Defining Long-term Residential Care in Canada

The two main types of residential care services are chronic care hospitals or chronic care units within hospitals, and long-term care facilities that provide multiple levels of care that cover clients at intermediate and extended care levels (Chan & Kenny, 2001). Chronic care hospitals or units provide care to persons who, because of chronic illness and marked functional disability, require long-term institutional care but who do not require all of the resources of an acute, psychiatric or rehabilitation hospital. There is 24 hour coverage by professional nursing staff, and on-call physician care is provided as well as care by other health and social specialities. Long-term residential care facilities (also called nursing homes or homes for the aged) are equivalent to lower levels of residential care in other countries and provide a protective and supportive environment to clients who can no longer live at home. Residents receive assistance with the activities of daily living, 24-hour surveillance, assisted meal service and professional nursing care and/or supervision, including supervision and medication (Chan & Kenny, 2001). The term residential care facilities refers to facilities with four beds or more that are funded, licensed or approved by provincial/territorial departments of health or social services. Apartments or other facilities (e.g. assisted living or retirement homes) not providing any level of care are not included in this definition (Statistics Canada, 2007).

According to a 2005/2006 survey of residential care facilities in Canada, there are 2,086 homes for older adults serving 196,242 residents and employing 158,732 workers. Nearly half (48%) of these care workers were part-time employees. Payment for resident-days in homes for the aged come primarily from the provincial health insurance plans although about 13% comes from other sources such as self pay (Statistics Canada, 2007:42). The amount coming from other sources varies by province from a low of 0% in Québec, 14% in British Columbia, 17% in Ontario, 21% in New Brunswick and 33% in Prince Edward Island (Statistics Canada, 2007:43-47). There are sizable differences in the expenditures per-capita on homes for those aged 65 and over by province. British Columbia ($1,874) and Ontario ($2,475) had the lowest expenditures per-capita and Saskatchewan ($3,348) and Manitoba ($3,287) had the highest with the other provinces and territories falling in-between (Statistics Canada, 2007:11).

Ownership of Long-term Residential Facilities in Canada

Homes for older adults fall into three broad categories of ownership: private (proprietary), government (federal, provincial and municipal) and not-for-profit (lay and religious operated facilities). Private sector homes constitute 54% of the ownership with not-for profit (24%) and government (22%) making up the rest (Statistics Canada, 2007:13). Government owned facilities are significantly larger than the not-for profit or for-profit sector homes (Berta et. al., 2006). Regional variations exist with government owned LTC facilities more likely in Alberta, the Prairies and Ontario, while for-profits dominate Eastern Canada and for-profits and not-for-profits co-dominate in the West (Berta et al., 2006).

Utilization

According to a 2005/2006 survey of residential care facilities in Canada, there are 196, 242 residents in homes for the aged. According to the 2001 Census, close to 7-8% of all seniors are institutionalized in Canada and the percentage increases with age, with 35% of all seniors 85 and over living in institutions (Cranswick, 2005). Census data also indicates that there are provincial differences in rates of institutionalization. Further the proportion of seniors residing in LTC facilities has been declining for both men and women and for all age groups. Individuals residing in homes for the aged are those in need of high levels of daily personal care entailing supervision or assistance with activities of daily living, 24 hour nursing care or supervision and a secure environment (Berta et. al., 2006). Trottier et al. (2006) show that nursing home residents are more likely to be women, to be living without a spouse and to have low incomes. Further, a recent hospital admission, having one or more problems with the activities of daily living, having a severe disability, having a debilitating chronic condition such as Alzheimer’s disease, urinary incontinence and the effect of a stroke are all strongly associated with living in

The Statistics Canada 2005/06 survey of residential facilities indicates expenses-per-bed were lower for privately-owned facilities ($39,001), than they were for not-for-profit ($52,845) and government facilities ($59,421) (Statistics Canada, 2007:13). Compared to not-for-profit and government owned homes for the aged, privately-owned homes for the aged operated with lower employee-per-bed, hours-per-bed and wages-per-bed ratios. Using this same data, Berta et. al. (2006) found that the national total direct care staffing levels is 4.47 hours per resident per day, however staffing levels varied by region, type of ownership and occupation. Government owned facilities are more likely to have higher staffing levels, including the highest nursing staff levels and overall direct care staffing levels. Not-for-profit facilities are intermediate in terms of staffing levels and for-profit facilities have the lowest levels of staffing levels. Not-for-profit facilities tend to have higher levels of unregulated staffing. This is partly explained by differences in the levels of care provided by type of facility. Government-owned facilities were more likely to have a higher proportion of residents receiving higher levels of care (Type 3) that required skilled employees and more hours of time. Berta and colleagues (2006) concluded that “Whether these [differences] are the manifestations of intentional strategic marketing/targeting decisions on the part of particular ownership types, or of historical-political processes, or both, we are unable to answer here” (p.191).

