Long-Term Care Funding in Canada

Summary

When Canada was founded, health care was delegated as a provincial responsibility. Although the federal government shares a portion of health care costs, it is not directly responsible for the planning, delivery, and governance of health services. The 1984 Canada Health Act set national standards for the provision of physician and hospital services, but it does not apply to home care and long-term care facilities. Consequently, each province has established a unique approach to long-term care, resulting in a health policy mosaic. This paper examines different approaches to funding long-term care with a particular emphasis on the impacts of regionalization and of the implementation of case-mix-based funding systems.     

Vertical axes on the long-term care continuum: a comparison of board and care and assisted living

As the continuum of long-term care has expanded, public funding has not accompanied new care options. I detail access, provider profits and resources, and care quality in two types of residential care that fall in the center of the continuum, assisted living and board and care. These two options provide examples of how limited public funding leads to vertical axes, which represent access to services, the resources providers draw on to give care, and the quality of long-term care services, at each service point on the long-term care continuum.     

NO ROOM FOR ABUSE

In Canada, media reports on health care tend to focus on the high costs of the health care system; reporting privileges the economic aspects of this social service. In the Canadian system, long-term care or chronic care is a type of service that is situated within the health care system. Long-term care institutions typically house older individuals who have lost a significant amount of autonomy and require constant care. Until recently, the services dispensed within these institutions were unseen by the media, and thus the public did not reflect much on these services. The publication of the Report of the Royal Commission on the Future on Health Care in Canada in 2002 has fostered a growing public awareness of the vulnerability of older individuals and those with chronic illnesses, and their relationship with their care-givers. Although it may be the case that the typical care for such persons in these situations is now emerging from a zone of invisibility, it is uncertain that the media coverage accurately portrays the realities of institutionalized care-giving. This essay examines the care practices in long-term care institutions in order to understand the processes at work in an environment in which care is commodified. The ‘area’ in which this caring labour is located is an area where constant moral compromise can create a climate where abuse can become endemic. This paper considers these environments and the potential for abuse in them in relation to the concept of ‘grey zone’, first formulated by Primo Levi and later adapted by Giorgio Agamben and Claudia Card, as well as in relation to the related concept ‘bare life’, also formulated by Agamben. The author argues that the ‘greyness’ produced by care practices that are bound to a cost-effective and task-oriented framework create an environment that is not conducive to proper moral behaviour.     

Vertical Axes on the Long-Term Care Continuum

Abstract

As the continuum of long-term care has expanded, public funding has not accompanied new care options. I detail access, provider profits and resources, and care quality in two types of residential care that fall in the center of the continuum, assisted living and board and care. These two options provide examples of how limited public funding leads to vertical axes, which represent access to services, the resources providers draw on to give care, and the quality of long-term care services, at each service point on the long-term care continuum.     

Organization and delivery of long-term care in Taiwan

Taiwan reached the World Health Organization (WHO) benchmark of 7% aged 65 and over for defining an aging population only as recently as 1993. With this proportion projected to double to 14% by 2020, Taiwan faces a rapid increase in need for long-term care. This article presents an account of the current service delivery system, which is divided between health and social affairs administrations, with a substantial role also taken by the Veteran Administration, and growing provision of facilities that operate outside the government-registered system. While a basic level of both institutional and community care services has developed, they are not organized into an integrated service system. Problems arising from the divisions and overlaps in responsibility are identified in relation to competition for resources, differences in regulation and eligibility, funding arrangements and misallocation of resources, and divergent views about the philosophical basis of long-term care. Other aspects of services fall under each jurisdiction, but there is also some overlap. A case study of Taiwan's second largest city, Kaohsiung City, reports the outcomes of these divisions as a thin spread of a range of services rather than a coordinated service network. Several planning exercises have been undertaken in recent years to address these problems, and although at an early stage of implementation, the outcomes of these plans are seen as shaping the future directions of long-term care in Taiwan.     

