Spending Your Golden Years at Home: Developing Home Care Services in Quebec
Economic Note explaining that a larger proportion of the total budget for elderly care must be dedicated to home care instead of institutions, notably by supporting informal caregivers
The Quebec population is aging faster than the current long-term care residence system can handle, which forces us to consider new ways of doing things. The government of Quebec must allow more seniors to remain in their homes by doing a better job of supporting informal caregivers, shows this new publication released by the MEI.
|Outillons les aidants naturels pour permettre aux aînés de rester à la maison (Le Journal de Montréal, October 13, 2022)
Soins à domicile: plus de ressources pour mieux outiller les aidants naturels (Le Journal de Montréal, October 13, 2022)
Seniors prefer home care over institutionalization (Troy Media, October 13, 2022)
This Economic Note was prepared by Maria Lily Shaw, Associate Researcher at the MEI. The MEI’s Health Policy Series aims to examine the extent to which freedom of choice and entrepreneurship lead to improvements in the quality and efficiency of health care services for all patients.
Quebec’s population is aging faster than the province’s current long-term care residence system will be able to handle. By 2030, nearly 25% of Quebec’s population will be aged 65 and over,(1) putting growing pressure on senior care. Moreover, most seniors prefer to remain in their homes as they age.(2) In order to give Quebec seniors what they desire and deserve, the province must develop its home care network in a way that both benefits seniors and is fiscally sound.
The Current Situation with CHSLDs(3)
The concept of a long-term care residence or “centre d’hébergement de soins de longue durée” (CHSLD), modelled after that of a hospital, was developed in the 1970s,(4) and has been the main pillar of senior care in the province ever since.
But Quebec’s elderly are experiencing difficulty accessing services. As of September 2022, over 4,380 people were on a waitlist for a place in a CHSLD,(5) with many of them residing in hospitals in the meantime.(6) This hobbles the province’s overall health system, because a hospital’s capacity to admit and accept transfers from the emergency department is reduced when beds are occupied with seniors waiting to get into a residence. The waitlist has in fact become so long that health authorities are now allowing long-term care institutions to have four residents per room, a directive that goes against the recommendation of Quebec’s coroner.(7)
The living conditions of those who are already housed in one of the province’s 321 public CHSLDs(8) are not as good as one would hope, a situation that has prevailed for several years.(9) Indeed, a 2017 quality assessment visit carried out by the Department of Health and Social Services(10) revealed that just 17.6% of the public institutions were deemed “entirely adequate” by those conducting the survey. Some 11.5% of public CHSLDs had a living environment that was “worrisome,” and 71% of them were judged to be “acceptable.”(11) As for the living environment of private funded CHSLDs, of which there are 60 in Quebec today,(12) none of those surveyed for the 2017 analysis were considered “worrisome” and 64.4% were deemed “entirely adequate.”(13)
The repercussions of these poor conditions, especially in the public facilities, were exposed during the first wave of the pandemic, when 69% of those who died of COVID-19 in Quebec as of June 28, 2020 lived in CHSLDs.(14)
Quebec’s seniors deserve a better quality of life, and to feel safe in their environment, especially considering the amount of public funds poured into health services for the elderly. In 2019-2020, Quebec spent 63.6% of its senior care budget on CHSLDs alone, or $2.4 billion.(15) This proportion will likely remain high for the foreseeable future, especially given the government’s plans to add over 2,600 institutional places to the system between 2018 and 2022,(16) and given that only 40% of these promised places had been delivered as of June 2022.(17)
Also, the cost of constructing one additional place in 2020 was over $362,000, a number projected to grow to over $506,000 before the year 2050.(18) Then there is the cost of housing people in a CHSLD: an average of $85,198 per year to house one person in a publicly funded long-term care home in 2020, a figure likely to rise in the coming year.(19)
Prioritize Funding for Home Care Services
In light of these poor living conditions, as well as the growing expenses related to institutionalized places in the system, Quebec must provide its elders with the services they need to remain in their own homes by promoting and developing the home care network. That network should be seen as a complement to CHSLDs, as some seniors have needs that require institutionalization. Indeed, given the state of their mental and physical health, some require nearly constant supervision that only CHSLDs can currently deliver in an appropriate way.
Moving forward, avoiding the premature institutionalization of seniors who are still independent in many areas of their daily lives should be paramount. With a well-developed home care system, keeping these seniors in their home would alleviate the need to add more places in CHSLDs.
This would require a transition to a system that recognizes the social and financial benefits of home care for the elderly. The home care network has not been prioritized in the province’s hospital-centric system, which has led to home care services being developed only on the sidelines.
According to the Canadian Institute for Health Information, one in nine Canadians placed in residential care could, in fact, have potentially stayed at home if adequate support had been available.(20) Considering the estimated 41,748 seniors housed in a CHSLD,(21) there may be over 4,600 of them who could be taken care of at home rather than in a facility.
