22 Fast, J. Keating, N., Oakes, L. , Conceptualizing and Operationalizing the Costs of Informal Elder
Care, NHRDP, 1997.
23 Aventis Pharma, 2002.
24 Harvard researchers found historic administrative costs in the U.S. to be four times greater than those in
Canada. Another significant cost factor is fraud. While the U.S. Medicare and Medicaid Programs are
busy taking numerous commercial suppliers of LTC services to court for fraud, Canadian policy makers
appear to think the problems do not exist here. Yet regulation and monitoring will inevitably become part
of a privatized LTC sector, driving costs up further.
25 Correction to original paragraph December 2002. Sentence 3 in paragraph 3 of Executive
Summary reflects correction. (Reference: Is the Balance Right, Premier's Advisory Council on Health,
December, 2001)
26 Calls for more private sector spending on health care are at odds with the fact that in 2000, Canada had
one of the highest levels of per capita private funding for health care of all the OECD countries ranking
third after the U.S. and Switzerland. (Every Number Tells a Story: A Review of Public and Private
Health Expenditures and Revenues in Canada 1980 2000, Conference Board of Canada, March 1999)
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Appendix
Insights from the Front Lines
NEW TAX ON THE DYING
My father had been on palliative home care and Mom, 88 was terrified of him dying when she was alone.
The nurse said he couldn't go to the hospital; he have to go to long term care. It was terrible with no
special treatment and no one seemed to notice when he was in pain. Mom got billed within days of his
admission and had to pay a month in advance. I can still see the look or horror on her face when she saw
the bill for over $1300 dollars and gasped "But I thought we had Medicare." Dad died 9 days later"
Family Member, CAC Alberta files, 1996
ASSESSED NEED FOR ALL LTC RESIDENTS: ONE BATH A WEEK: "We just don't get it until
we're there. I never thought my mother who was so impeccable would actually smell. I can't believe the
care she doesn't get at that nursing home."
Laurie, Edmonton, 2002
GETTING ANSWERS
"Many people often just need some help to get washed or dressed in the morning when they are ill or
have problems after being in hospital but it seems impossible to find out what someone is eligible for."
Outreach worker,
Edmonton Seniors Organization, 2002
WAREHOUSING
"The people who need the most care and are almost totally dependent get the least care. I call it
`warehousing'. These are people who are incontinent and can't dress or wash themselves, but they are
still people too. Sometimes there is only one person for 10 or 15 people, and the quality of the care you
get depends how far you are down the hall. If you are in the first room, you may be gotten up and washed
at 5 o'clock in the morning, and if you are at the end of the hall, you can sleep in. But if you are at the end
of the hall, you also have to wait the longest to get pottied."
Community Care Nurse
Southern Alberta, 2002
FILLING IN THE GAPS WITH TIME AND MONEY
"Many families either go in daily to feed a parent in long term care or pay someone to go in and feed
them or they don't get fed.. One woman paid $10,000 per month at a private lodge to make sure her
failing mother was fed and taken care of."
Bev McKay, Families Allied to Influence
Responsible Eldercare (FAIRE),2002
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PUSHED INTO PRIVATE MARKETS: THE NEXT GENERATION OF POOR
"I finally got a call from the private lodge with a special 20 bed unit for people with dementia. It costs
about $2340 a month, but it's going up another $200. Mom's been there well over a year now waiting for
a public bed and I'm starting to worry. With her income, she'll have used up all her savings in 2 ½ years
and then what will I do? I'm now starting to get a little worried about me. I wasn't able to work much all
those years caring for Mom, and only make about $11 dollars an hour as a personal care aide myself. I
thought I'd get at least a small inheritance, but now if I don't get a place soon, it's going to be all gone."