Organization and Delivery of Long-Term Care in Taiwan

Summary

Taiwan reached the World Health Organization (WHO) benchmark of7%aged 65and over for defining an aging population only as recently as 1993. With this proportion projected to double to 14% by 2020, Taiwan faces a rapid increase in need for long-term care. This article presents an account of the current service delivery system, which is divided between health and social affairs administrations, with a substantial role also taken by the Veteran Administration, and growing provision of facilities that operate outside the government-registered system. While a basic level of both institutional and community care services has developed, they are not organized into an integrated service system. Problems arising from the divisions and overlaps in responsibility are identified in relation to competition for resources, differences in regulation and eligibility, funding arrangements and misallocation of resources, and divergent views about the philosophical basis of long-term care. Other aspects of services fall under each jurisdiction, but there is also some overlap. A case study of Taiwan's second largest city, Kaohsiung City, reports the outcomes of these divisions as a thin spread of a range of services rather than a coordinated service network. Several planning exercises have been undertaken in recent years to address these problems, and although at an early stage of implementation, the outcomes of these plans are seen as shaping the future directions of long-term care in Taiwan.     

Predisposing,Enabling, and Need Predictors of Community versus Institutional Long-Term Care

Abstract

This research explored characteristics of the elderly that are associated with the use of long-term care services. Using the 1999 National Long Term Care Survey, logistic regression was employed to examine the relationship of race with the use of formal and informal long-term care. This study also examined the relationship of health insurance with the use of formal and informal long-term care. The Andersen Model on health services utilization was used as the theoretical framework. The findings indicated that race was not associated with the use of long-term care but rather with predisposing, enabling, and need variables. Health insurance was found to be associated with the use of long-term care even after controlling for predisposing enabling and need variables.     

The savings approach to financing long-term care in Singapore

Singapore is grappling with provision of services for the current generation of older people at the same time as building the foundation for the coming generations of elderly. In this article, I analyze four sets of factors that are shaping long-term care policy and financing in ways that are almost unique to Singapore. First, current developments can only be understood in the context of the Central Provident Fund (CPF) that was established by the Government of Singapore in the 1950s to ensure that the working population saved for retirement; the Medisave and related schemes for financing health care were subsequently developed alongside the CPF. Most recently, the existing funding arrangements have been extended to some long-term care services, and options for further extensions are under consideration. Second, the government's philosophy of maintaining the primacy of family support for the elderly has been expressed through a number of initiatives that provide financial and other incentives to families, combined with an emphasis on community care. The third factor is the relationship between government and the voluntary welfare organizations that are the major providers of institutional and community services. Finally, a series of government-sponsored reviews and advisory councils have provided for widespread consultation on policy options. These developments are directed to achieving a multi-pillar approach in which intergenerational transfers through taxation will be limited, and the role of individual savings and insurance will be increased.     

The Contribution of Voluntary Organizations to the Care of Children with Life-limiting Incurable Disorders and their Families

A national postal survey of voluntay organizations providing for children with life-limiting incurable disorders (n = 147) is described. The majority of organizations originated from the motivation of parents or care workers in response to deficiencies in service provision from other agencies. A wide variety of services were available from the organizations with over half providing an information service, emotional support and counselling, patient and family support and a telephone helpline. The provision of some services, for example respite care, was, hoverer, associated with the size of annual budgets. Publicity, referral and funding arrangements are also discussed. The role of voluntary organizations as partners in care with statutory agencies is discussed in the light of instability of funding arrangements and the use of health and social work staff as the main source of information about voluntary services to parents. Areas of further research in this field are suggested.     

Worthy? Crowdfunding the Canadian Health Care and Education Sectors

Crowdfunding, the practice of asking for money from others using the Internet, is a major private means through which Canadians are funding their health care and education. Crowdfunding has proliferated in Canada during the 2010s and continues to grow, approaching the revenues of Canada's major traditional charities. Proponents describe it as an empowering practice from which anyone can benefit. If its gains are inequitably distributed, however, increasing reliance on this private funding mechanism, especially in core areas of welfare state provision, can further exacerbate inequalities of opportunity and income. This study asks why Canadians turn to health care and education crowdfunding and how equitably funds are raised using this novel method. Based on a mixed methods analysis of 319 campaigns conducted on two prominent crowdfunding platforms between 2012 and 2014, we find that crowdfunding users’ needs frequently correspond to known gaps in the contemporary social safety net, including in the area of cancer care, and that campaigns for older and visible minority Canadians face a disadvantage. We argue that health care and education crowdfunding is a response to the shortcomings of Canadian welfare state provision, but one that reproduces offline inequalities with potentially perilous consequences for democratic life and individual suffering.     

