cmhc research report environment scan on canadian seniors' transitions to special care...

ReseaRch RepoRt

Environment Scan on Canadian Seniors’Transitions to Special Care Facilities

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ENVIRONMENT SCAN ON CANADIAN SENIORS’ TRANSITIONS TO SPECIAL CARE FACILITIES

FINAL REPORT (November 2011)

Submitted by:

i CMHC Seniors’ Transitions to Special Care Facilities Final Report (DRAFT)

Acknowledgements This study was undertaken on behalf of Canada Mortgage and Housing Corporation. The authors would like to thank Mariam Lankoande for her valuable input and assistance. We also wish to thank those who participated in interviews or provided reports and studies. 1) Andrew Ramlo, Director Urban Futures Institute

2) Brenda Loubert, Administrator Casselholme Foundation

3) Calvin Jourdrie, Long Term Care Subsidization Manager, Health PEI

4) Christian Fisker, Ontario Retirement Communities Association and Chartwell REIT

5) David Pedlar, Director of Research Veterans Affairs Canada

6) David Stansen, Co‐ordinator, National Housing Research Committee (NHRC) and External Liaison

7) Donald Shiner, Professor, Mount Saint Vincent University; co‐investigator for the Atlantic Housing Research Alliance project

8) Donna Mushrow, Policy Consultant, Newfoundland and Labrador Department of Health and Community Services

9) Francine Cloutier, Societe d’habitation du Quebec

10) Janice Clark, Advisor New Brunswick Senior and Healthy Aging Secretariat

11) Johanne Villeneuve, Ministere de la Famille et des Aines

12) Kathleen Cruttenden, Professor University of New Brunswick; co‐investigator for the Atlantic Housing Research Alliance project

13) Kathleen Morris, Director Health Systems Analysis and Emerging Issues, Canadian Institute for Health Information

14) Laurie Johnston, CEO, Ontario Retirement Communities Association

15) Laurie Weiman, Seniors Consultant Saskatchewan Ministry of Health Community Care Branch

16) Lois Cormack, President Specialty‐Care

17) Lori Mitchell, Winnipeg Regional Health Authority Home Care Program

18) Michelynn Lafleche, Director of Research, United Way of Greater Toronto

19) Marie‐Noelle Ducharme, Lecturer, Universite du Quebec a Montreal

20) Marion Pringle, President, Long Term and Continuing Care Association of Manitoba

ii CMHC Seniors’ Transitions to Special Care Facilities Final Report (DRAFT)

21) Nancy Cooper, Director of Policy and Professional Development, Ontario Long Term Care Association (OLTCA)

22) Paul Williams, Professor University of Toronto; Co‐Director of the CIHR Team and of the Canadian Research Network for Care in the Community

23) Ron McMahon, Director Nunavut Bureau of Statistics

24) Teresa Snider, Manitoba Seniors and Healthy Aging Secretariat

25) Tricia Khan, Senior Director Client Services, Erie St. Clair CCAC

26) Willa Rea, Co‐Chair NHRC Housing Data Working Group

Consulting Team The consulting team for this project consisted of: Christine Pacini, Partner, SHS Consulting Johanna Hashim, Senior Research and Policy Analyst, SHS Consulting The information in this publication is a result of current research and knowledge. It is not intended for the content to be relied upon as professional or expert advice or opinions. Readers should evaluate the information, materials and techniques cautiously for themselves and consult appropriate professional resources to see if the information, materials and techniques apply to them. The images and text are guides only. Project and site‐specific factors (climate, cost, aesthetics) must also be considered.

INTRODUCTION

The Environment Scan on Canadian Seniors’ Transitions to Special Care Facilities provides a comprehensive picture of seniors’ transitions from private dwellings to special care facilities based on available literature. In this study, seniors are people aged 65 or older. It presents a synthesis of the findings from a review of literature, data collection and key informant consultations. The overall purpose of the study was to review the state of knowledge on seniors’ transitions by:

■■ conducting a comprehensive literature review on seniors’ housing transitions to special care facilities and the implications of seniors’ housing transition trends for housing; and

■■ compiling and analyzing available data on seniors’ housing transitions to special care facilities.

METHODOLOGY

This study was undertaken in two phases.

Phase One involved a comprehensive review of literature on seniors’ housing transitions from private dwellings to special care facilities with a focus on the past two decades.

Phase Two of the study involved identifying data sources on seniors’ housing transitions, collecting and analyzing this data, identifying data gaps and areas for further research, and providing recommendations on how to fill these gaps. Consultations with key informants were conducted to identify data sources, validate and build on the findings from Phase One, and identify additional studies or reports to supplement the information gathered in Phase One. A list of key informants was developed and included representatives of seniors’ organizations, developers of seniors’ housing, academics who have expertise in seniors’ issues, and representatives of provincial and territorial ministries.

FINDINGS

In 2011, there were close to five million seniors in Canada, representing 14.8% of the population. This was up from 13.7% in 2006.1 By 2036, it is estimated that almost a quarter of the population (23.7%) will be made up of Canadians 65 years or older. Statistics Canada data shows that the majority of seniors live in private dwellings, while the remainder (7.9% of seniors in 2011) live in collective dwellings, which include special care facilities.2

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RESEARCH HIGHLIGHT

Environment Scan on Canadian Seniors’ Transitions to Special Care Facilities

1 The report: Environment Scan on Canadian Seniors’ Transitions to Special Care Facilities is based on data from the 2006 Census. This research highlight has been updated with 2011 Census data.

2 In the 2006 Census, “special care facilities” refer to nursing homes, residences for senior citizens, and chronic and long-term care and related facilities.

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There were variations in the proportions of seniors in special care facilities across provinces and territories. Quebec had the largest proportion of seniors in special care facilities in 2011, at 9% followed by Alberta (8.8%), Manitoba (7.4%), Prince Edward Island (7.2%), and Saskatchewan (6.9%). New Brunswick had the smallest proportion (4.4%) among the provinces, while Nunavut and the Northwest Territories had the smallest proportion (1.9%) overall.

The proportion of the senior population in special care facilities does not necessarily reflect the share of the senior population in the provinces and territories. While New Brunswick had the largest proportion of seniors among the provinces and territories in 2011, at 23.7%, only 4.4% of New Brunswick seniors are in special care facilities. Alberta on the other hand had a smaller proportion of seniors (11.1% of the total population), but 8.8% of Alberta seniors reside in special care facilities.

