Canada is Not Keeping Pace with the Home and Community, and Nursing Home Care Needs of its Rapidly Ageing Population

September 10, 2019

NIA Report lays the foundation for More Responsive Long-Term Care System in Canada

All Canadians deserve to age with dignity and to receive high quality care in a setting appropriate to their needs. Canada’s provinces and territories, however, are struggling now more than ever to meet the long-term care needs of Canada’s rapidly ageing population, be it at home, in the community, or in designated buildings such as nursing homes.                                                                                                           

 In his latest report, Enabling the Future Provision of Long-Term Care in Canada, Dr. Samir Sinha explores the current landscape of the full range of long-term care services across Canada to determine how Canadians can be best supported to age with greater quality of life, better health outcomes, and dignity through appropriate models of care and support and best practices. The report comprehensively examines and outlines major challenges to delivering cost-effective, and high quality care. This sets the basis for a robust discussion on the potential enablers of a better, more responsive system of long-term care for older Canadians encompassing care and supports at home, in the community and in designated buildings, such as nursing homes. 

“Our health care system was built over 50 years ago when the average age in Canada was 27 and life expectancy was significantly lower than it is today. Our system of universal healthcare focuses on providing physician based and acute hospital-based healthcare,” said Dr. Samir Sinha. “The system was not built to focus on the realities of today with a growing number of Canadians living into their 80’s with complex and diverse needs.” As a result over 430,000 adult Canadians were recently estimated to have unmet home care needs while over 40,000 Canadians are currently on waitlists for nursing homes due, in part, to a lack of available home and community-based care.

Dr. Sinha’s report is the first in a three-part series by the National Institute on Ageing (NIA) in collaboration with AdvantAge Ontario, the Canadian Medical Association (CMA), Essity, and Home Instead Senior Care that examines the current systems of long-term care being delivered for older Canadians. The second report, authored by Dr. Bonnie Jeanne MacDonald, Dr. Michael Wolfson, and Dr. John Hirdes will show projected future costs of home, community, and nursing home care, and the personal tax impact that would be necessary to cover Canada’s growing costs in care. The third and final report of the series will then bring together experts in financial and health policy to present options and recommendations for a feasible and fiscally responsible set of policy scenarios, which bring the right type of needed reforms to our future systems of long-term care, and high-quality care services for older adults that can be both affordable and increasingly sustainable.

It’s always easier to be critical of the past and present than it is to optimistically envision the future and the path to get there. This NIA series will attempt to do both. The provision of health and social care, requires constant evolution in response to changing circumstances and priorities. The overall goal of this Policy Series will be to help government policy and decision makers, existing care providers, and members of the general public to clearly understand the options available to meet the long-term care needs for Canada’s ageing population.

Getting started on this journey, Dr. Sinha unpacks the vast and complex landscape of long-term care across Canada to diagnose the challenges and lay the foundation for a path forward.

Here’s what we know.

We are struggling to meet the needs of ageing Canadians

Waitlists for long-term care are an issue in many parts of the country. In Ontario, the number of Ontarians approved and waiting for a nursing home bed grew by 45 per cent from 2015 to 2018. By 2018, 32,835 Ontarians were on a waitlist for nursing home care, with an average placement time of 158 days. In British Columbia, 1,379 people were waiting for a nursing home bed in March 2018, an increase of 7 per cent from the previous year.  Meanwhile, over 430,000 adult Canadians were recently estimated to have unmet home care needs.

The number of Canadians receiving any type of long-term care service ranges from 763,735 to 1,256,575. This represents between 13 to 21.2 per cent of Canadians over the age of 65. It is also estimated that 22 per cent of older Canadians entering into nursing home environments could be better cared for at home with appropriate home and community supports which are not always available.

On any given day, approximately 7,500 patients with alternate level of care (ALC) designations account for 14 per cent of the total number of currently hospitalized Canadians. These are patients who occupy a bed in an institution but no longer require the intensity of services provided in that setting. Providing these individuals with care at home or in their communities or in building-based long-term care settings like nursing homes in a timelier manner instead of within hospitals could save approximately $2.3 billion annually in hospital-based ALC spending. This is more than a third of the total transfers provided by the federal government to provinces and territories to improve access to and quality of home care.

This situation is taking a toll on Canadians. A poll conducted by Ipsos for the CMA found that 88 per cent of Canadians are worried about growing health care costs due to the ageing population, while 58 per cent believe many Canadians will delay their retirement to afford the health care they need to remain healthy and independent in their communities. Canadians are ready to take the issue to the ballot box in the upcoming election with 66 per cent of Canadians over age 55 reporting that they will vote for the party they believe has the best plan for the future of health care in Canada.

There is no single definition of long-term care in Canada

In Canada, long-term care services are recognized as an extended health service and not a core–insured service under the Canada Health Act, resulting in considerable variation in the types and amounts of services being provided across the country. Each province and territory has its own unique legislation, regulations, and set of policies governing long-term care. While the approach may differ between jurisdictions, they all face similar challenges in relation to quality, access, efficiency, financial sustainability, political will, and ability of each government to pay for its long-term care services.

