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Expanding home-based options for long-term care could save the system money and increase patient satisfaction, experts argue

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Canada’s hospitals are increasingly overburdened, with too many patients and too few rooms and staff to keep up with demand. Similar challenges are being faced in the long-term care (LTC) system. Could a different approach to LTC help to tackle both problems?

In the winning submission for this year’s Hunter Prize for Public Policy, “Bringing Long-Term Care Home,” Dr. Ashley Flanagan, health research and policy manager at the National Institute on Ageing, and Dr. Kristina Kokorelias, program manager for Sinai Health and the University Health Network’s Healthy Ageing and Geriatrics Program, argue that it might. 

Inspired by successful models in countries such as Denmark—and cognizant of Canada’s aging population—Flanagan and Kokorelias call for Canada to expand its home care options. Not only would this relieve the overreliance on traditional LTC homes, but it would also take some of the pressure off of hospitals—many of which are crowded with patients who require LTC but lack access. This has led to long wait times for emergency and elective procedures and the rise of “hallway medicine,” where care is provided in corridors and other nontraditional spaces due to a lack of available beds. 

Flanagan and Kokorelias advocate for a “Virtual LTC at Home Program” through which integrated care teams would provide robust, cost-effective home care services to elderly persons living in their own households or with family. They suggest that this strategy could reduce the reliance on institutional care, potentially alleviate the strain on hospitals and LTC homes, and align with the preferences of most older Canadians. A 2022 Ipsos poll found that 95 percent of those asked wanted to age at home.

Implementation could bring savings

Alternatives to the current LTC system are urgently needed, especially as Canada’s health-care infrastructure deals with both the fallouts of the COVID-19 pandemic and an aging population. Some projections suggest that nearly one in three Canadians could be 65 or older by 2068. 

Currently, 15 percent of acute-care hospital beds in Canada are occupied by patients who do not require acute care but have no other place to go to. 

“Our long-term-care system was not really functioning at all right before COVID, but with COVID it basically collapsed entirely,” says Shawn Whatley, a physician and Munk senior fellow in health policy at the Macdonald-Laurier Institute.

Flanagan and Kokorelias suggest that their proposal could be implemented by utilizing existing infrastructure and community-based care providers to offer LTC-equivalent care at home. Coordinated care teams would involve key partners such as community support services agencies, health-care service providers, primary care providers, and community paramedics to provide a range of services, including health care, support, and monitoring. 

In addition, existing LTC homes could collaborate with this program to offer locally delivered home- and community-based care, potentially reducing the need for some individuals to move into LTC homes and facilitating smoother transitions when necessary.

Krystle Wittevrongel, a senior policy analyst with the Montreal Economic Institute (MEI), thinks the proposal is a great idea. She notes that the MEI is a strong supporter of increasing home care as opposed to institutional care. 

“Shifting to caretaking, there’s huge cost savings, as opposed to long-term institutionalized care,” she says. 

The proposal points out that the costs associated with the planned creation of more LTC beds are projected to reach $34 billion, and a shift toward greater home care would curtail the need for further expenses. The authors note that according to the Ontario government, the care of in-hospital patients who are awaiting an LTC bed costs $750 per day, while home-based LTC care costs $200 per day. 

More ‘beds’ really means more nurses 

While provincial governments often refer to expanding the number of beds available for hospitals or LTC, Whatley says this actually refers to recruiting more staff.

“Whenever you [speak about] a ‘bed’ in a hospital or long-term care, what that means is a nurse,” he says. “Our Canadian hospitals have lots of beds, but we don’t have nurses taking care of the people that could be in those beds. That’s what we mean when we say hospital capacity is over 100 percent.” 

As with many other aspects of health care, Canada suffers from a shortage of working nurses. In 2023, there were 24 percent more nursing job vacancies than the year prior, with more than one-third of all nurses working overtime. 

Whatley is concerned that an expanded home-care system would put additional pressure on nurses. “We’re going to take patients and put them in a home where they may be alone,” he says. “They’d have to be pretty high-functioning to be alone.”