Organizational structure,leadership and readiness for change and the implementation of organizational cultural competence in addiction health services

Increasing representation of racial and ethnic minorities in the health care system and on-going concerns about existing health disparities have pressured addiction health services programs to enhance their cultural competence. This study examines the extent to which organizational factors, such as structure, leadership and readiness for change contribute to the implementation of community, policy and staffing domains representing organizational cultural competence. Analysis of a randomly selected sample of 122 organizations located in primarily Latino and African American communities showed that programs with public funding and Medicaid reimbursement were positively associated with implementing policies and procedures, while leadership was associated with staff having greater knowledge of minority communities and developing a diverse workforce. Moreover, program climate was positively associated with staff knowledge of communities and having supportive policies and procedures, while programs with graduate staff and parent organizations were negatively associated with knowledge of and involvement in these communities. By investing in funding, leadership skills and a strategic climate, addiction health services programs may develop greater understanding and responsiveness of the service needs of minority communities. Implications for future research and program planning in an era of health care reform in the United States are discussed.     

The Savings Approach to Financing Long-Term Care in Singapore

Summary

Singapore is grappling with provision of services for the current generation of older people at the same time as building the foundation for the coming generations of elderly. In this article, I analyze four sets of factors that are shaping long-term care policy and financing in ways that are almost unique to Singapore. First, current developments can only be understood in the context of the Central Provident Fund (CPF) that was established by the Government of Singapore in the 1950s to ensure that the working population saved for retirement; the Medisave and related schemes for financing health care were subsequently developed alongside the CPF. Most recently, the existing funding arrangements have been extended to some long-term care services, and options for further extensions are under consideration. Second, the government's philosophy of maintaining the primacy of family support for the elderly has been expressed through a number of initiatives that provide financial and other incentives to families, combined with an emphasis on community care. The third factor is the relationship between government and the voluntary welfare organizations that are the major providers of institutional and community services. Finally, a series of government-sponsored reviews and advisory councils have provided for widespread consultation on policy options. These developments are directed to achieving a multi-pillar approach in which intergenerational transfers through taxation will be limited, and the role of individual savings and insurance will be increased.     

A survey of Colorado's migrant farmworkers: access to health care

This report utilizes data collected in a 1986 sample survey of 329 adult (18 to 50 years old) migrant farmworkers in Colorado to determine their health needs, health services utilization, and overall access to care. Health needs include selected indices of medical, dental, nutrition, and reproductive health. About 1/4 of the population had no usual source of health care. Upstream states such as Colorado are responsible as the primary providers of health services for those who either have no source of health care at their home base or experience a variety of barriers in their attempts to access services. Women are most likely to have had a medical visit over the past 12 months and are more likely to have experienced hospitalization. Unfortunately, although their contact with medical professionals is more frequent, the family planning needs of women are not being met. A large disparity exists between ideal family size and number of pregnancies and live births. The findings of this survey document the inferior health status of the migrant farmworker population in Colorado. Hunger, poverty, and environmental hazards increase the risk of illness, while at the same time, barriers to care often prevent migrants from accessing needed health services. Recommendations include 1) promoting and funding family planning and reproductive health services for migrant farmworker women and their partners, 2) incorporating trained family planning promoters in the migrant health delivery system, 3) maintaining successful models of restorative dental care for adults, 4) increasing access to services in nontraditional settings, 5) increasing use of ancillary personnel to provide services, especially dental services, 6) maintaining outreach programs in the available food programs, and 7) encouraging migrant health programs to provide leadership in the development of alternative food sources.     

Effect of childlessness on nursing home and home health care use

This study examines the likelihood of nursing home and home health care use for childless older Americans. Four research questions are addressed: (1) Are the childless elderly at a greater risk of nursing home and home health care use? (2) Is it childlessness per se or not having children with particular characteristics that affects the likelihood of using these formal long-term care services? (3) Does having additional children beyond the first one have a significant effect on the use of these services? (4) Are the effects of childlessness different on the likelihood of nursing home and home health care use? Longitudinal data from the first (1993) and second (1995) waves of the Asset and Health Dynamics Among the Oldest Old Survey (AHEAD) and multinomial logistic regression models are used for the analyses. Separate models are developed for women and men, each controlling for a variety of demographic, socioeconomic, and health-related characteristics of sample persons. Findings indicate childlessness as an important risk factor, especially for older women's use of nursing home services. Implications of findings for planning for long-term care needs of the baby boom generation are discussed.     