Reasons why seniors move to special care facilities

A number of factors influence seniors’ decision to move from their private home to a special care facility. In general, most seniors would prefer to stay in their own homes. It is often factors beyond their control that drive them to move to a special care facility. Health status is one of the primary reasons seniors move to special care facilities. Several studies have found that someone experiencing health challenges was significantly more likely to live in an institution than someone in good health. In addition, the type of health issue is directly correlated to the probability of living in a special care facility. For example, a study found that seniors with Alzheimer’s disease or dementia were more likely to move to a special care facility than those who had diabetes, hypertension or coronary artery disease.3

The availability of care in the home is another major factor that influences seniors’ decision to move to a special care facility. Several studies found that a move to an institution is not always the result of deteriorating health status but may be the only option available to seniors who live alone and who do not have family or friends to help care for them. One study found that publicly provided home care reduced the probability of institutionalization by about 45%. The authors also found that social support reduced the probability of institutional living arrangements in the range of 49% to 62%.4

Other factors that influence seniors’ decision to move to a special care facility include age, income, education, marital status, living arrangements, and the presence of home adaptations. The probability of living in a special care facility increases with age; having low income or education levels; being single, separated or divorced; and living alone. Gender seems to be a determinant as well, but it is more a result of longer life expectancy for women than an independent factor that influences seniors’ decision to move. As the gap in life expectancy between men and women narrows, there may be more men moving to special care facilities or more couples seeking alternatives to institutionalization.

In addition, the policies and programs in the seniors’ province of residence may also influence their decision to move. Regions with a larger supply of beds in special care facilities may have higher rates of institutionalization. In addition, policies on payment for accommodation may influence whether a senior moves to a nursing home or residence for seniors, sometimes regardless of their care needs. Further, provincial and territorial budgets for home care are factors in the rates of institutionalization, as these determine the availability of, and access to, care in the community.

3 Mitchell, L., et al. (2008). Long Term Care Strategy: An Examination of Clients Across the Care Continuum. Winnipeg Regional Health Authority and Centre on Aging, University of Manitoba.

4 Sarma, S., Hawley, G., and Basu, K. (2009). “Transitions in Living Arrangements of Canadian Seniors: Findings from the NPHS Longitudinal Data.” Social Science and Medicine, 68, pp. 1106-1113.

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Timing of transitions to special care facilities

The move from a private dwelling to a special care facility generally occurs between the ages of 80 and 85, but age alone does not determine whether seniors will move from their private dwelling to a special care facility. Other factors, such as health status and the availability of care in the community, in association with age, influence a senior’s decision to move. As life expectancy increases, particularly disability-free life expectancy, the average transition age may also rise.

Research and key informant consultations were not able to identify data showing the proportion of the senior population transitioning to special care facilities each year in the past decade. It can be inferred from the available data that only a small proportion of seniors move to special care facilities each year. This is supported by the fact that only 7.1% of the Canadian senior population in 2011 lived in special care facilities5 (up from 6.3% in 2006).

Patterns of transition to special care facilities

The literature suggests that there are three kinds of moves often made by seniors. The first move is undertaken right after retirement and is primarily for amenity or lifestyle reasons where the senior moves to be in a location with more desirable and age-appropriate amenities. The second move is done to be near a primary caregiver when the senior becomes moderately disabled and can no longer manage without help. The third move is to an institution when the senior’s needs are too much for the caregiver to handle.6

There are a number of variances to this pattern. For example, a low-income senior household may not have the option of moving for amenity or lifestyle reasons. In addition, for seniors with no children or younger relatives who may be able to provide some assistance,

moving to an institution may be their only option, particularly if there are no formal supports available in the community. Another deviation from the pattern may be seen among immigrant communities, where seniors sometimes live with their children or relatives despite their relatively good health.7

Some key informants felt that there was no typical pattern in the housing transitions of seniors. They felt that each individual had a unique pattern but that these were often influenced by the senior’s health status and financial situation. Some key informants also suggested that the availability of home care or informal care influenced the pattern of transition a senior followed. An informal caregiver, such as a child or relative, or the availability of formal home care in the community allows seniors to stay in their own homes longer, if not permanently.

Key informants stated that they expected patterns of seniors’ housing transitions to change as a result of the aging of the baby boomers. There was no data to support this, since the oldest of the baby boomers only reached 65 in 2011. But baby boomers’ attitudes and the changes that have occurred, such as a focus on staying healthy longer and staying in the workforce longer, suggest that changes will be experienced in this sector as well.

Housing preferences and actual transition patterns

A survey of Atlantic Canadian seniors found that 88% of respondents had no plans to move from their current dwelling.8 When offered a home care alternative, 90% of Canadian veterans chose to remain at home rather than move to a nursing home.9 In spite of this, many seniors do realize that, as they age, their health will deteriorate and that there is a good chance they will need to move to some form

5 Source: Statistics Canada, 2011 Census, Catalogue no. 98-313-XCB2011024.6 Litwak, E. and Longino, C. (1987). “Migration Patterns Among the Elderly: A Developmental Perspective.” The Gerontologist, Vol. 27(3), pp. 266-272.7 Litwak, E. and Longino, C. (1987). “Migration Patterns Among the Elderly: A Developmental Perspective.” The Gerontologist, Vol. 27(3), pp. 266-272.8 Shiner, D. (2007). Report on the Atlantic Seniors’ Housing and Support Services Survey.9 Pedlar, D., Lockhart, W., and Macintosh, S. (2009). “Canada’s Veterans Independence Program: A Pioneer of “Aging at Home.” ” Healthcare Papers,

Vol. 10(1), pp. 72-77.

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of seniors’ housing that offers support services. A study found that seniors’ expectations of their living arrangements in the future are largely based on their personal profile.10 This means that, despite the fact that most seniors would like to age in their own homes, for someone whose health status is not good and who does not have access to home care, the expectations of transitioning to a special care facility are quite high.

Implications of seniors’ transitions to special care facilities

The aging of the population has significant effects on housing, communities and governments. Since the majority of seniors would prefer to age in their own homes, there will be increasing pressure for programs that facilitate aging in place, including home care programs and programs that support informal caregivers. The aging of the baby boomers will increase the demand for these programs, as information on this population group suggests that they will not accept institutionalization as the only option.