There is paucity of research on human resource issues in long-term care facilitates. There is research on the nursing workforce, but data on nurses working in long-term care facilities is rarely separated out. In the nursing human resources sector study, O’Brien-Pallas et. al., (2004a) identified nursing shortages, more particularly with RNs and LPNs, to be an important issue. Compared to other nursing occupations, the retention rates were highest for RPNs and their retirement rates were lowest. LPNs had the lowest retention rate of all nursing occupational groups and were most often hired on a causal basis (O’Brien-Pallas et. al., 2004b). They were also more likely to be hired in a LTC setting. Factors contributing to nursing shortages included the aging of the nursing workforce and early retirement as well as difficulties recruiting new nurses. The long-term care sector identified difficulties recruiting new graduates at their sites noting that new graduates were more interested in working in acute care. Other factors contributing to the nursing shortages included the lack of full-time positions, workload demands, difficult clients and isolation/rural challenges. The migration of nurses to the United States was also identified as a factor contributing to difficulties with recruitment and retention. Among nursing occupations RNs represent the highest proportion of hires from outside of Canada.

Research on working conditions indicates concerns with heavy workloads, violence/abuse in the workplace, health and safety, and the need for education to promote safe practices (O’Brien-Pallas et. al., 2004a). In terms of utilization and types of employment, the human resource sector study revealed variations in working conditions among nursing occupational groups (O’Brien-Pallas, 2004b). RNs across all health sectors including community health care and long-term care facilities were more likely to work in a unionized environment, had more educational support available and experienced the highest access to continuing education provisions among all nursing groups. Compared to acute care hospitals, the long-term care sector had the lowest nurse to patient ratios. O’Brien-Pallas et. al. (2004b) argue that in LTC the caseload is so heavy that nurses responsibility is to direct care and delegate functions of care to be carried out by aides and other multi-skilled workers. This is of particular concern because the acuity of clients and the complexity of their care have been increasing in recent years due to health care restructuring. They note that the level of workload and adequacy of resources have been major concerns expressed by nurses in Canadian studies over the past 5 years.

Recognizing that due to current restructuring of healthcare system, the process of filling in the positions and finding the right fit in long-term settings is extremely difficult, in 2004, the Ministry of Health and Long-Term Care (MOHLTC) published a resource kit for the long-term care facility operators. This kit, called Targeted Recruiting by Long-Term Care Facilities, as a part of broader guide titled Recruitment & Retention Tactics for the Long-Term Care Facility Sector, outlines tips and strategies on how to target professionals for recruitment to rural communities, how to target graduating students for recruitment and how to tap into underutilized labour pools such as mature workers, and workers who are new to Ontario (Ministry of Health and Long-Term Care, 2004). Especially interesting for the purpose of this report is the third section of this kit- the one that focuses on targeting and recruiting new and established immigrant groups. In the opening parts of that section, it is stated that immigrants represent a great recruitment opportunity for LTC facilities because: 1) many immigrants are in process of getting their qualifications recognized; therefore, by offering them an initial opportunity, the chances are great that they will stay in facility that secured them their first job; 2) many facilities may require workers with knowledge or skills relating to certain cultural groups.

After elaborating on source countries and destination patterns of old and most recent immigrant groups, among other actions, the kit recommends that employers:

1. get in touch with settlement organizations which more often than not provide employment programs and job search workshops through which potential employees may be targeted
2. go to ESL classes in local communities and colleges in order to meet and recruit new immigrants to their facility
3. advertise job positions in ethnic newspaper
4. distribute job flyers or information pamphlets at local meeting sites such as community centers, shopping centres, grocery stores, local coffee shops or restaurants and places of worship where specific immigrant communities are located
5. go into the community and talk with the community leaders or religious leaders about opportunities their facility can offer new immigrants
6. offer public transportation discounts as new immigrants may lack transportation to areas where demand for workers are high
7. offer on-the-job training programs (Ministry of Health and Long-Term Care, 2004).