These 41,748 individuals who receive such care while living in a CHSLD constitute just over 21% of the 195,714 elderly people in need of support due to loss of autonomy.(22) Thus, while the majority of seniors in need of care are actually receiving it in their homes, the budget allocated to those living in CHSLDs is far greater than the funds dedicated to home care services (see Figure 1). In the context of Quebec’s Support Program for the Autonomy of Seniors (SAPA), only 22% of the budget was dedicated to home care services in 2019-2020, whereas nearly 64% was dedicated to caring for seniors in CHSLDs.(23)
Quebec’s historical reliance on institutional care has prevented its elderly from reaping all the well-documented benefits of aging in the comfort of their own homes. For instance, having access to reliable and high-quality home care can allow seniors to maintain control over their daily lives, instead of having to adhere to the schedule of a CHSLD. In addition, living in a familiar environment can be beneficial to those suffering from dementia, and the preservation of their autonomy can have a positive impact on their sense of well-being and quality of life.
It also makes it easier for relatives and friends to visit their loved ones, a privilege that some were refused during the pandemic, when visitors were no longer authorized in the institutions.(24) In addition, the cost of home care is generally billed by the hour, allowing for greater flexibility in payment plans. For people who need only part-time support, the cost of home care is therefore lower than that of a residential nursing facility.
Aside from these benefits, developing the home care network in a manner that would allow more seniors to remain in their own homes would coincide with what most Quebecers desire. Indeed, a 2021 survey revealed that 71% of them wish to remain in their homes at age 75 and up, with less than 1% of the population seeing themselves living in a CHSLD.(25)
While receiving support in the comfort of one’s home is what most people prefer, in its current state, Quebec’s home care network cannot meet the demand. Given the heavy reliance on institutional care, the network is underdeveloped and relatively underfunded when compared to the funds dedicated to maintaining the public housing institutions.
The Current Situation with Home Care in Quebec
The government of Quebec has recognized the need to improve its home care network, by committing to a series of projects and added spending in the years to come.(26) However, in order for the program to not become an extra weight on already overburdened taxpayers, part of the funding must come from amounts freed up from reduced dependence on CHSLDs.
The demand for such services is undoubtedly on the rise. As of March 2022, there were 45,637 Quebecers on a waitlist to receive home services from a care provider. This is a significant jump from just one year earlier, when 41,346 names were on the list.(27)
One way of supporting in a targeted manner those in need of financial aid to pay for home care is through tax credits, of which there exist several in Quebec. The majority are for services and devices purchased by seniors to maintain their autonomy in their home. Others are to support their caregivers in their duties. Despite these existing funding opportunities, a lack of awareness, bureaucracy, and strict eligibility requirements may have led them to be underutilized by the population, and especially caregivers.
For instance, the tax credit for costs incurred for the rental or purchase and installation of equipment in seniors’ homes for the purpose of maintaining their autonomy may not be reaching its full potential. Indeed, the companies that develop such equipment are subject to significant regulatory obstacles that act as barriers to innovation. Obtaining access to the potential clientele for testing purposes or for focus groups is challenging and can take several years. This results either in poorly adapted products or simply in the abandonment of projects. Long delays in the production of goods can be costly, and new businesses in particular can run out of funds before their products even reach the people who need them.(28)
Similarly, government programs intended to provide financial support to such companies are stunted by bureaucracy, discouraging businesses from applying in the first place. Moreover, even if a business does develop an innovative product, with or without financial assistance, the home care network is notoriously slow to adopt new technologies. New products therefore may not be eligible for the tax credit for some time. Consequently, companies tend to develop and deliver their products outside of Quebec, in the United States or other parts of Canada, depriving the province’s seniors of new technologies such as fall-prevention equipment that could enable them to stay in their homes.(29) In 2019, only 9,411 people claimed this tax credit.(30)
Finally, there is the eligibility requirement for caregivers. They only become eligible for some of their designated tax credits if they have lived with the individual they are assisting for a full year. For those who do not live with the person they are caring for, they are only entitled to the tax credit if they have assisted the individual for 365 consecutive days.(31) Considering these strict eligibility requirements, it is no surprise that these tax credits are relatively underutilized.
In 2018, a combined total of 59,197 people claimed the tax credits for caregivers.(32) That is just 4% of the estimated total number of caregivers in the province that year, which totalled nearly 1.5 million people.(33) Considering that 33% of caregivers feel they need financial support,(34) the tax credits are clearly not reaching all the people who could stand to benefit from them.