In investigating the landscape of long-term care across Canada, Dr. Sinha finds that we don’t have a common definition of long-term care in Canada, making it especially difficult to create integrated systems of care for older Canadians and to easily share best practices across the country. The report highlights that there are almost as many definitions as there are Canadian jurisdictions and health systems. This creates clear challenges in understanding how much is spent on the provision of long-term care, where and how services are delivered, how they are delivered, and who and how many are using them. And it creates confusion for Canadians and their caregivers, who may not know what services and options are available, and what is funded publicly as opposed to requiring an out-of-pocket expense. After extensive consultation and investigation, Dr. Sinha and the NIA chose to define the provision of long-term care as: A range of preventive and responsive care and supports, primarily for older adults, that may include assistance with Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs) provided by either not-for-profit and for-profit providers or unpaid caregivers in settings that are not location specific and thus include designated buildings or in home and community-based settings.


Understanding the cost of care in Canada

The report estimates that in 2018, Canada spent $33 billion on the provision of long-term care, representing 13 per cent of the overall health care spending in Canada, based on calculations made by Dr. Michael Wolfson.  Even so, Dr. Sinha’s report highlights that Canada spends less of its GDP on long-term care than most other OECD countries. Canada also spends significantly less of its long-term care spending on home and community care vs. nursing home care. On average, OECD countries spend 65% of their long-term care spending on care in designated buildings like nursing homes and only 35% on home-based care. Canada in comparison spends 87% of its long-term care dollars on care in designated buildings and only 13% on home-based care. Countries like Denmark spend 36% of their long-term care funding on care in designated buildings and 64% on home-based care.

Federal, provincial, and territorial governments across Canada know that this needs to change. Under mounting fiscal pressures, provinces and territories have thus put an emphasis on providing more care at home especially after this became a focus of the last federal election in 2015. In 2017, the federal government allocated $6 billion over 10 years to support the expanded provision of home and community-based care. Despite this investment, there’s a remains a substantial gap between the publicly funded home care that is being made available and what Canadians’ actually need. Furthermore, Canadians are not being encouraged or enabled to consider options for home-based care from the private system to fill the gap in care.

Table 1.png

Addressing the challenges in the provision of long-term care: Where do we begin? 

Where do we begin? – It’s a question many Canadians ask themselves when they need long-term care, and the answer is rarely ever straightforward or simple. The reality is that most Canadians have no way of knowing what to expect ahead of time, or how to best navigate publicly supported long-term care services.  Currently, the long-term care services that are made available lack the level of flexibility and choice needed to meet the diversity of needs of care recipients, care providers, and unpaid caregivers.

Working with its partners, national experts, and stakeholders, Dr. Sinha identified four broad categories of challenges that must first be addressed in order to advance the future provision of long term care in Canada. These include acknowledging:

  1. Challenges faced by older Canadians and their unpaid caregivers in receiving care

  2. Challenges faced by care providers and unpaid caregivers in delivering care

  3. Challenges in the organization and delivery of care

  4. Challenges to the public and private financing of care   

Opportunities for the Future Delivery of Long-Term Care

There is no denying there are big challenges ahead, but it can also be viewed as an opportunity to rethink our collective approach to meeting the growing and varied needs of Canada’s ageing population. There are many examples of innovative models of care, support and care practices from around the world that could be introduced to the Canadian context or if already present somewhere in Canada, expanded to other jurisdictions.

The NIA has created a frame work to contextualize the different innovations in long-term care by segmenting Canada’s older population into four categories across the long-term care continuum. This framework focuses on the combinations of issues and needs that with increasing complexity can significantly impact a person’s ability to live independently in the place of their choice. The framework is laid out as a pyramid with four levels that correspond to an increasingly smaller and complex characteristic sample of the population as the pyramid ascends while identifying some of the innovations that can support the future provision of long-term care for these individuals.

Conceptual Framework.png

Emerging Enablers

Demand for long-term care will continue to grow, and there is little doubt that if Canadians have the option and ability, they want to age in place of their choice. Canadians deserve to age with dignity, independence and respect. To make this a reality, Dr. Sinha outlines key enablers that could help foster the comprehensive and positive change needed. These include:

  1. Enabling evidence-informed integrated person-centered systems of long-term care, accounting for the expressed needs and desires of Canadians. 

  2. Supporting system sustainability and stewardship through improved financing arrangements, a strong health care workforce, and enabling technologies.

  3. Promoting the further adoption of standardized assessments and common metrics to ensure the provision of consistent and high-quality care no matter where Canadians need it.

  4. Using policy to enable care by presenting governments with an evidence-informed path towards needed reforms.

We know that Canadians are anxious about their actual and potential future care needs in older age, that care providers are doing their best to meet these needs, and that governments are increasingly awakening to the reality that long-term care in Canada isn’t currently well-positioned to keep pace with its rapidly ageing population with increasingly diverse and complex needs. Dr. Sinha’s foundational report brings together these concerns to lay the foundation for moving forward with systems of long-term care that can better meet the needs of Canadians into the future. 

 You can read more about what needs to be done so that Canadians get the access they deserve to appropriate and affordable long-term care options in Dr. Sinha’s report, Enabling the Future Provision of Long- Term Care in Canada.  

 The National Institute on Ageing is a Ryerson University think tank focused on the realities of Canada’s ageing population. We are Canada’s only think tank dedicated to policy solutions at the intersections of healthcare, financial security, and social well-being. Through our work, our mission is to enhance successful ageing across the life course and to make Canada the best place grow up and grow old. Follow us on Twitter. 

By Arianne Persaud| Communications and Public Affairs Manager, National Institute on Ageing| Email:

Allan McKee