Daughter, 2002
BUYER BEWARE
"I've worked with a number of housing and assisted living buildings over the years, both for-profit and
not-for-profit. It really depends on the owner/operators, their philosophy and if they are fully occupied or
not. Some are good, and some really take advantage of people with add-on charges and unbundling
everything from the basic rent. People need to be careful and not just read the brochures. But it is often a
crisis, like the death of a spouse or some new health problem that will lead to them needing this kind of
facility."
Nursing Consultant, Calgary, 2002
CHERRY PICKING
"We don't allow you to rent is if you can't get from point A to point B, if you have a wandering problem
or anyone who needs attention on a regular basis such as someone with dementia or a brain injury. The
R.N. on site comes with the building and residents are only charged if they need if they need a needle or a
dressing change, doctors appointments. We also provide personal care or whatever service someone
wants for a fee."
Manager, private assisted living complex
COMMERCIAL INTERESTS FOLLOW THE MONEY
"Private operators need 60-80-100 bed operations to make a go of it and rural Alberta just doesn't fit the
bill."
Regional representative, rural RHA
CAPTIVE MARKET
"We just started something new with the Region where we get paid a "package" amount for providing
services to some of our residents who are eligible for Home Care - a kind of block funding. Yes, we are
a little concerned that this will affect our returns on sales of services, but we're hoping that by providing
some public services, people will be encouraged to top up. For example, the public home care program
will only pay for one bath week if the person is continent and 2 baths per week if the person is
incontinent. If people benefit and like the service, they may choose to purchase more, and baths assists
cost $16 per hour."
Manager, private lodge
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SOPHISTICATED CONSUMERS
"I try to be up front with potential residents about the costs, but the marketing people sometimes get a
little overzealous. It can be expensive and people need to think about these things, but they are usually in
a crisis when they are making a decision and it isn't easy. We've had 2 people in their 90s who outlived
their funds and had to move."
Nurse Manager, Private Assisted Living Residence
WHEN THE MONEY RUNS OUT
"Mom scrimped and saved all her life and did without many things so that she would never have to be in
a nursing home or be a burden on her family. But with the low returns on her savings and paying for care
only a few hours per day and three evenings a week for years, almost all her savings are gone. Home Care
doesn't provide any help for people with dementia. She's now out of money and out of choice.
Daughter , 2001
NOT NECESSARILY WEALTHY
" Most of my clientele are retired people. Many of them coming to me wanting give up the hassle of
home ownership, repairs and shovelling snow. They want to sell their house and move into a
condominium or one of the new rental accommodations for seniors. When markets were treating us
wonderfully this was economically viable to do so. But these days with the volatility of the market, the
most you can get for a $165,000 tax paid capital investment from the sale of your home with a fully
guaranteed investment is about 4.5% paid monthly. That's only about $619 dollars per month. After taxes
they may be lucky to have $500 per month. Add to that the Old Age Security of about $500 per month,
and any CPP earnings and its still not a lot, and it leads to people going through their assets very quickly.
With a longer life expectation and little earning power, assets can disappear pretty quickly. I don't
recommend that people sell their houses now. I encourage them to try and stay in their homes.
Gary Keiller, Financial Advisor,2002
TOLL ON CAREGIVERS HEALTH
"I can't believe it went on so long without any help. For months, I rarely saw my husband or my friends,
and would only drop in to work to meet my most pressing obligations. I had some health problems of my
own but not time to see a doctor. I was so emotionally drained and exhausted, I ended up taking another
4 months off work to deal with my own health problems."
Corinne, Edmonton, 2002
FAMILY BREAKDOWN
"Mom was incontinent and I couldn't go out anymore. She was getting harder and harder to handle, and
my husband was getting frustrated because I could never go anywhere with him. It seemed that I did
nothing but work and take care of Mom and all her health problems. I also really need to work more
because we didn't have that much money."