In spite of the desire to age at home, there will still be a number of seniors who will require special care facilities. This number is expected to rise as a result of the increase in the senior population. In addition, some studies suggest that the people entering special care facilities will have higher care needs on account of the prevalence of certain health conditions, such as dementia, and the advanced age at which seniors move to special care facilities. In 2007, an estimated 450,000 Canadians over 65 years had dementia, and 260,000 of these seniors had Alzheimer’s disease. The Canadian Alzheimer Society estimates that, by 2031, about 750,000 Canadians will have dementia.11 In addition, data suggests that there may be a need to consider providing accommodation in special care facilities for couples rather than just individuals as the gap in life expectancy between men and women narrows.

Gaps in data and information

The review of the current state of knowledge on seniors’ housing transitions from private dwellings to special care facilities identified a number of data and information gaps. One of these gaps is the lack of common terms and definitions across the country. Another gap was the lack of consistent data on seniors moving from private dwellings to special care facilities. Developing standards for the collection of data on admissions to special care facilities would help ensure the availability of consistent data throughout the country.

Data was not available on the annual proportion of the senior population moving from private dwellings to special care facilities by age category. By gathering data on the number of seniors entering special care facilities each year across the country and comparing this data to annual population estimates from Statistics Canada, it would be possible to calculate the proportion of seniors moving each year. This would help provide an accurate picture of the overall need for these facilities and provide a basis for policy and program decisions.

The review also found that, in some cases, it was difficult to get the same type of data for nursing homes and residences for seniors. This data would be useful in comparing the population of these two types of special care facilities, in determining the current and future need for these types of facilities, and in making policy decisions.

Addressing these gaps involves modifying the way in which data is gathered and the type of data that is being collected. Considering that data collection is undertaken by different government agencies and different jurisdictions, it would be useful to find a collaborative way of addressing the data gaps that have been identified.

10 Akamigbo, A., and Wolinsky, F. (2006). Reported Expectations for Nursing Home Placement Among Older Adults and Their Role as Risk Factors for Nursing Home Admissions.

11 Ascent Strategy Group (2008). Final Report: Trends, Projections and Recommended Approaches to Delivery of Long-term Care in the Province of Prince Edward Island 2007-2017.

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Areas for further research

The environment scan and key informant consultations also identified some areas for further research to better understand seniors’ transitions from private dwellings to special care facilities. One area that may warrant further research is the implications of the narrowing gap in life expectancy between men and women on the need for special care facilities. Another area is the impact that the increasing disability-free life expectancy would have in the use of special care facilities.

Further research could include how programs to facilitate aging at home may further decrease the proportion of seniors moving to special care facilities, in spite of the increase in the proportion of seniors in the population. Further research on the Balance of Care model (which examines the proportion of clients on the waiting list for nursing homes who could safely and cost-effectively be supported in their own homes or in supportive housing in their communities) could also be undertaken to better understand alternatives to institutionalization and support a re-examination of policy and program priorities.

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Although this information product reflects housing experts’ current knowledge, it is provided for general information purposes only. Any reliance or action taken based on the information, materials and techniques described are the responsibility of the user. Readers are advised to consult appropriate professional resources to determine what is safe and suitable in their particular case. Canada Mortgage and Housing Corporation assumes no responsibility for any consequence arising from use of the information, materials and techniques described.

©2013, Canada Mortgage and Housing CorporationPrinted in CanadaProduced by CMHC

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Housing Research at CMHC

Under Part IX of the National Housing Act, the Government of Canada provides funds to CMHC to conduct research into the social, economic and technical aspects of housing and related fields, and to undertake the publishing and distribution of the results of this research.

This Research Highlight is one of a series intended to inform you of the nature and scope of CMHC’s research.

CMHC Project Manager: Mariam Lankoandé

Consultant: SHS Consulting

08-10-13

http://www.cmhc.ca

INTRODUCTION

L’Étude de conjoncture sur la transition des aînés canadiens à des établissements de soins spéciaux se fonde sur la documentation disponible pour brosser un portrait complet de la transition des aînés d’habitations privées à des établissements de soins spéciaux. L’étude porte sur les aînés de 65 ans et plus. Elle présente une synthèse des conclusions tirées d’un examen de la documentation, de la collecte de données et de consultations auprès d’intervenants clés. L’objectif global de l’étude consistait à examiner l’état des connaissances sur la transition des aînés par :

■■ l’examen complet de la documentation sur la transition domiciliaire des aînés à des établissements de soins spéciaux, ainsi que sur les implications sur le logement des tendances en matière de transition domiciliaire des aînés;

■■ la compilation et l’analyse des données disponibles sur les transitions domiciliaires des aînés à des établissements de soins spéciaux.

MÉTHODOLOGIE

Cette étude a été effectuée en deux phases.

La phase I comportait un examen approfondi de la documentation sur les transitions domiciliaires des aînés de résidences privées à des établissements de soins spéciaux, en portant une attention particulière aux deux dernières décennies.

La phase II de l’étude comportait l’établissement de sources de données sur les transitions domiciliaires des aînés, la collecte et l’analyse de ces données, l’identification de lacunes dans les données et de domaines pour poursuivre les recherches et l’élaboration de recommandations sur la manière de combler ces lacunes. Des consultations auprès d’intervenants clés ont été menées pour déterminer les sources de données, valider et compléter les conclusions de la phase I et proposer des études ou rapports supplémentaires dans le but d’ajouter aux informations recueillies pendant la phase I. Une liste d’intervenants clés a été dressée et comportait notamment des représentants d’organismes de personnes âgées, des promoteurs d’ensembles d’habitation pour les aînés, des universitaires avec une expertise sur les questions liées aux aînés et des représentants de ministères provinciaux et territoriaux.

CONCLUSIONS

En 2011, il y avait près de cinq millions d’aînés au Canada, représentant 14,8 % de la population. Cette proportion est une hausse puisqu’en 2006, les aînés représentaient 13,7 % de la population1. D’ici à 2036, on prévoit que près du quart de la population (23,7 %) sera composé de Canadiens âgés de 65 ans ou plus. Les données de Statistique Canada montrent que la majorité des aînés vit dans une habitation privée, alors que les autres (7,9 % des aînés en 2011) habitent dans des logements collectifs institutionnels, dont des établissements de soins spéciaux2.

