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Jumping on the
Alberta Bandwagon
Does B.C. need this
kind of Assisted Living?
September, 2002
By:
Wendy L. Armstrong
Alberta Chapter
Consumers' Association of Canada
Prepared for:
The Hospital Employees Union
British Columbia
Based on research for CAC Alberta's report "Eldercare On the Auction Block"
(2002) and
presentation to Seniors, Health and Housing Policy Forum, SFU, Vancouver, BC,
May 2002.
Copies of the report are now available from CAC Alberta at (780) 426-3270 or
cacab@ecn.ab.ca
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Jumping on the Alberta Bandwagon:
Does B.C. need this kind of Assisted Living?
by Wendy L. Armstrong
Alberta Chapter, Consumers' Association of Canada
Many British Columbians are concerned about the provincial government's
plan to drastically alter residential care for seniors. In the spring of 2002, Victoria
announced the closure of 3,000 beds in traditional long-term care facilities and a
concurrent scheme to invest federal housing dollars in Assisted Living complexes
for seniors. To appease the public's worries (and confusion) about these moves,
some officials have talked soothingly about B.C. emulating "the Alberta model".
Just what is the Alberta model?
In the last decade the province of Alberta was pulled in two different
directions. On the one hand, innovators were able to pilot three new public models
that yielded many valuable ideas about alternatives to old-style facility care.
Unfortunately, these pilot projects were overwhelmed by another, much stronger
trend in Alberta: the unravelling of
public coverage and the growth of
"Public coverage of many
private-pay markets. Today public
long-term care services has all
coverage of many long-term care
but disappeared in Alberta"
services - residential and in-home - has
all but disappeared in Alberta. Public
access is not far behind. As their loved one's health deteriorates, elderly spouses
and adult children now must deal with buying or providing care on their own.
Indeed, so much of the burden and cost of care has been offloaded to families, 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 U.S.
system is administratively more expensive than Canada's, health authorities in
Alberta are now spending more money administering an increasingly fragmented
and privatized system, and less money actually funding and delivering health
services.
Stepping away from public coverage
The dire situation in Alberta did not arise by accident. In 1990 the province
simply stopped constructing new nursing homes and auxiliary hospitals, even
though Alberta's population was to increase by almost 500,000 over the next
decade. Bed shortages led to restricted access for the neediest patients only.
Direct care staffing was cut almost in half. Terminally ill cancer patients were
moved out of acute care hospitals into LTC facilities, where they were charged per
diem fees. Much-promised home supports for seniors with less serious physical
and cognitive impairments failed to materialize - and even decreased.
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In 1994 the province began to surreptitiously withdraw funding from the
support side of long term residential care. This was part of a mounting trend by the
Klein government to separate the costs of "health" from the costs of "housing."
Direct care costs (health care provided by professionals and others) would
continue to be publicly funded, but other support and living expenses (housing,
cleaning, meals, laundry, monitoring, etc.) would gradually become the personal
responsibility of seniors in LTC settings, whether in an auxiliary hospital, Assisted
Living or at home.
The ever-growing shortfall created by downsizing beds and reducing quality
in public LTC created tremendous opportunities for real estate developers. A
lucrative private-pay market arose in Alberta, mainly lodges and retirement homes
based on the commercialized, U.S.-style "Assisted Living" model.1
"Assisted Living": What does it mean?
When Assisted Living originated in the U.S. in the late 1980s, it represented
a new and progressive approach to the needs of special populations with limited
abilities. The original Assisted Living model calls for a home-like setting that gives
residents control over their private space. Residents are helped to maintain their
existing capacity for self-care, self-direction, and social interactions. In contrast to
old-style nursing homes, residents are encouraged to do as much as possible for
themselves in an environment of managed risk - under the watchful eye of a care
organization that coordinates all necessary health and support services.
This approach to Assisted Living may include a basic package of meals,
housekeeping, and help with personal care such as bathing, grooming, or
transferring. It may also offer the option to purchase individualized services over
and above the basics. Naturally, the original philosophy envisions homes and
services that are affordable and accessible to seniors in need.