In Ontario there are no educational standards for health care aids/personal support workers (Smith, 2004). Some workers have no formal training while others have three to five months of community college training. In 1997, the Government of Ontario established the Ontario’s Personal Support Worker (PSW) training program, a single program that consolidates and substitutes the former Health Care Aide and Home Support Worker training programs (Personal Support Network of Ontario, 2008). Its aim was to standardize college programming offered across the province, widening the focus of college programs to make sure graduates possess the skills to be flexible and to continue to learn and adapt, and providing public accountability for the quality and importance of college programs (Ministry of Training, Colleges and Universities, 2008). The PSW curriculum is a minimum of 500 hours in length and is provided by Ontario Community Colleges, Registered Private Career Colleges, some Boards of Education and not-for-profit organizations (Ontario Community Support Association, 2008). Still, as the program fees are high , it remains out of the reach for many wishing to pursue the PSW career (Service Employees International Union, 2006). Taking such fact into consideration, it is not surprising that a review of 20 nursing homes in Ontario indicated a need for staff training and education. The report recommends more training particularly in gerontology, recognition and prevention of abuse, communication skills, dementia care and palliative care (Smith, 2004).

In order to be able to work in many of the long-term and home care setting in BC, one has to graduate in the Home Support/Resident Care Attendant Program (Vancouver Community College, 2008). This program lasts somewhere in between 23 and 27 weeks (depending on the college at which it is taught) and combines class and practical experience. After completion of this program, the graduates are prepared to work in a variety of settings, including intermediate care, special needs, extended care, home support and some adult day centres.

It is important to highlight the fact that in many provinces, homemaking and personal care are done by the same workers (e.g. Saskatchewan, Québec, New Brunswick, Nova Scotia, Prince Edward Island, Newfoundland, Yukon, Northwest Territories) (Health Canada, 2006). For instance, Ontario has attendant care workers who do both homemaking and personal care. In general, the training requirement for homemakers is less than that of personal care workers. When homemaking and personal care are performed by the same worker, personal care usually takes priority over basic housework.

Issue of registration/licensure with regard to PSWs in BC, Ontario and Québec:

Personal support workers are unregulated health care providers and thus, there is no officially recognized "certification" or "registration examination" (Ministry of Training, Colleges and Universities, 2008; OCSA, 2008). There is no regulating body for those graduating in PSW program (OCSA, 2008). In doing their work, PSWs are monitored by a regulated health professional, supervisor, or, in the case of supported independent living environment are directed by a client. In performing their assigned duties, they have to safely and competently follow care/service plans, oral directions, and written guidelines, and to comply with established policies and procedures. PSWs must not engage in a controlled act (Regulated Health Professions Act, 1991) if the authority is not conferred upon them by a regulated health professional who, in coming up with such a decision, has referred to the clearly specified directions outlined by their regulatory body.

In Québec, the division of tasks is somewhat different. The equivalent to a PSW who work in long term care facilities in Québec falls under the rubric of “Assistance à la personne en établissement de santé” and is generally called préposé(e) aux bénéficiaires (PABs), aides infirmières/aides infirmiers or aides-soignant(e). These workers are required to undergo a 750 hour course which includes resuscitation. The prerequisites for this course are the same as in other provinces in Canada. At the end of this training, a certification is awarded. With this certification they are eligible to work in hospitals, long-term care facilities and rehabilitation centres. The 750 course, available through Emploi Québec, is subsidized by the Ministry of Education in Québec, leaving a modest fee of $100-$150 for the student to pay. This training program is in great demand, and therefore there can be waiting lists of 6 months or more to take the certification course. There are private institutions which also offer the certification course, but they charge between $12,000 and $14,000. In order to work in the public sector, one must prove that they have this certification, though there are some loopholes. PABs working in the public sector earn between $16.54/hour and $18.14/hour. In the private sector, however, PABs are not required to have this certification. They can take courses of a much shorter duration (between 5 days and 400 hours) and be eligible to work. Their salaries are generally somewhere between $8.75/hour and $14/hour. According to statistics Québec, the number for 2005 indicate that 36,400 PABs work in public institutions while 38 6000 work in private institutions for a total of 75,000 PABs in Québec. PABs are attempting to organize and become recognized as a profession. They are lobbying to create a professional order which requires that all PABs obtain the same training, regardless of the sector they are hired in. Furthermore, the FPBQ hopes to increase the training of PABs to allow them to administer medications, a task which often occurs in Québec illegally (FPBQ publication May, 2008).

Workers in home-care are called auxiliaire familial et social (AFS) and required to take a more extensive training course which lasts between 975 hours (in urban regions) and 1800 hours (in rural regions). The subsidized course costs between $330 and $600 and includes training on home-care related tasks. Again, AFSs who are hired through public facilities but those hired through agencies often have less training. In the public sector, these workers earn between $17.19/hour and $18.87/hour, but much less in the private sector (www.fpbq.com and www.avenirensanté.com).