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LE POINT EN RECHERCHE

AU CŒUR DE L’HABITATION

Étude de conjoncture sur la transition des aînés canadiens à des établissements de soins spéciaux

1 Le rapport : Étude de conjoncture sur la transition des aînés canadiens à des établissements de soins spéciaux est fondé sur des données du Recensement de 2006. Ce Point en recherche a été mis à jour à partir des données du Recensement de 2011.

2 Dans le Recensement de 2006, le terme « établissements de soins spéciaux » fait référence à des maisons de soins infirmiers, des résidences pour personnes âgées et des établissements de soins de longue durée.

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Des variations ont été constatées dans les proportions d’aînés résidant dans des établissements de soins spéciaux selon les provinces et les territoires. Le Québec avait la plus importante proportion d’aînés en établissement de soins spéciaux en 2011 avec 9 %, suivi de l’Alberta (8,8 %), du Manitoba (7,4 %), de l’Île-du-Prince-Édouard (7,2 %) et de la Saskatchewan (6,9 %). Le Nouveau-Brunswick avait la plus petite proportion (4,4 %) parmi les provinces, alors que le Nunavut et les Territoires du Nord-Ouest avaient la plus petite part (1,9 %) dans l’ensemble.

La proportion d’aînés en établissement de soins spéciaux dans une province ou un territoire ne correspond pas nécessairement à la part de la population âgée dans l’ensemble. Le Nouveau-Brunswick renfermait la plus importante proportion d’aînés parmi les provinces et territoires en 2011, avec 23,7 %, alors que seuls 4,4 % des aînés néo-brunswickois sont hébergés dans des établissements de soins spéciaux. En revanche, même si l’Alberta avait une proportion inférieure d’aînés (11,1 % de la population totale), 8,8 % des aînés albertains résidaient dans des établissements de soins spéciaux.

Les motifs derrière le déménagement des aînés dans des établissements de soins spéciaux

Un certain nombre de facteurs influencent la décision des aînés de déménager de leur logement privé à un établissement de soins spéciaux. En général, la plupart des aînés préféreraient rester dans leur maison. Ce sont souvent des facteurs hors de leur contrôle qui les poussent à déménager dans un établissement de soins spéciaux. L’état de santé est l’une des raisons principales derrière le déménagement des aînés dans de tels établissements. Plusieurs études ont observé qu’une personne aux prises avec des problèmes de santé était nettement plus susceptible de vivre en institution qu’une personne en bonne santé. En outre, la nature du problème de santé est directement corrélée à la probabilité de vivre en établissement de soins spéciaux. Par exemple, une étude a montré que les aînés souffrant de la maladie d’Alzheimer ou de démence étaient plus susceptibles de déménager dans un établissement de soins spéciaux que ceux souffrant de diabète, d’hypertension ou d’une insuffisance coronarienne3.

La disponibilité des soins à domicile est un autre facteur majeur qui influe sur la décision des aînés de déménager dans un établissement de soins spéciaux. Plusieurs études ont montré qu’un déménagement dans une institution n’est pas toujours la conséquence d’un état de santé qui se détériore, mais peut constituer la seule option disponible aux aînés qui vivent seuls et n’ont pas de famille ou d’amis pour prendre soin d’eux. Une étude a montré que les soins à domicile publics réduisent la probabilité de l’institutionnalisation d’environ 45 %. Les auteurs ont également observé que le soutien social réduit la probabilité d’avoir recours à des formes institutionnelles de logement de l’ordre de 49 à 62 %4.

D’autres facteurs qui influencent la décision des aînés de déménager dans un établissement de soins spéciaux comprennent notamment l’âge, le revenu, la scolarisation, l’état matrimonial, les conditions de logement et la mise en place de dispositifs d’adaptation dans la résidence. La probabilité de vivre en établissement de soins spéciaux augmente avec l’âge, ainsi qu’avec le fait d’avoir un revenu faible ou d’être faiblement scolarisé, d’être célibataire, séparé ou divorcé et de vivre seul. Le sexe semble également être un facteur déterminant. Au lieu de constituer un facteur indépendant qui influence la décision des aînés de déménager, cependant, son effet est davantage attribuable à une plus longue espérance de vie chez les femmes. Au fur et à mesure que s’amenuise l’écart d’espérance de vie entre les hommes et les femmes, il pourrait y avoir davantage d’hommes qui déménagent dans des établissements de soins spéciaux et plus de couples à la recherche de solutions autres que l’institutionnalisation.

En outre, les politiques et programmes de la province de résidence des aînés peuvent également influencer la décision de ces derniers de déménager. Les régions offrant une plus grande disponibilité de lits en établissement de soins spécialisés pourraient afficher des taux plus élevés d’institutionnalisation. De plus, les politiques de subventions à l’hébergement pourraient influencer la décision d’un aîné de déménager dans un foyer de soins infirmiers ou une résidence pour personnes âgées, parfois sans égards à ses besoins de soins de santé. Par ailleurs,

3 L. Mitchell et coll., Long Term Care Strategy: An Examination of Clients Across the Care Continuum. Winnipeg Regional Health Authority and Centre on Aging, University of Manitoba, 2008.

4 S. Sarma, G. Hawley et K. Basu, « Transitions in Living Arrangements of Canadian Seniors: Findings from the NPHS Longitudinal Data », Social Science and Medicine, 68, 2009, p. 1106-1113.



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les budgets provinciaux et territoriaux pour les soins à domicile sont des facteurs qui influencent le taux d’institutionnalisation, étant donné qu’ils déterminent la disponibilité des soins dans la communauté et la possibilité d’y avoir accès.

Le choix du moment de faire la transition à un établissement de soins spéciaux

Le déménagement d’une habitation privée à un établissement de soins spéciaux survient généralement entre l’âge de 80 et 85 ans. Toutefois, l’âge à lui seul ne détermine pas la décision d’un aîné de faire cette transition. D’autres facteurs tels que l’état de santé et la disponibilité des soins dans la communauté, en plus de l’âge, influent sur la décision d’un aîné de déménager. Au fur et à mesure que l’espérance de vie augmente, en particulier celle sans incapacité, l’âge moyen de transition risque également d’augmenter.

