Some Thoughts – and Questions – about Our Aging Population and Health Care Needs.

Norman Rowen
14 June 2021

In the midst of our year of Covid-19, there have been so many reports about the terrible toll the initial phases of the pandemic took on the elderly.  Indeed, more than three quarters of the deaths in the early going were seniors, most notably in long-term care homes.  And there have been announcements about how we can protect these residents in the future, just as there were following other similar, if less dramatic, events where the elderly in long term care paid a heavy price.  We’ll see what really changes.

While that’s all true, it might also be useful to step back a bit to understand the bigger picture.

My partner of nearly half a century hates it when I say I’m “old”, but “elderly” doesn’t sound much different to me.  She’s likely reflecting a lifelong understanding that it’s hard to grow old gracefully (though she most certainly has).  So, whether we talk of “old”, “elderly”, a “senior”, it’s reality for many of us.  I’ve had quite a number of discussions over the last few years with others in both city and country about what our next years might be like.  Of course, health care is a main topic, but it also gives way to how people feel about where we’ll live and what choices we may – or may not – have.  This is where housing and health care meet.

To begin, there are a few things we need to wrap our heads around.  As TWIG’s new upcoming report has shown, the number of Ontario seniors will exponentially keep growing.  The population over 70 will have grown from 1 million in 2001, to nearly double that (1.87M) today, to nearly 3 million in a decade, and 3½ million in twenty years.  That’s a seismic increase.

The pandemic tragedy has meant that we’ve paid attention to the numbers in long-term care.  Again, TWIG undertook to provide estimates based on the current ratio of population to those in long term care and retirement homes.  In 2001, there were fewer than 400 such institutions; about one for more than 2500 people over 70.  Today, there are more than 800 and a slightly lower ration of one per 2300.  If we look ten years down the road, we’ll be needing more than 1100 and, in twenty years, more than 1400 or early twice the number we have today, based on current ratios.

Of course, many health planners and economists have wondered how we’ll pay for this and how we’ll ensure enough of the several types of staff require to meet the needs of these institutionalized elderly.  While we all haven’t got dementia now, many of us will as we age.  And we know that many of the elderly are institutionalized precisely for this reason: they need care we cannot provide at home.

Of course, that suggests a second point we need to get our heads around: the estimates assume that the same proportion will be institutionalized.  While the increases in seniors in long term care are large, they constitute only about five percent of the elderly.  Nearly 95% will continue to live and receive care and support in the community.  This is an important part of the big picture.

And the human resources, the actual people needed to take care of and support our elderly will similarly increase with the increased population of seniors.  For example, if we look at just personal support workers (PSWs).  TWIG’s projection, based on the current labour force in long-term care homes suggests we’ll need about 50,000 additional PSWs over then next twenty years; half of these in the next decade; and that’s in addition to replacing those leaving these jobs. (The Ontario Government has estimated that 40% of PSWs leave the health care sector within a year of training.)  When we add those to PSWs working in the community, going into people’s homes (and retirement homes), that number easily doubles to more than 100,000.  According to TWIG’s estimate of new and replacement needs, Ontario currently needs nearly 15,000 new PSWs annually, rising to more than 25,000 per year by 2045.  In addition to PSWs, we will need more registered nurses, registered practical nurses, geriatricians, physio and occupational therapists, and other allied health professionals.

The question of who pays for such a large increase in staffing cannot be avoided indefinitely.  Nor can the question of how to recruit people to fill these jobs when wages have been traditionally so poor that premiums during Covid have been considerable; and when wages in institutions rise above minimum wage, filling jobs in the community-based sector becomes even more difficult with a $5/hour (25%) difference between the two sectors.  But how to plan and deliver the human resources is a second order question.  The first question is what a “system” to support seniors and the elderly should look like.

First, under what conditions can and should an elderly person be in a long-term care facility?  Who are those who really require constant care?  Over time, these have become people with more and more serious medical needs including dementia.  Picard, following from other studies, suggests that the ratio of staffing in such facilities needs to change to ensure more direct nursing care (though still the majority of care would be by PSWs and RPNs).  While more expensive, nursing homes had nursing care for a reason: it was needed.  And, if we continue to limit such homes to those with more complex needs, we will again.  And we’ll have to pay for it.  We need a clear plan for who should receive such intensive care, how it will be staffed, how it will be funded, and how we’ll ensure quality.  No matter who we’re serving in such institutions, the standard of care we rightfully must expect won’t be achieved without well paid, regular (not casual) staffing by people who actually want to do a good job and are given the support so they can.

Second, the number of older adults in institutional care is a reflection of the relative absence of support in the community.  For this, Picard makes clear that we owe it to ourselves to consider a number of alternative models of care from countries which have shown that the quality of life seniors enjoy, even as we age and need more help, can be delivered effectively in the community at a reasonable cost.  Since the overwhelming proportion of the elderly will be in the community, it is absolutely essential that we get it right.  But what does that mean? The stories of inadequate, poorly paid, transitory home care staffing are legion matched only by the promises of governments to fix it.  As the saying goes, we’re long past “a day late and a dollar short”.

