By Dr. Karen-Marie Elah Perry June 2020
This report is dedicated to the memory of Frances Belich (1927–2016) and of Carol Pearlstone (1940–2019).
This report is co-published with the Hospital Employees’ Union and the BC Health Coalition
Shannon Daub, Jean Kavanagh, Emira Mears and Terra Poirier Layout: Susan Purtell
Copyedit: Grace Yaginuma
Cover photo: vuqarali / Shutterstock.com
COVID-19 has shone a light on the state of long-term care for seniors in Canada, including problems resulting from years of underfunding, privatization and precarious working conditions faced by an undervalued, marginalized workforce dominated by racialized and immigrant women. These problems are not isolated to long-term care—rather, they are symptoms of a larger crisis in our fragmented system of home- and community-based health care for seniors.
This qualitative study looks at the state of assisted living prior to the pandemic in terms of the quality and appropriateness of services it provides to seniors, the conditions for both residents and workers, and the legislative and regulatory frameworks that govern assisted living.
The research findings reinforce the urgent need for action driven by the experiences and voices of seniors, their families and the front-line workers who provide care amid frequently impossible circumstances. This study is by no means a comprehensive review of the assisted living sector— but it raises serious concerns that warrant such a review by the BC Seniors Advocate.
The evolution of assisted living in BC
Assisted living was introduced as a substitute for long-term care (nursing homes) with the aim of providing a less institutional, more home-like environment—which is important and highly val- ued by seniors. But for the government of the day, it was also attractive as a cost-saving measure (i.e., by their calculation about as half as expensive to provide as long-term care).
Some assisted living residences are publicly subsidized; others are entirely private pay. In publicly subsidized assisted living, residents pay a monthly charge of 70 per cent of their after-tax income and are deemed eligible to access services by their health authority. In private-pay assisted living, residents pay 100 per cent of the cost directly to the operator, and if the resident requires an additional service, it comes with an additional charge.
Since its introduction in 2002, the assisted living sector has grown to more than 7,600 units provincewide. Troublingly, the majority are owned and operated by for-profit companies, and more than 40 per cent are entirely private pay. The growth of for-pro t and private-pay assisted living, and related a ordability concerns, are analyzed in detail in a companion paper to this study Assisted Living in British Columbia: Trends in Access, A ordability and Ownership.
In 2016, the provincial government initiated legislative changes with the goal of increasing access to assisted living so that more seniors could age in place. This is a positive goal—how- ever, the changes were introduced without a review of the sector to determine if it was, in fact, providing access to quality, affordable services. As a result, many key issues were not examined, including how effective the system was at responding when the physical and/or cognitive health of a resident deteriorated; the implications of having a large portion of the residences that are entirely private-pay; and an assessment of the funding and staffing that would be required to support more seniors to age in place.
Since that time, concerns have been raised by assisted living residents, and their families, and care workers about the living and working conditions in these residences. In response to these concerns, this research project focused on gaining a better understanding of the current state of assisted living in the province.
A key ethical value meant to underpin policy related to assisted living is respecting people’s autonomy—that is, respecting their capacity to maintain a level of independence and make meaningful informed choices regarding their care. Currently, BC’s philosophy of care in assisted living emphasizes residents’ “right to choose to live at risk” but without acknowledging the realities surrounding resident “choice.”
Quality of care impacts resulting from undervalued and overworked staff
Research participants in this study had a lot to say about current working conditions for LPNs and care aides. Virtually all care aide and LPN participants in the study emphasized the need for more staff to cope with the increasing complexity of resident care needs. Many reported missing lunch or coffee breaks or paying out-of-pocket for supplies residents could not afford. Care aides also emphasized the wide breadth of their duties, the inadequacy of wages as com- pared to their counterparts in long-term care, heavy workloads and very high injury rates. Many care aides experienced precarious part-time working conditions throughout their career, often working on call.
In subsidized and especially private-pay assisted living, front-line staff reported being unable to do what they ethically know they should as a result of institutional constraints like low sta – ing levels and a lack of resources. These constraints create moral distress for both care aides and LPNs.
[We have] residents coming into care, not accurately or adequately assessed, it happens. And to watch somebody struggle to try to get up because my co-worker is busy, like it just…I feel terrible and it shouldn’t happen, but it does. And ultimately, it’s the residents who suffer for it, you know, physically, [and with their] dignity. (Devorah, care aide)
Care aides emphasized the wide breadth of their duties, the inadequacy of wages as compared to their counterparts in long- term care, heavy workloads and very high injury rates.
To read the recommendations and the full study, please click on:
The Place of Assisted Living in BC’s Seniors Care System
ASSESSING THE PROMISE, REALITY AND CHALLENGES