La recherche et les consultations auprès d’intervenants clés n’ont pas permis de repérer des données établissant la proportion de la population âgée qui fait la transition à des établissements de soins spéciaux chaque année dans la dernière décennie. On peut déduire des données disponibles que seule une petite proportion d’aînés déménage dans des établissements de soins spéciaux chaque année. Ceci est étayé par le fait que seulement 7,1 % de la population âgée canadienne vivait en établissement de soins spéciaux en 20115 (contre 6,3 % en 2006).

Parcours de transition à des établissements de soins spéciaux

La documentation laisse entendre qu’il y a trois sortes de transition souvent effectuées par les aînés. La première survient immédiatement après la retraite, principalement pour des raisons de commodité ou de style de vie, lorsque l’aîné s’installe dans un endroit muni de services plus attrayants et appropriés à son âge. La deuxième s’effectue pour se rapprocher d’un dispensateur de soins primaires, lorsque l’aîné souffre d’une incapacité modérée et ne peut plus fonctionner sans aide. La troisième transition est celle à un établissement, lorsque les besoins de l’aîné excèdent les capacités du dispensateur de soins6.

Ces parcours peuvent présenter des variantes. Par exemple, un ménage de personnes âgées à faible revenu n’a peut-être pas la possibilité de déménager pour des raisons de commodité ou de style de vie. De plus, pour les aînés sans enfants ou sans parents plus jeunes pour leur fournir une aide, le déménagement dans un établissement pourrait être leur seule option, particulièrement si aucun soutien formel n’est offert dans la collectivité. Une autre variante par rapport aux trois grands parcours s’observe parmi les communautés d’immigrants, dans lesquelles les aînés habitent parfois avec leurs enfants ou parents même si leur santé est relativement bonne7.

Certains intervenants clés étaient d’avis qu’il n’y avait pas de parcours typique en matière de transition domiciliaire chez les aînés. Ils trouvaient que chaque individu suivait son propre cheminement, souvent influencé toutefois par son état de santé et sa situation financière. Certains intervenants clés ont également avancé que la disponibilité des soins à domicile ou des soins informels influençait les modalités de transition de l’aîné. La présence d’un dispensateur de soins informels, tel qu’un enfant ou un parent, et la disponibilité de soins à domicile formels dans la communauté permettent aux aînés de demeurer dans leur maison plus longtemps, voire en permanence.

Les intervenants clés ont affirmé qu’ils s’attendaient à ce que les parcours de transition domiciliaire chez les aînés évoluent en raison du vieillissement des baby-boomers. Il n’y avait pas de données pour appuyer cette affirmation, puisque les plus âgés des baby-boomers n’ont atteint l’âge de 65 ans qu’en 2011. Toutefois, les attitudes des baby-boomers et les changements qui sont survenus, notamment l’importance accordée au maintien d’une bonne forme physique à plus long terme et à la prolongation des années de travail, laissent croire que des changements vont se faire sentir dans ce secteur également.

Préférences en matière de logement et parcours de transition réels

Un sondage auprès d’aînés de l’Atlantique canadien a permis de constater que 88 % des répondants n’avaient aucune intention de quitter leur logement actuel8. Lorsqu’on

5 Source : Statistique Canada, Recensement de 2011, Catalogue n° 98-313-XCB2011024.6 E. Litwak et C. Longino, « Migration Patterns Among the Elderly: A Developmental Perspective », The Gerontologist, Vol. 27(3), 1987, p. 266-272.7 E. Litwak et C. Longino, « Migration Patterns Among the Elderly: A Developmental Perspective », The Gerontologist, Vol. 27(3), 1987, p. 266-272.8 D. Shiner, Report on the Atlantic Seniors’ Housing and Support Services Survey, 2007.




4

leur offrait le choix des soins à domicile, 90 % des anciens combattants canadiens ont choisi de demeurer à la maison plutôt que de déménager dans une maison de soins infirmiers9. Malgré cela, bon nombre de personnes âgées sont conscientes que leur santé va se détériorer avec le vieillissement et qu’il y a de bonnes chances qu’elles devront se tourner vers une forme quelconque de résidence pour personnes âgées qui leur offre des services de soutien. Dans le cadre d’une étude, on a constaté que les attentes des aînés quant à leurs conditions de logement à l’avenir sont largement fondées sur leur profil personnel10. Cela signifie que même si la plupart des aînés souhaiteraient vieillir dans leur propre maison, les attentes liées à la transition vers un établissement de soins spéciaux sont plutôt élevées lorsque la personne n’est pas en bonne santé et n’a pas accès à des soins à domicile.

Les implications de la transition des aînés à des établissements de soins spéciaux

Le vieillissement de la population a d’importants effets sur le logement, les collectivités et les gouvernements. Étant donné que la majorité des aînés préférerait vieillir dans sa propre maison, les pressions se feront de plus en plus fortes pour créer des programmes facilitant le vieillissement à domicile, notamment des programmes de soins à domicile et de soutien aux dispensateurs de soins informels. Le vieillissement des baby-boomers augmentera la demande pour ces programmes. En effet, les renseignements disponibles sur ce segment de la population portent à croire que celui-ci ne va pas accepter l’institutionnalisation comme unique option.

Malgré le souhait de vieillir chez soi, un certain nombre d’aînés vont avoir besoin d’établissements de soins spéciaux. On s’attend à ce que ce nombre augmente avec l’augmentation de la population âgée. En outre, certaines études semblent indiquer que les gens qui sont admis dans des établissements de soins spéciaux auront des besoins de soins de santé accrus, en raison de la prévalence de certaines maladies comme la démence, et en raison de l’âge avancé auquel les aînés déménagent dans un établissement de soins

spéciaux. On estime que le nombre de Canadiens âgés de 65 ans et plus et atteints de démence en 2007 s’élevait à 450 000, dont 260 000 souffraient de la maladie d’Alzheimer. La Société Alzheimer du Canada estime que d’ici à 2031, environ 750 000 Canadiens souffriront de démence11. De plus, les données laissent croire que l’hébergement de couples dans des établissements de soins spéciaux, et non seulement des individus, pourrait être à envisager, en raison de l’amenuisement de l’écart d’espérance de vie entre les hommes et les femmes.