While there may be only one or two nurses for a floor of 20 patients in a hospital or care home, he says, those patients are at least housed in a facility where there are cameras, locked doors, and safety measures in place. This may not always be available in a home-care system, even with remote monitoring. And patients with more complex needs—such as those with dementia—may require additional care.

Many tend to sleep during the day and become very active in the evenings, he points out. “They’ll be up all night walking around and we have to lock the doors and have all sorts of alarms to make sure they can’t turn the stove on,” he says, adding that these safety measures are automatically in place in a purpose-built nursing facility. 

Whatley also notes that matching patients with nurses is not an automatic process akin to pressing a button on a vending machine. 

“There is a relationship, and relationships require trust, communication, rapport—and it’s very, very hard to develop that if you’re getting a new provider every other week,” he says, pointing out that scheduling could also be a challenge.

Most home nursing providers will offer 24 hours of care, but with limited staff, a nurse’s schedule may not always be optimal. 

“That hour of care may be provided at a time that really doesn’t work out well for the patient,” he says. “When their [the patient’s] daughter is already at home or has to work, or when their daughter’s off picking up the kids from school. It has to work at the right time.” 

Challenges with implementation 

Flanagan and Kokorealis’s proposal would involve 24/7 remote monitoring of vital signs to ensure that people can receive preventative and connected care from paramedics, as well as individualized alerts and quick responses to changes in their health. 

And yet, Wittevrongel notes that she did not see any mention of interoperable digital health records in the proposal, which she believes is integral to implementing a shift to home-based LTC. “This information [needs to be] readily available, especially to the paramedics and people in the community who are helping these people out,” she says. 

Emmanuelle Faubert, an economist at the MEI, also points out that transferring the necessary infrastructure and equipment from an institution to a home for the purposes of care presents a challenge. She notes that while shifting to home care would be a better option for most people who need long-term care, there are exceptions. “People that have very complex needs might be better in institutionalized care because providing all this equipment and services might not be [feasible],” she says. 

Comparisons to foreign health-care systems requires caution 

In their proposal, Flanagan and Kokorelias point to Denmark as an example Canada could follow in terms of home-based long-term care. 

Although both countries have publicly funded health-care systems, they differ in key ways. Canada has a single-payer system in which the government is the sole payer for health-care services, funded primarily through general taxation at the provincial level. In contrast, Denmark employs a multi-payer system with a mix of public and private funding sources, including general taxation and private health insurance options. 

Within this system, Denmark employs an “aging-in-place” model for elder care that focuses on allowing older adults to remain in their own homes and communities for as long as possible.

While Denmark’s system is indeed appealing, Whatley and Wittevrongel caution that comparing Canada’s health-care system to that of any foreign country requires geographic, economic, demographic, and cultural context. 

“I get a little bit worried with comparisons,” Whatley says. “Certainly, we should look and learn. But you can’t copy and paste the policy from somewhere else.”

“We have to build something that will work in Canada for our geography, for our level of population density,” he continues, pointing to Italy as an example of how a comparison that looks good on paper can break down with closer analysis. “In Italy, almost 65 percent of people between the ages of 18 and 34 are still living at home with their parents. That’s a completely different context in which to address a health policy issue than in Canada.”

With regards to Denmark—a small and densely populated country—Whatley notes that the greater metropolitan areas of Vancouver or Toronto are comparable, but that more isolated urban centres such as Kenora or Prince George would not be (the BC Nurses Union recently declared a full-blown staffing crisis in the mostly rural northern part of the province). 

Wittevrongel adds that cultural considerations also need to be taken into account. “Denmark culturally treats their elders very differently. The whole system has much more choice embedded in it,” says Wittevrongel. 

Canada’s climate consensus is collapsing. Can it be salvaged?

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As the world meets in Dubai for the COP28 climate conference, it’s become increasingly unclear if Canada will be able to achieve its own emission reduction targets. The national consensus around the carbon tax, once declared the winner of the 2019 federal election by the CBC, is collapsing

A majority of Canadians now oppose carbon tax increases, and a slim majority have concluded the tax is ineffective at combating climate change (this appears to be a counterfactual conclusion, but the voter is always right). Canadians don’t want to give up: a large majority are concerned about climate change and wish the government was doing more. They just don’t want to pay for those efforts. Climate is a looming concern, but rent is an immediate one. 