A 10-foot rope for a 50-yard drop: the CLASS Act in the patient protection and Affordable Care Act

The Community Living Assistance Services and Supports (CLASS) Act, part of the 2010 health care reform, would have paid a daily cash payment toward the costs of long-term care. This article points out that although the CLASS Act may have been sufficient to cover the costs of most home- and community-based services, it was an inadequate response to the most pressing long-term care financing problem facing baby boomers: nursing home care costs. The risk of needing a nursing home is higher than other catastrophic risks. Boomers lack savings to pay those costs. CLASS aimed to encourage people to use home- and community-based services to substitute for nursing home care, but research spanning decades shows there is little substitution effect.     

Motivations to Pursue Accreditation in Children's Mental Health Care: A Multiple Case Study

Accreditation is a growing, worldwide phenomenon that has spread to a range of industries and fields, including nonprofit social services and mental health care. Thousands of organizations are accredited, but it is not known what is driving the growth of this phenomenon. Using a multiple case study design, this exploratory study aimed to understand children's mental health agencies' motivations to pursue accreditation. In‐depth interviews, focus groups, document reviews, and limited observations were conducted at five children's mental health agencies that had recently undergone or were undergoing the Council on Accreditation process. Agencies were influenced by external factors, such as policies that require accreditation, wanting to assert their positions in the field, and the need to increase funding opportunities. Other factors were internal, related to agency leadership using accreditation as a platform for change and agencies' genuine intent to improve services. Implications for agencies, accreditors, and future research are offered.     

Pflegebedürftigkeit im Lebensverlauf

The paper investigates levels of functional health in old age as an outcome determined by support from family members and the individual’s financial assets. It addresses the question to what extent these risk factors for functional health also apply to the risk of long-term care (LTC) as defined by German Law SGB XI and may thus be transferable. Three hypotheses are presented, relating the individual’s economic resources and social integration to functional health limitations and to the onset of LTC. Results are stratified by levels of care, taking into account changes in levels of care over time as well as the location of care (at home or in a nursing home). The analysis is based the German Socio-Economic Panel (SOEP). For males it was shown that presence of close relative or spouse reduces the utilization of care (according to the LTC- definition by German Law (SGB XI). For males, long-term care was mostly provided by the spouse. The need of care depends not only on functional health status but also on the type of (family-)network. Substitution could not be found in the lower income groups. The utilization of LTC even increases for less affluent males living with a spouse due to financial incentives provided by LTC insurance. Substitutability of care services may thus vary by income group.     

Reducing Funding Risk and Implementing a Fundraising Plan: A Case Study

Small nonprofit organizations in the health care and human services fields can find themselves frozen into a dependence on government funding. They run the risk of constricting their management choices and neglecting other potential funding sources. Often a fundamental shift in attitude is necessary in order to deemphasize service-based contracts and to transform private fundraising into a central activity of the business.     

Oral health in long-term care: The implications of organizational culture

When an investigation designed to compare extant models of delivering oral health and dental services to the institutionalized elderly revealed that structural variables explained very little of the difference between effective and ineffective programs, secondary analytic techniques were employed to consider alternative explanations. The original study was a program evaluation based on a comparative case study of 12 long-term care (LTC) facilities. Data for each case included interviews with administrators, care providers, family members, and residents, administrative documentation, and clinical measures of oral health from the residents. The secondary analysis revealed the mechanisms through which the organizational context of each facility influenced the effectiveness of the oral health services. In addition, it revealed how administrative and leadership issues influenced the quality of care.     

"We are forgotten on earth": international development targets,poverty, and gender in Ethiopia

This article describes the obstacles faced by the Ethiopians in having affordable, good quality basic health care services, reproductive health care services and primary education. The findings highlight the link between limited access to basic services and poverty, low incomes, insecure livelihoods and poor nutrition. Research findings on four Ethiopian sites indicated that majority of the population have inadequate diets, insufficient health care and education facilities, compounding gender discrimination and lack of women empowerment, and inaccessible reproductive health care. After analyzing gathered information, three areas of concern were focused upon: poverty viewed as an emergency; the need to invest in citizenship and education; and aid conditionalities, conflict and poverty. This paper suggests that to overcome poverty and the prevailing gender inequality, massive investments in basic adult, primary and secondary education and women involvement in governance and citizenship are necessary. To implement all these, the call for international support for funding is deemed necessary.