Lacunes dans les données et l’information

L’examen de l’état actuel des connaissances en matière de transitions domiciliaires des aînés de résidences privées à des établissements de soins spéciaux a permis de cerner un certain nombre de lacunes dans les données et les informations disponibles. Une de ces lacunes concerne l’absence de termes et de définitions uniformisés à l’échelle du pays. Une autre lacune concerne l’absence de données cohérentes sur les transitions d’aînés de résidences privées à des établissements de soins spéciaux. Le fait d’élaborer des normes pour la collecte de données sur les admissions en établissement de soins spéciaux permettrait d’assurer la disponibilité de données cohérentes à l’échelle du pays.

Des données sur la proportion annuelle de la population âgée qui déménage d’une habitation privée à des établissements de soins spéciaux par catégorie d’âge n’étaient pas disponibles. En recueillant des données sur le nombre d’aînés admis en établissement de soins spéciaux chaque année partout au pays, et en comparant ces données aux estimations annuelles de la population établies par Statistique Canada, il serait possible de calculer la proportion d’aînés qui déménagent chaque année. Ceci permettrait d’avoir un portrait précis pour déterminer les besoins touchant ces établissements et fournir la base pour prendre des décisions en matière de politiques et de programmes.

L’examen a également révélé que, dans certains cas, il était plus difficile d’obtenir des données de même nature pour les maisons de soins infirmiers et les résidences pour personnes âgées. Ces données seraient utiles pour comparer

9 D. Pedlar, W. Lockhart et S. Macintosh, « Canada’s Veterans Independence Program: A Pioneer of “Aging at Home” » Healthcare Papers, Vol. 10(1), 2009, p. 72-77.

10 A. Akamigbo et F. Wolinsky, Reported Expectations for Nursing Home Placement Among Older Adults and Their Role as Risk Factors for Nursing Home Admissions, 2006.

11 Ascent Strategy Group, Final Report: Trends, Projections and Recommended Approaches to Delivery of Long-term Care in the Province of Prince Edward Island 2007-2017, 2008.



Société canadienne d’hypothèques et de logement 5

la population de ces deux types d’établissement de soins spéciaux, déterminer les besoins actuels et futurs touchant ces établissements et prendre des décisions en matière de politique.

Pour s’attaquer à ces lacunes, il faut modifier la façon dont les données sont recueillies ainsi que la nature de ces données. Étant donné que la collecte de données est effectuée par divers organismes gouvernementaux et différentes instances, il serait utile de trouver une façon concertée de combler les lacunes identifiées relativement aux données.

Domaines de recherche à approfondir

L’étude de conjoncture et les consultations auprès d’intervenants clés ont également cerné des domaines de recherche à approfondir, afin de mieux comprendre les transitions des aînés d’habitations privées à des établissements de soins spéciaux. Un domaine où d’autres recherches pourraient être utiles concerne les implications de l’amenuisement de l’écart d’espérance de vie entre les hommes et les femmes sur les besoins en matière d’établissements de soins spéciaux. Un autre domaine concerne l’impact possible de l’augmentation de l’espérance de vie sans incapacité sur l’utilisation d’établissements de soins spéciaux.

Parmi les recherches à poursuivre, on trouve notamment la manière dont les programmes qui facilitent le vieillissement chez soi pourraient diminuer davantage la proportion de personnes âgées qui déménagent dans des établissements de soins spéciaux, malgré l’augmentation de la proportion d’aînés au sein de la population. D’autres recherches sur le modèle de l’équilibre des soins (portant sur la proportion de clients en liste d’attente pour des maisons de soins infirmiers qui pourraient être soignés de façon sûre et économique dans leur propre maison ou dans des logements avec services de soutien dans leur collectivité) pourraient également être menées pour mieux comprendre les solutions de rechange à l’institutionnalisation et venir appuyer un réexamen des priorités en matière de politiques et de programmes.



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iii CMHC Seniors’ Transitions to Special Care Facilities Final Report (DRAFT)

Table of Contents Acknowledgements .................................................................................................................. i

Consulting Team ...................................................................................................................... ii

1.0 Introduction ................................................................................................................. 1

1.1 Background and Purpose ................................................................................................. 1

1.2 Objective .......................................................................................................................... 1

1.3 Defining Special Care Facilities ........................................................................................ 2

1.4 Approach and Methodology ............................................................................................ 3

2.0 General Characteristics of Seniors................................................................................. 5

2.1 Characteristics of Senior Movers ..................................................................................... 7

3.0 Seniors’ Transitions to Special Care Facilities .............................................................. 10

3.1 Reasons Why Seniors Move to Special Care Facilities ................................................... 10

3.1.1 Health Status ......................................................................................................... 10

3.1.2 Availability of In‐Home Care .................................................................................. 13

3.1.3 Age ......................................................................................................................... 16

3.1.4 Income ................................................................................................................... 16

3.1.5 Province of Residence ........................................................................................... 18

3.1.6 Education ............................................................................................................... 21

3.1.7 Marital Status ........................................................................................................ 22

3.1.8 Other Factors ......................................................................................................... 23

3.1.9 Summary of Determinants of Moving to Special Care Facilities ........................... 25

3.2 Timing of the Transition to Special Care Facilities ......................................................... 26

3.2.1 Average Age of Seniors in Special Care Facilities .................................................. 26

3.2.2 Proportion of Seniors in Special Care Facilities ..................................................... 29

3.3 Patterns of Transition to Special Care Facilities ............................................................ 30

3.3.1 Typical Course from Private Dwellings to Special Care Facilities .......................... 30

3.3.2 Changes in the Patterns of Transition ................................................................... 31

3.4 Housing Preferences and Actual Transition Patterns .................................................... 32

3.4.1 Seniors’ Housing Preferences ................................................................................ 32

3.4.2 Seniors’ Actual Housing Transitions Patterns ........................................................ 33

3.5 Implications of Seniors’ Transitions to Special Care Facilities ....................................... 35

3.5.1 Implications for Governments ............................................................................... 35

3.5.2 Summary ................................................................................................................ 40

4.0 Gaps in Information .................................................................................................... 41

4.1 Gaps in Data and Information ....................................................................................... 41

4.2 Areas for Further Research ............................................................................................ 43

4.3 Summary of Recommendations .................................................................................... 45

4.3.1 Addressing Data Gaps in Collaboration with Others ............................................. 45

4.3.2 Recommendations for Future Research ................................................................ 46

5.0 Conclusion .................................................................................................................. 47