The Creation of a Training Program for Caregivers
In addition to financial support provided by the existing tax credits, many caregivers would also benefit from home care, help from health care professionals, as well as information and guidance (see Figure 2). This last element, the need for information and guidance, must not be overlooked considering the important role that informal caregivers play when it comes to caring for Quebec’s elderly. It is estimated that relatives provide between 70% and 75% of the care required at home.(35)
In terms of the number of hours spent caring for relatives, according to a 2020 report, informal caregivers in Quebec devote an average of nine hours a week providing assistance or care, for a total of approximately 743 million hours a year.(36) Their contribution thereby saves the Quebec health care system $10.6 billion a year, a conservative estimate based on replacing informal caregivers with workers paid at Quebec’s minimum wage of $14.25/hr.
Considering the important role played by informal caregivers and the amount of time they spend assisting people in need, it is imperative that proper training be made available to them so they can safely and effectively care for their loved ones. The government of Quebec should facilitate the creation of a training program designed specifically to meet their needs.
A training program for informal caregivers could offer a range of guidance on such things as how to navigate Quebec’s multiple tax credits and how to use some general accounting tools, which can help make sure the caregiver and the person they are taking care of receive all the tax credits they qualify for. Since 43% of caregivers assist individuals with physical and neurological conditions,(37) the training program could also include an orderly or a nurse showing them how to safely change bandages, change the sheets of a bed with minimal physical strain if a person is bedridden, operate a hospital bed and ensure proper posture, and effectively use aids such as transfer boards(38) or gait belts.(39)
For this to have the best chance of succeeding, the government must leave it up to private organizations, whether they be for- or not-for-profit, to design, administer, and deliver the program. Such organizations(40) already exist and have developed an expertise in helping caregivers find the resources they need. In the context of a province-wide training program, they would create partnerships with professionals, such as orderlies and nurses, who are already providing home care.
Promotion is a crucial component of such a project, given that 65% of those caring for seniors feel they are unaware of the resources at their disposal.(41) Caregivers must be informed that such assistance exists. Health care professionals treating the person in need could inform them of the existence of the program.
Moreover, the training program could bridge the gap that exists between Quebec and other provinces where caregivers receive more support. Indeed, the proportion of caregivers who reported being supported in executing their caregiving duties in 2018 was relatively uniform across the rest of the country, ranging from 71% to 78%. In Quebec, that proportion was just 58%.(42)
The heavy reliance on institutional settings to care for Quebec’s elderly has had serious and sometimes dire effects on their well-being, from subpar living conditions to a higher COVID-19 death rate during the first wave of the pandemic.
The government must rethink its dependence on CHSLDs in favour of services offered in the home, especially in terms of the allocation of financial resources. In other words, a larger proportion of the total budget for elderly care must be dedicated to home care instead of institutions. The funds that are freed up as a result of this shift should be redirected to a training program managed by existing organizations with an expertise in supporting caregivers. The end goal of such a program would be to delay or avoid having to institutionalize seniors due to a lack of caregiver know-how. Increasing existing tax credits could also be considered.
Additionally, the development of new technologies aimed at helping to preserve the autonomy of seniors within their home must be simplified for entrepreneurs in the province. Regulatory barriers and bureaucratic obstacles must be eliminated in order for new products to reach customers in a timely manner.
Quebec’s seniors deserve to be offered quality services in their home, where the majority of them want to remain in their golden years.
- Author’s calculations. Institut de la Statistique du Québec, Population projections – Québec, Detailed tables, Population selon l’âge et le sexe, scénario Référence A2022, Québec, 2021-2066 (in French only), consulted August 12, 2022.
- Réseau de coopération des EÉSAD, “Soutien à domicile – Chez moi pour la vie, le choix des québécois selon un sondage Léger,” CISION, February 17, 2021.
- There are three types of CHSLDs: public, private funded, or private unfunded. The public CHSLDs are financed and managed by the government. Private funded facilities are subsidized by the government but run by entrepreneurs. The remaining institutions, private unfunded CHSLDs, are managed independently and receive no public financing. Index Santé, Les CHSLD publics, privés conventionnés et privés, consulted September 18, 2022.
- Nicholas-James Clavet, Le financement du soutien à l’autonomie des personnes âgées à la croisée des chemins, Chaire de recherche sur les enjeux économiques intergénérationnels, February 2021, p. 2.
- Department of Health and Social Services, Données de la liste d’attente pour une place en centre d’hébergement de soins longue durée (CHSLD), Période 3 2022-2023, consulted August 12, 2022.
- CBC News, “Quebec allowing up to 4 residents per room in long-term care, despite ongoing pandemic,” August 19, 2022.
- Department of Health and Social Services, Publications, Répartition des capacités et des services autorisés au permis par installation : fiche technique, consulted August 24, 2022.
- Protecteur du citoyen, Rapport spécial du protecteur du citoyen, La COVID-19 dans les CHSLD durant la première vague de la pandémie, November 23, 2021, p. 64.
- The survey covered 356 CHSLDs between April 1st, 2015 and March 31, 2017.