Since its inception in Oregon, Assisted
Living has branched out in many less-than-
"The original vision of
authentic directions in the U.S. and Alberta. The
Assisted Living has been
term is now applied to housing situations and
care models that do not embody the original
largely co-opted by
philosophy. Today, Assisted Living is more likely
commercial operators
to refer to multi-unit apartments with varying
looking for a high return
amounts of on-site personal supports (meals,
on investments."
housekeeping, and social activities) and
personal care available 24-hour-a-day, all of which must be purchased by the
resident. Regrettably, the original vision has been largely co-opted by commercial
operators looking for a high return on investments.
In Alberta, the reality of Assisted Living is a crisis in access, costs, and
funding.
Let's look at the private and public faces of this kind of care housing today.
1 These support costs are sometimes called "hotel costs".
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Assisted Living for profit
As in the U.S., developers and realtors in Alberta promote Assisted Living
as a residential option that falls somewhere between independent living and
nursing home care. 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.
Seniors either buy their own unit as a life lease or they pay rent. 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 $20-28 per hour.
The business of itemizing and tracking these fragmented clusters of service
is itself pricey an administrative cost that is passed on to the "consumer."
These for-profit facilities operate in a regulatory void, even though many
residents are captive and vulnerable consumers due to their emotional, physical,
and cognitive impairments. If the price of a bath or incontinence care rises too
high, they often have nowhere to turn. If a service or building feature goes wrong,
they often dare not risk complaining. Opportunities for exploitation abound. One
Alberta facility charges residents $7 for a single wheelchair ride from the front door
to their room.
Alberta pilots a public model
While these private-pay complexes were sprouting on Alberta soil, several
innovative models of care were being piloted. The Good Samaritan Society's
Assisted Living project in the early 1990s was based on the original, non-profit
model in Oregon. Caring partnerships among operators, families, and residents
were central to the philosophy. The Good Sam model offered basic services (e.g.,
one meal a day) with opportunities to purchase up. As with traditional nursing
homes, residents were placed by a public health authority and paid a per diem fee.
An evaluation of the project by researchers at the University of Alberta
identified a number of benefits and limitations.2 On the plus side, participants were
pleased that the care was indeed enhancing the well being of residents. On the
minus side, major concerns arose about added costs and burdens for family
members. Expressed in dollars, researchers found that families were contributing
$5,800 per resident per year or 41% of direct service costs (above per diems).
2 EPICC Evaluating Programs of Innovative Continuing Care was an interdisciplinary research project conducted
between 1995-1998. Contact Dr. Norah Keating or Dr. Janet Fast, Department of Human Ecology, University of Alberta.
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Expressed in time, families were contributing 50 hours per month in direct
services out of a total of 95 hours per resident. The researchers strongly
recommended that policy makers "incorporate informal costs, like unpaid
caregiving time, out-of-pocket costs and personal costs, into their decision-
making" about Assisted Living. They were also alarmed about the social and
economic well being of the largely part-time staff.
By the time the evaluation was completed in 1998, however, the
privatization die had been cast. Recommendations were ignored. Instead, the
province and regional health authorities began to see Assisted Living as an
opportunity to shift even more costs to residents, including building costs, drugs,
and many other services normally covered in facility settings (such as
transportation to medical appointments).
Here's how it works today.
"Alberta seems to be moving
"Designated" Assisted Living
towards making seniors pay
for anything that is not,
Existing commercial Assisted Living
narrowly speaking, a direct
operators and new non-profit operators use
their own capital and/or public housing
healthcare service."
money to build suitable rental units.
Owner/operators then set a rental price to recover their investment capital,
operating expenses, support service costs, and any profit margin. The RHA
contracts with the operator for control over entry to a number of units and for a
specific basket of care services (up to $1,500 per month in Calgary, 2002).
Candidates for nursing home care are then placed in these units through the
region's single point of entry process - that is, if the person is able and willing to
pay the rent.
Rental agreements are between the individual and the owner/operator.
Drugs and many other supplies must be privately purchased from retail
pharmacists. Families take on a greater role to make up for less monitoring by
health professionals. Definite limits exist regarding aging in place. In fact, seniors
and their families may need to purchase extra care even for temporary episodes of
illness, or else face dislocation.
Shrinking the healthcare basket
Alberta is now talking about shifting even more costs away from the public
healthcare plan. In 1999 the province's LTC advisory committee suggested that
individuals should start paying for personal care provided in any LTC setting:
nursing homes, Assisted Living, at home, etc. (Personal care is usually delivered
by a care aide who assists with dressing, bathing, eating, bedtime, housekeeping,
and monitoring.) In short, the province seems to be moving towards making
seniors pay for anything that is not, narrowly speaking, a direct healthcare service.