Appendix A: Questions Asked During the Consultations ........................................................ 48

iv CMHC Seniors’ Transitions to Special Care Facilities Final Report (DRAFT)

Appendix B: Data Tables ....................................................................................................... 50

Appendix C: ADL Hierarchy Scale ........................................................................................... 51

Bibliography .......................................................................................................................... 52

List of Tables Table 1: Household Living Arrangements of Seniors by Age: Canada; 2001 and 2006 .................................. 5 Table 2: ADL Performance Hierarchy of Assessed Residents in Residential Care Facilities, 2007/2008 to 2009/2010 .................................................................................................................................................... 13 Table 3: Odds Ratios for Income Sources for Seniors Without a Disability in Long Term Care Homes Compared with Seniors with Severe / Moderate Disabilities in Private Households: Canada, 1996/1997 . 17 Table 4: Estimated Income Required to Afford the Average Rent for Bachelor Units and Private Rooms in Retirement Homes: Canada, 2011 ............................................................................................................... 17 Table 5: Access to Beds in Homes for the Aged: Canada; 2008/2009 .......................................................... 19 Table 6: Trends in the Capture Rate for Seniors Housing: Canada; 2009‐2011 ........................................... 20 Table 7: Odds Ratios for Marital Status for Seniors Without a Disability in Long Term Care Homes Compared with Seniors with Severe / Moderate Disabilities in Private Households: Canada, 1996/1997 . 23 Table 8: Average Age of Residents in Residential Care, 2007‐2010 ............................................................ 27 Table 9: Average Age of Residents in Residential Care Facilities, 2009‐2010 ............................................. 27 Table 10: Residents on books in Residential Care Facilities (Homes for the Aged) by Age: Canada 2003/2004 to 2007/2008 ............................................................................................................................. 28 Table 11: Trends in the Number of Nursing Home Admissions by Age: Quebec, 1991‐2005 ..................... 29 Table 12: Average Nursing Home Admissions: Prince Edward Island; 2000‐2006 ...................................... 29 Table 13: Selected Health Characteristics of Residents in Residential Care Facilities: Canada, 2007‐2010 . 39

List of Figures Figure 1: Proportion of Population 65 years and older in Special Care Facilities by Province and Territory: Canada, 2006 .................................................................................................................................................. 6 Figure 2: Proportion of the Population 65 years and older and Proportion of the Population 65 years and older in Special Care Facilities by Province and Territory: Canada, 2006 ....................................................... 7 Figure 3: Per Capita Home Care Budgets for Persons 75 years and Older by Province: Canada, 2004/2005 ...................................................................................................................................................................... 21

1 CMHC Seniors’ Transitions to Special Care Facilities Final Report (DRAFT)

1.0 Introduction

1.1 Background and Purpose

The population in Canada aged 65 years and older is expected to increase significantly in the coming years due to the aging of the baby boomer population. In 2006, Canadians aged 65 years and older made up 13.7% of the total population. By 2036, it is estimated that almost a quarter of the population (23.7%) will be made up of Canadians 65 years and older. Statistics Canada data shows that the majority of seniors live in private dwellings while the remainder live in collective dwellings (7.5% in 2006), which include healthcare institutions such as nursing homes and hospitals. Research done by Statistics Canada (2006) in A Portrait of Seniors in Canada, has found that the rate of institutionalization of seniors had declined since the early 1980s, particularly for those aged 85 years and older. In 2001, 32% of seniors aged 85 years and older lived in collective dwellings, down from 38% in 1981.1 Overall, the proportion of seniors in collective dwellings has decreased in the last three decades. In 1981, 8.8% of seniors lived in collective dwellings. This proportion decreased to 8.5% in 19912, 7.4% in 20013 and 7.5% in 20064. Canada Mortgage and Housing Corporation (CMHC) initiated this study to examine seniors’ transitions from private dwellings to special care facilities. In particular, the study aims to understand the reasons why seniors move to special care facilities, the proportion moving each year and the implications of this transition for housing. The study also looks at the state of knowledge on seniors’ transitions from private dwellings to special care facilities, identifies data gaps and provides recommendations on how to address these gaps.

1.2 Objective

The overall purpose of this study is to review the state of knowledge on seniors’ transitions from private dwellings to special care facilities by:

Conducting a comprehensive literature review on seniors’ housing transitions to special care facilities and the implications of seniors’ housing transition trends for housing;

Compiling and analysing available data on seniors’ housing transitions to special care facilities.

1 Statistics Canada (2006). A Portrait of Seniors in Canada. Catalogue no. 89‐519‐XIE 2 Statistics Canada (1996). The Population in Collective Dwelllings: Canada, 1971‐1991. Catalogue no. 91F0015MIE 3 Statistics Canada (2002). 2001 Census: Analysis Series – Collective Dwellings. Catalogue no. 96F0030XIE2001004 4 Statistics Canada, 2006 Census, Catalogue no. 97‐554‐XCB2006054


1.3 Defining Special Care Facilities

For the purpose of this study, “special care facilities” include nursing homes and residences for senior citizens and are defined as follows:

Nursing homes are long‐term care facilities that provide a range of services for elderly residents from moderate and periodic assistance up to regular continuous nursing and personal care, with medical supervision as required. Nursing homes are one type of long‐term care facility. The terminology used to describe nursing homes, the types of services they offer and the administrative structure under which they operate vary by province5. Examples include auxiliary hospital (Alberta), charitable home for the aged (Ontario), CHSLD (Quebec), continuing care centre (Alberta), government / private manor home (Prince Edward Island), group living environment for dependent elderly (Nunavut), intermediate care facility (British Columbia), long‐term care facility (Ontario), municipal home for the aged (Ontario), personal care home (Manitoba, Northwest Territories), residential continuing care facility (Yukon Territory), special care home (Saskatchewan). Residences for senior citizens provide minimal to moderate personal care and supervision for elderly residents who are independent in most activities of daily living. Examples include community residence (New Brunswick); community care facility (Prince Edward Island); foyer de retraite; foyer de repos (Québec); home for the aged (Nova Scotia); personal care home ( Newfoundland and Labrador, Saskatchewan, British Columbia); residential long‐term care facility (Northwest Territories); rest home; retirement residence; retirement home; senior citizens’ home; seniors’ lodge (Alberta) .6