- Department of Health and Social Services, “Visites ministérielles d’évaluation de la qualité de vie en CHSLD, Bilan statistique national, Période du 1er avril 2015 au 31 mars 2017,” November 2017, p. 2 as cited in Patrick Déry, “Does Entrepreneurship Make a Difference in Health Care? The Case of Private Funded CHSLDs,” MEI, Viewpoint, October 2019, p. 1.
- Department of Health and Social Services, op. cit., endnote 8.
- Department of Health and Social Services, op. cit., endnote 11, p. 2.
- Protecteur du citoyen, op. cit., endnote 9, p. 15.
- Author’s calculations. Institut de la statistique du Québec, Population of Québec by age and sex, July 1, 1971-2021 (in French only), consulted September 27, 2022; Commissaire à la santé et au bien-être, Portrait des ressources financières du système de santé et de services sociaux québécois pour les aînés, Government of Quebec, 2021, p. 36.
- Department of Health and Social Services, “Budget 2021-2022 – Investissement de 334 M$ sur cinq ans pour renforcer les services en hébergement pour les aînés,” press release, April 16, 2021.
- Jocelyne Richer, “Maisons des aînés: seulement 40 % des places promises prêtes avant l’élection,” Le Soleil, June 15, 2022.
- Samuel Sponem et al., Le coût des services d’hébergement des personnes âgées au Québec, HEC Montréal, October 2021, pp. 34-35.
- Author’s calculations. Nicholas-James Clavet, op. cit., endnote 4, p. 17; Commissaire à la santé et au bien-être, “Portrait des organisations d’hébergement et des milieux de vie au Québec,” Government of Quebec, 2021, p. 11.
- Canadian Institute for Health Information, 1 in 9 new long-term care residents potentially could have been cared for at home, consulted September 16, 2022.
- For all types of CHSLDs combined. Commissaire à la santé et au bien- être, op. cit., endnote 19, p. 14.
- Nicholas-James Clavet, op. cit., endnote 4, p. 3.
- Commissaire à la santé et au bien-être, op. cit., endnote 19, p. 36.
- Charles Lecavalier, “Coronavirus: messages urgents aux Québécois,” Le Journal de Montréal, March 14, 2020.
- Réseau de coopération des EÉSAD, op. cit., endnote 2.
- Department of Health and Social Services, “Budget 2021-2022 – Les ministres Dubé et Blais annoncent un investissement de 750 M$ sur 5 ans pour intensifier l’offre de services publics en soutien à domicile,” press release, May 31, 2021.
- Fanny Lévesque, “Les listes d’attente s’allongent,” La Presse, March 3, 2022.
- Information obtained through stakeholder interviews.
- Government of Quebec, Dépenses Fiscales Édition 2020, March 2021, p. C.17.
- This is a simplified description of the eligibility requirements for two of Quebec’s tax credits that are reserved for caregivers. Revenu Québec, Tax Credits, Tax Credit for Caregivers, Caregiver Providing Care to a Person 18 or Over with an Impairment, consulted September 5, 2022; Revenu Québec, Tax Credits, Tax Credit for Caregivers, Caregiver Living With a Person (Not His or Her Spouse) 70 or Over Without an Impairment, consulted September 11, 2022.
- Government of Quebec, op. cit., endnote 30, p. C.4.
- Institut de la statistique du Québec, “Portrait of informal caregiving in 2018: more than 1 in 5 people in Québec were caregivers,” press release, February 9, 2022.
- Research on Aging Policies and Practices, “Caregivers in Quebec: impact of caregiving on well-being,” University of Alberta, May 2020, p. 2.
- Health Council of Canada, Seniors in need, caregivers in distress: What are the home care priorities for seniors in Canada? April 2012, p. 30.
- Research on Aging Policies and Practices, “Caregivers in Quebec: economic costs and contributions,” University of Alberta, May 2020, p. 1.
- Research on Aging Policies and Practices, op. cit., endnote 34, p. 1.
- “Transfer boards are stiff boards used to ease the transfer of wheelchair users from their bed or chair to a wheelchair. They bridge the gap between the patient and the wheelchair’s seat so the user can slide across without being lifted.” Transfer Master, “The Physical Demands of a Family Caregiver,” May 11, 2021.
- “A gait belt is a wide fabric belt that the patient wears around their waist. They are used to help patients with mobility or balance issues to stand up from their bed or wheelchair and to walk.” Transfer Master, “The Physical Demands of a Family Caregiver,” May 11, 2021.
- Canadian Centre for Caregiving Excellence, Caregiver Resources, consulted September 18, 2022.
- Index Santé, “Du soutien à portée de main : l’Appui pour les proches aidants d’aînés lance une grande campagne nationale,” 2018.
- Darcy Hango, “Support received by caregivers in Canada,” Statistics Canada, January 8, 2020, p. 3.