Arlene, Calgary, 2002
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Selected Bibliography
A Framework for Growth: Citizenship, Opportunity and Fairness in the New Millennium: A Discussion
Paper, The Premier's Council on the Status of Persons with Disabilities, 1997
A Housing Policy Framework for Alberta: Family and Special Purpose Housing,
Alberta Community Development: Seniors Services and Housing Division, August, 2000
Alberta Senior Citizens Housing Association (ASCHA) and Housing Directory, ASCHA,
http://www.ascha.com
Allen Gray Continuing Care Centre. "Gentle Approach Service Packages for The Place at Lakeside",
handout, April 2002
Assisted Living Federation of America web-site, http://www.alfa.org
Basic Service Standards for Continuing Care Centres, Alberta Health, April 1994
C.A. MacDonald and Associates, Publicly Funded Drugs in Community Settings: Background Report,
Alberta Health, February, 1998.
Canadian Health Services Research Foundation (CHSRF), "Myth: the aging population will overwhelm
the healthcare system", Mythbusters series, CHSRF website.
Carrington Group of Companies (Carrington Properties and Life Style Options Ltd) Website,
http://www.carringotnonline.com
Caufield, T.A., von Tigerstom, B. editors, Health Care Reform and the Law in Canada: Meeting the
Challenge, The University of Alberta Press, 2002
CPL Canada website: Long Term Care Real Estate Investment Trust and Central Park Lodges Inc., 2002,
http://www.cplcanada.com
Charpentier, Michele, The Law and the Relationships of Dependency Experienced by Seniors: the case of
privately operated homes for the aged, Gerontology and Geriatrics Research Centre, Sherbrooke Geriatric
University Institute, Law Commission of Canada, July 1999.
Continuing Care Centres of Tomorrow: A Role Statement For Alberta's Long Term Care Facilities, Long
term Care Facilities Sector Role Statement Working Group, Alberta Health, October, 1994
Continuing Care Strategic Service Plan: Phase II Expectations 2002-2012, Strategic Planning Division,
Alberta Health and Wellness, August, 2001.
Eldercare On the Auction Block
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32
Damsma, A., Eales, J, Gardner, L., Keating, N., Expressions of Authenticity in New Models of Continuing
Care for the Elderly, Evaluating Programs of Innovative Continuing Care (EPIIC), University of Alberta,
Department of Human Ecology, March 1998
"Extendicare nurses profit streak", The Toronto Star, August 9th, 2002, thestar.com
Dermode-Scott, B., "Public may take on home care costs", Medical Post, July 16th, 2002
Designated Assisted Living Provider Agreement: Between Calgary Regional Health Authority and
Central Park Lodges Ltd., June 13th, 2000, CRHA website, 2001
Diversicare Management Services website, http://diversicare.ca/
Dosman, D., Keating, N., Fast, J., Costs of Direct Services Provided by Formal and Informal Caregivers
to Seniors in Residential Continuing Care, Evaluating Programs of Innovative Continuing Care (EPICC),
University of Alberta, Department of Ecology, March 1998.
Families Allied to Influence Responsible Eldercare website, www.faireldercare.org
Fast, J., Keating, N., Oakes, L., Conceptualizing and Operationalizing the Hidden Costs of Informal
Eldercare, Final Technical Report to the NHRDP Development Program, 17/03/97
Grant, Nancy K., & Reimer, M., Indicators of Quality of Care as Perceived by Residents, Significant
Others and Nursing Staff in Long Term Care Facilities, 1991, Alberta Health Library.
Health Canada, Canada Health Act Annual Reports, 1995/1998 to 1999/2000
Health Aging: New Directions for Care, Parts 1, 2, & 3, Long Term Care Policy Advisory Committee,
Alberta Health and Wellness, November, 1999
Healthy Aging: New Directions for Care, Public and Stakeholder Response to the final report of the Long
Term Care Advisory Committee, Alberta Health and Wellness, April 2000
Himmelstein, D.U., MD, Lewontin, J.P., Woolhandler, S., MD, MPH, Who Administers? Who Care?