To address that concern, the Government of Canada is aiming to reduce national emissions by 40 to 45 percent below 2005 levels by 2030, and put us on a path to achieve net-zero emissions by 2050. The carbon tax—including the consumer and industrial components—is estimated to represent approximately one-third of those projected reductions, making it a large part of the strategy. 

Pierre Poilievre, however, has made scrapping the carbon tax a key policy plank. That didn’t work for Andrew Scheer in 2019; two-thirds of voters backed a party that endorsed a tax, suggesting Canadians saw it as necessary to combat climate change. Today though, as cost of living concerns dominate politics, any policy with “tax” in the name will be a difficult sell. The carbon tax’s impact on liveability does appear to be minimal, and many Canadians receive the climate action incentive payment. But the tax is a visible contributor to gas bills, while the Climate Action Incentive Payment is an obscure line in the depths of your chequing account. 

Those nuances have been lost in the government’s oft-dire communication strategy, and all this confusion has consequences. After Ottawa recently announced a carbon tax exemption for oil-heated homes in Atlantic provinces, Scott Moe declared Saskatchewan would stop collecting the tax unless it also received exemptions. Danielle Smith has mulled challenging the exemptions in court. An unpopular, uneven tax is unlikely to be a winning issue in the next election, leaving the carbon tax to risk death by a thousand grumblings. 

Whatever your thoughts on the carbon tax, it’s not difficult to imagine a future where it’s gutted or axed. How can Canada make up for it? Will Poilievre or Justin Trudeau have the political will to implement policies that make Canada’s attendance at COP more than ceremonial? And are there any ideas that could avoid politicization in today’s, well, climate? 

Dale Beugin, the executive vice president of the Canadian Climate Institute, tells The Hub that Trudeau’s recent carveouts will have little effect on emissions. But any policy that’s sporadically applied raises questions about how much the government really believes in its own ideas. 

“Exceptions undermine signalling, and could have bigger ramifications,” Beugin says. “From a policy perspective, it’s creating perceptions that policy might change again in the future. That’s really bad for attracting investment for low-carbon technologies, it’s really bad for emissions reductions. Long-term policy certainty is critical to doing what the policy is supposed to do.” 

Beugin was quick to point out that a carbon tax is only the most visible tool in a robust toolbox of regulations, subsidies, and pricing schemes. The output-based pricing system (OBPS) for industrial emitters continues to function without political drama, and Beugin highlighted oil and gas methane regulation as a winning program; the government gets fewer emissions of a powerful greenhouse gas, and the industry avoids leaky pipes and lost profits. But if the carbon tax dies, we’ll need much bigger ideas. 

A rejection of the carbon tax is not an inherent rejection of climate policy. Debate, Beugin says, is “healthy,” as long as we’re debating between sincere policy options. But having “some kind of sound policy is starting to become a minimum requirement.” The 2019 election was about far more than the carbon tax, but it was notable that Scheer’s plan would have left Canada far from its emissions reduction target. That approach is unlikely to be viable again, electorally or existentially. 

“It doesn’t seem like there’s a world in which we don’t have strong climate policy,” Beugin says. “We’re seeing the impact of climate change with forest fires and floods, it’s increasingly present in Canadians’ lives. Climate impacts could be worth half a year of GDP growth in 2025. And it’s increasingly obvious the world is moving. Canada’s ability to attract international investment is starting to be affected by climate policy.” 

Beugin points to the fact that investment decisions are now pivoting around the availability of cheap, clean, low-carbon electricity. LG Chem spurned Ontario out of concern this would be lacking, while an Alberta solar farm drew Amazon to the province. Clean electricity attracts capital, which Beugin notes “isn’t going to happen without some policy signals.” Climate policy, then, could be presented as a job creator, not as a purse-pinching burden. 