Regions would be obligated to pay only for approved services provided by
licensed health professionals such as RNs, yet these professionals provide little
daily care to at-risk seniors. Only people with very low income would have their
personal care covered by the public plan.
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If this direction is embraced, Alberta's LTC sector will be more or less
reduced to three functions: 1) care by RNs and other professionals, whose work is
very limited in LTC settings; 2) claims adjudication by regional care coordinators
(i.e., administering the shrunken system); and 3) care of the destitute.
The myths behind the "Alberta model"
These changes in Alberta's health care are predicated on a few widely
promoted assumptions, all of which are ideologically biased and factually suspect.
They include the following myths.
Myth #1: "People who need LTC services are sophisticated consumers with
lots of money."
Reality Check. Few Canadians can be called sophisticated consumers of these
kinds of care services and care housing. The need for LTC services usually arises
due to a major personal crisis such as a stroke or the death of a care giving
spouse. Families are often desperate for help. Even with experience, evaluating
complex service options is both difficult and time-consuming.
Further, most people over age 65 are not swimming in dollars. The median
income of seniors in Alberta was just over $1,400 per month in 1997. 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 paycheque away from serious
financial problems. In the so-called land of plenty, Alberta families have the
highest median debt-load in Canada.
Myth # 2: Shifting the costs and burden of care to family members is
costless to society
Reality Check. In fact, shifting sizeable costs and burdens to the family is
expensive on personal and societal levels. The stress of constant caregiving can
lead to emotional, financial, and health breakdowns. Employers of family
caregivers also pay the price in sick time claims, lower productivity, and indirect
administrative costs, according to a recent employer benefit plan survey.
Caregivers who are forced to drop out of the workforce may become the poor
seniors of the next generation. Research also shows that when family members
are stretched too thin by myriad physical tasks and responsibilities they cannot
provide the emotional support that is the key predicator of health in the elderly.
Forcing seniors, who have paid into the public system for years, to give up
almost all their income or spend all their savings and assets to obtain care is a
grim betrayal of their generation. It could also be viewed as a new kind of
inheritance tax. Forcing middle-aged children to buy into the high-priced private
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health insurance market is nothing more than an ill-conceived economic
development scheme to prop up North American insurance industry.
Myth #3: Private healthcare markets will provide better service and better
value for the money
Reality Check. Real competition, affordable prices, and quality controls are difficult
to achieve in private healthcare markets due to the nature of the demand and the
many opportunities for exploitation (i.e. vulnerable and often desperate people).
Further, a fragmented and privatized system is more costly to run than a public
system. As the number of suppliers and payers increase, so too do the costs of
documenting, monitoring, and regulating. Alberta is seemingly sprinting towards a
U.S.-style private-pay model of LTC, despite the fact that the American healthcare
system has administrative costs four
times higher than the rest of
"Forcing seniors, who have paid
Canada's.
into the public system for years, to
For example, the
give up almost all their income or
administrative costs of Alberta's
spend all their savings to obtain
health authorities rose 15.2 percent
between 1997/1998 and 1999/2000,
care is a grim betrayal of their
more than for any other category
generation."
except research and education.
Alberta's managers are spending ever-increasing amounts of time, energy, and
money determining eligibility, evaluating, assessing, documenting, approving,
coordinating, billing and collecting, and arranging for ever tinier units of care from
multiple agencies- instead of delivering services themselves. Billing clerks are
displacing Registered Nurses.
Beware the "Alberta model"
Assisted Living's promise 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. Assisted Living was conceived as a dignified
and responsive model of care for individuals with chronic or declining conditions.
But with Alberta's pattern of privatization and its neglect of the progressive public
model, Assisted Living could easily regress to the state of yesterday's unregulated
and abysmally staffed nursing homes, just as today's traditional long term care
facilities have deteriorated. There is a very big difference between autonomy and
abandonment.
Organizations and individuals are rightfully concerned about the recent
proposals for long-term care in British Columbia. Careful monitoring and much
lobbying are needed to avoid jumping on the Alberta bandwagon. The "Alberta
model" is nothing more than a quick trip down a rocky road to U.S. brand long term
care, fraught with crippling costs, lawsuits for fraud, stories of abuse, underpaid
staff, and a high toll in family bankruptcies.
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