Medical Administrative and Clinical Employment in the U.S. and Canada, American Journal of Public
Health, Vol 86, No. 2, February, 1996
Hollander, Marcus J., The Costs and Cost-Effectiveness of Continuing Care Services in Canada, Queen's-
University of Ottawa", 1994.
" Is Assisted Living the right choice?", Consumer Reports Magazine, January 2001,
http://www.consumerreports.org
Keating et al, Defining Eldercare: Components and Perspectives, NHRDP Project No. 6609 1964,
University of Alberta, October 1996 (authors)
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33
Long-term Issues for Long-term Care in Alberta, Alberta Long Term Care Association, 08/01
Long Term Care Review: Summary of Consultations with Experts & Summary of Consultations with
Public, Alberta Health and Wellness, 1999
Long Term Care Review: Future Scenarios: Continuing Care Service Needs in Alberta, November 1999,
Alberta Health and Wellness, 1999
Looking to the Future: A Discussion Paper on an Agenda for Older Albertans, unpublished report,
Alberta Seniors Ministry, December 1992.
Mackie, R. and Campbell, M., "Tories alter nursing home fee-hike plan", Globe and Mail, August 1,
2002, Page A
Population Research Laboratory, Health Survey 2001, University of Alberta, 2001.
Premier's Advisory Council on Health, A Framework for Reform: Context Papers, Alberta Government,
12/01
Premier's Advisory Council on Health, A Framework for Reform: Report of the Premier's Advisory
Council Health, Alberta Government, 12/01
Przybylski, B. et al, A Study of the Outcomes of Enhanced Physical Therapy and Occupational Therapy
Hours of Service to Long Term Care Residents in a Nursing Home Setting, Submitted to Long Term Care
Branch, Alberta Health, September, 1993.
Report of a Study to review Levels of Service and Responses to Need in a Sample of Ontario Long Term
Care Facilities and Selected Comparators, PricewaterhouseCoopers LLP, Ontario Association of Non-
Profit Homes and Services for Seniors and the Ontario Long Term Care Association, January 11, 2001.
Research on Aging, Policies and Praxis (RAPP), Department of Human Ecology, University of Alberta,
http://www.hecol.ualberta.ca/rapp/
Reclaiming Medicare, Parkland Institute, University of Alberta, May 2002
Residents of Alberta's Long Term Care Facilities: A Descriptive Profile, Long Term Care Branch,
Alberta Health, 1991.
Sauve, R., "The Wealth of Canadians and Their Families", People Patterns Consulting, Vanier Institute of
the Family website
Schalm, C., Lier, D., The Public Program Costs of Three New Models of Continuing Care, Evaluating
Programs of Innovative Continuing Care (EPICC), Alberta Health, March 1998.
Eldercare On the Auction Block
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34
Strategic Directions and Future Actions: Healthy Aging and a Continuum of Care, Alberta Health and
Wellness, April 2000
Supportive Housing for Seniors: Rising to the Challenge, Conference Proceedings, Greater Edmonton
Foundation, Edmonton May 2 &3, 1996.
Taking Stock, Consumers' Association of Canada (Alberta), 1996
The Party of the First Part...": Contracting in Health Care, Conference Summary Report, May22-23,
1997, CHEPA, McMaster University, Hamilton, Ontario.
The Safety of Adults Living in Residential Care Options: Final Report, Interdepartmental Working Group
on Private Care and Group Homes, Government of Alberta, April, 1998
The Shame of Canada's Nursing Homes: A Testimony of the Experiences of Older Persons in Care
Facilities in Canada, Families Allied to Influence Responsible Eldercare (FAIRE), September 2001.
The Metlife Study of Employer Costs for Working Caregivers, Metropolitan Life Insurance Company,
June, 1997
The MetLife Study of Employed Caregivers: Does Long Term Care Insurance Make a Difference,
Findings from a National Study by the National Alliance for Caregiving and LifePlans Inc., March 2001.
The Waterford of Summerlea: "Services Available", hand-out, Edmonton, Alberta, 2002
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