“It increasingly feels like the engine that’s driving climate policy is not just abstract targets, but growth and competitiveness,” Beugin says. “More and more, the key factor that drives good climate policy is the idea that you can’t lag too far behind the world, or you’re not going to be able to compete.” 

More clean electricity would also allow Canada’s EV charging network to scale up and make electric vehicles more desirable. And, with the country in desperate need of more housing stock, there’s an opportunity to build a wave of low-emission homes. But if the carbon tax goes, industry will likely have to pick up the slack.   

 “The OBPS is a real opportunity,” Beugin says. “It cuts on both edges, it drives emission reductions because it sets expectations about industrial carbon price, and it protects the competitiveness of high-emission steel, cement, and aluminum producers because it ensures they have incentives to reduce emissions by improving performance, not shipping production elsewhere. Low carbon projects that reduce emissions can generate credits worth cash.” 

The carbon tax has been a political nightmare because it has visible costs and obscure benefits. Regulatory policies aren’t invisible, but they can be market-friendly. “You’re requiring emitters to do something they wouldn’t have otherwise done,” Beugin says. “That may be easier and more amenable to conservatives if there are market-based mechanisms backed in; if you have compliance flexibility, ways to avoid doing the most expensive things while still having incentive to do the cheap things. If we assume the OBPS is robust and stable, that’s a good way to cover a big chunk of emissions in a way that doesn’t undermine competitiveness.” 

Then there is adaptation, which Beugin calls the “poor cousin” of climate mitigation. This, essentially, is future-proofing, from hardening infrastructure against floods to adjusting agricultural practices for extreme weather to modernising financial regulations so the climate risks of projects are disclosed; no one wants to invest in real estate built on a floodplain. “There’s a lot to do there,” Beugin says. “Canada has started down that road, it has a broad framework, but there’s a ton of work to be done in starting to send those signals to adapt. That’s still growing, and it’s not very partisan.” 

However Canada chooses to move forward, our policy signals need to be clear and consistent, not riddled with headline-dominating exceptions. By this time next year, it’s possible the United States will be on the verge of abruptly reversing its climate policy. If Canada is to stay prepared and competitive, we cannot afford such slip-ups. 

The thing that’s most painful for industry and investments is wild oscillations,” Beugin says. “They would much rather have some certainty. There may be a strong case, even if the U.S. falls on its face again, for moving steadily and with certainty in the Canadian markets.” 

Beugin sees a path forward to net zero. Climate Institute modelling says Canada can hit at least two-thirds of its 2030 targets with safe bets technologies; clean energy, electric vehicles, and other technologies with few variables. Wildcard technologies that may or may not pan out, like extracting CO2 with direct air capture, should contribute two-thirds by 2050. “To deploy safe bets, we need steady, incremental policy like regulations or output-based carbon pricing,” Beugin says. “Wildcards can be driven by incentives for innovation. Canada really needs policy for both.” 

The hard reality of climate change, Beugin says, lies between denying its existence and worrying that it’s already too late to act. Federal policy needs to be genuine, broad, stringent, and consistent, not mercurial and optics-driven. And provinces need to get in the game instead of griping from the sidelines. 

“What’s been interesting, and maybe problematic, is that it’s really been the federal government driving climate policy,” Beugin says. “But the provinces have a role to play, especially on things like buildings and electricity. So there’s an opportunity there for provinces to send some signals to electricity regulators and utilities to really start to scale up that clean electricity. That could make a huge difference.” 

As attractive as the image of Canadians putting aside their differences for the sake of survival may be, it’s economics that could finally unite even the staunchest political opponents. Every voter wants jobs, and every party wants to be seen making them. COP summits may be dogged by criticism, but their very existence is a sign the low-carbon economy is coming. A drive to compete in it could become Canada’s new climate consensus, as long as our policy is more than mere theatre. 

“A black-and-white conversation around doing nothing or doing everything is not stable because of the trends we’re seeing in markets and the acceleration of climate impacts,” Beugin says. “There are near-term benefits to competing in this low-carbon global economy. The competition for capital is starting to get pretty fierce. That is imminent and short-term and urgent.”