When I’ve talked to my peers, most imagine of some form of collective living, not individuals or couples in totally separate homes or apartments.  Rather, people see some grouping of half dozen or a dozen people who can share caregiving with each other and all the routine tasks of maintaining the household (albeit with some paid maintenance help from time to time which is increasingly difficult to come by, particularly for small but important tasks).  The Covid experience has (or should have) made the toll of isolation unacceptable in all but extreme situations.  But has it taught us enough about possible forms of more collective living? Some of these lessons come from movements such as “co-housing”, “co-living” and “co-care”.  Begun in Denmark in the 1960s, there are now many variations on this theme of mutual support through intentional design of physical space to provide both private and collective functions.  In Canada, we have the Canadian Cohousing Network as a potential resource (www.cohousing.ca).  A key challenge going forward might be how to integrate more complex health care supports into models which have been primarily focused on housing.

The variety of possible group living situations has barely begun to be explored in Canada.  Nor do we know enough about when and what kind of supports are available now and will be required.  For example, when my mother-in-law was beginning to experience dementia, her partner was able to keep her safe.  Until he wasn’t.  And, at that point, he was smart enough to acknowledge he couldn’t and ask for help.  My wife and her sister were able to step in, for a while, but eventually some institutional care was arranged, at considerable cost.  It could have, should have been possible for her to remain in her own home if particular supports were reliably available.  But they weren’t.  And for us, as it likely will be for our children and grandchildren, the lives of younger generations cannot be completely given over to caring for our individual elderly family.  As my dear mother-in-law used to say “you kids have your own busy lives”.  And no matter how often we said “we’re fine”, we all knew there were limits to what we could do.[1] 

Third, we had precious few choices in selecting an institution.  Few “family” living situations were around then; actually only one that was both small and secure and, most important, caring.  These are the kinds of situations where housing and care options need to be greatly expanded.  Both cities and country have their own challenges.  Housing and zoning in the city make co-housing on a larger scale hard to imagine without it becoming “institutional”.  In the country, distance and lack of professional supports make the able-bodied exhausted at the prospect of caring for multiple friends and neighbours.  I’ve seen it happen.  But I’ve also seen some communities where new housing for seniors could have been built with, for example, communal kitchens, and other indoor common spaces that didn’t require getting in a car, while still preserving some independent spaces. And what of intergenerational options besides having your own children caring for their own parents?  We need to understand how those kinds of communities could also be realized.

These are at least three of the big picture questions that await us.  We’re not starting from scratch though.  Picard and others have pointed to many other jurisdictions that have and are now trying things, that have learned lessons about what people need and want; and about the challenges of actually doing things differently than what we’ve done till now.  We always talk about being a learning culture or organization or society – or at least wanting to be.  Well, here’s another chance.  Let’s learn from others.

Denmark is the country Picard emphasizes for its focus on supporting the elderly to remain at home, thus limiting institutional care by ensuring the necessary supports are in place.  He offers the contrast that Denmark spends 80% of it’s funding on care in the community while we spend that proportion on institutional care.  In a column this past February, Picard also points to Australia for their insights.

On first reading of his examples two lessons come into view: first, providing the right level of care at the right time; and, second, ensuring that care at all levels is high quality; that is, that it is properly staffed and properly paid, meets the highest standards, and is monitored regularly by practitioners responsible for ensuring the appropriateness and continuity of care.  We need to learn such lessons and apply them to how we deliver what our elders need and deserve.  We need to stop assuming we know the answers.  Or that the answer is simply more money when we need to think through “money for what?”

And if there’s a third lesson from Picard it may be his plea for action; that we’ve studied the problems enough, for decades, in reports from academics, practitioners, and coroners. Rather, we need to identify, commit, and implement solutions. Now, not later.

Years ago, Charlie Leadbeater told a group of us in Canada that the challenge in providing human services – health, education, social services – is to design them in a way that we provide the high touch and often intensive support people need in a manner that is also efficient and can be flexibly scaled for different situations.  That’s a tall order.  The lessons from experience across many sectors showed that most actual programs of successful innovative supports were either too small to sustain let alone scale up, or were sacrificed to the gods of finance and false economies.  It’s hard to find the sweet spot.  But it’s there… or could be.  Picard warns that if we don’t find it, we’ll remain lost in our current failures: too many people not getting the support they need when they need it – at great cost in dollars and lives.

We can’t really predict the future.  We make educated guesses at best.  We really don’t know what it might be like were there are any number of alternative approaches to caring for the elderly – for all the different older folks who will need different things at different times.  But the fact that we don’t know what it’ll feel like or how these alternatives would actually work should excite us, not scare us.  After all, as a wise school board official told me when we were just beginning to design Pathways to Education in Regent Park “What’ve we got to lose?”   Indeed.

Norman Rowen designed the Pathways to Education Program at the Regent Park Community Health Centre and was it’s first Program Director. Together with Carolyn Acker, then ED of the Health Centre, they built Pathways to Education Canada to support the program’s replication in other communities, now in twenty sites from Atlantic Canada to British Columbia.  Now mostly retired, he has continued a four decade long career of research, evaluation and policy analysis in education and training. . 

1 The past year has shown both the benefits and the challenges of caring for both older and younger generations. With respect to older Canadians, Picard has said: “I think you have to remind them that everyone’s going there eventually. We’re all on a fast stream to taking care of our parents and our grandparents. This is simple demographics — there are fewer children born, our parents are living longer, and it just means there’s going to be more and more caregivers, and they’re going to be younger and younger. There’s going to be a lot more pressure to do this on everyone. Even younger people really have to take this to heart. It’s going to be a lot more people caring for their parents and their grandparents.” [https://thetyee.ca/Culture/2021/03/02/Andre-Picard-Q-And-A-Elder-Care-Canada/]

Some Thoughts – and Questions – about Our Aging Population and Health Care Needs.
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