For consistency throughout the report, “nursing homes” will be used to refer to long‐term care facilities that provide moderate and periodic assistance to regular continuous nursing and personal care. “Residences for seniors” will be used to refer to facilities that provide minimal to moderate personal care and supervision for elderly residents who are independent in most activities of daily living, including retirement residences and seniors housing. These terms will be used regardless of whether the source literature uses different terminology that is used in the province or territory. The term “special care facilities” will be used when referring to both nursing homes and residences for seniors or when the data presented is for the ‘special care’ category in the 2006 Census. In some cases, “residential care facilities” will be used to refer to all facilities in Canada with four or more beds providing assistance such as counselling, 5 Statistics Canada (2010). 2006 Census Dictionary. Catalogue no. 92‐566‐X p. 164‐165 6 Statistics Canada (2010). 2006 Census Dictionary. Catalogue no. 92‐566‐X p. 165


custodial, supervisory, personal, basic nursing and/or full nursing care to at least one resident and that are funded and approved by provincial or territorial departments of health or social services. Excluded are those facilities providing active medical treatment (general and allied special hospitals). The ‘special care facilities’ category in the Census includes residential care facilities.

1.4 Approach and Methodology

This study was undertaken in two phases and involved a review of literature, key informant consultations, data collection and analysis and data sources identification. Phase One: Review of Literature on Seniors’ Housing Transitions

Phase One involved a comprehensive review of literature on seniors’ housing transitions from private dwellings to special care facilities with a focus on the past two decades. The findings from the review of literature were presented in an annotated bibliography and included relevant information on the determinants of moving to special care facilities, characteristics of senior movers and seniors’ housing preferences. The review focused primarily on literature published in Canada in the last two decades but also includes literature published in the United States to provide a basis of comparison as well as additional insight into the topic. Search engines, such as Google Scholar, the Canadian Housing Information Centre, the University of Guelph’s online library catalogue, and the Canada Mortgage and Housing Corporation’s website were used to find sources and literature. Once key sources of information were identified, the relevant websites were searched extensively. This yielded a diverse range of resources and literature that included reports, articles and websites from federal, provincial and municipal governments, professional organizations, academia, and non‐profit organizations. A total of 24 reports were identified as relevant and included in the annotated bibliography. The review of literature in Phase One also identified several data and information gaps. In particular, literature on the following topics was very limited:

The proportion of the seniors’ population moving from private dwellings to special care facilities each year in the last decade;

Whether there is one or more typical courses by which seniors move from private dwellings to collective dwellings;

Whether patterns of transition have changed over time and if they are likely to change as the baby boomers age; and,

The implications of seniors’ transitions from private dwellings to special care facilities for housing.


Phase Two: Data Collection and Analysis

Phase Two of the study involved identifying data sources on seniors’ housing transitions, collecting and analyzing this data, identifying data gaps and providing recommendations on how to fill these gaps. Consultations with key informants were conducted to identify data sources, validate and build on the findings of Phase One, and identify additional studies / reports to supplement the information gathered in Phase One. A list of key informants was developed and included representatives of seniors organizations, developers of seniors housing, academics who have expertise in seniors issues, representatives of provincial and territorial ministries, authors of literature identified in Phase One of this study, and CMHC staff. A total of ten interviews were conducted in addition to email correspondence with 16 key informants. These key informant consultations resulted in the identification of 34 new reports / studies on topics that are relevant to seniors’ housing transitions to special care facilities. The consultations also resulted in over twenty new key informants that provided information and data sources related to seniors’ housing transitions to special care facilities. Phase Two also involved analyzing the data and information that was collected through the key informant consultation process as well as the additional research that was conducted. This report represents a synthesis of findings from the literature and key informant interviews. It is intended to provide a comprehensive picture of seniors’ housing transitions from private dwellings to special care facilities based on available literature. In addition, data and information gaps were identified and recommendations were developed to address these gaps. Areas for further research were also identified and are outlined in this report.


2.0 General Characteristics of Seniors

In 2006 there were over four million seniors in Canada, representing 13.7% of the total population. According to Statistics Canada population estimates, this proportion grew to 14.1% by 2010 and population trends indicate that the senior population will continue to grow, particularly with the aging of the baby boomers. Of the total senior population, 7.5% lived in collective dwellings7 and only 6.3% lived in special care facilities8 in 2006. The proportion of the senior population living in institutions/ collective dwellings decreased from 8.8% in 1981 and 8.5% in 1991 but increased slightly from 7.4% in 2001.9 The largest proportion of seniors in private households lived with their spouse or partner. For those 65 years and older, this proportion increased from 63.9% in 2001 to 64.8% in 2006 for those 65 years and older. An increase in this category was also experienced by those in the 85 years and older age group (from 36.9% in 2001 to 39.2% in 2006). In contrast, seniors living alone saw a slight decrease, from 28.9% in 2001 to 28.1% in 2006 (see Table 1).

Table 1: Household Living Arrangements of Seniors by Age: Canada; 2001 and 2006

Living Arrangements 65+ 85+

2001 2006 2001 2006

Spouse / Partner 63.9% 64.8% 36.9% 39.2%

With Children 0.1% 0.2% 0.0% 0.0%

With Relatives 5.4% 5.2% 12.1% 10.7%

With Non‐Relatives 1.7% 1.7% 1.7% 1.5%

Alone 28.9% 28.1% 49.3% 48.6%

Total 100.0% 100.0% 100.0% 100.0% Source: Statistics Canada 2006 Census Catalogue no. 97‐553‐XCB2006019 and 2001

Census Catalogue no. 97F0005XCB2001004

A key informant suggested that this trend will continue in the future as the gap in life expectancy between men and women will continue to narrow. It was also suggested that this would have an impact on the number of seniors moving to special care facilities

7 In the 2006 Census, “collective dwelling” refers to a dwelling of a commercial, institutional or communal nature. Included are lodging or rooming houses, hotels, motels, tourist homes, nursing homes, hospitals, staff residences, communal quarters (military bases), work camps, jails, missions, group homes, and so on. 8 In the 2006 Census, “special care facilities” refers to nursing homes, residences for senior citizens, and chronic and long‐term care and related facilities. 9 It should be noted that the methodology for data collection with regard to collective dwellings was modified for the 2006 Census, with new categories of collective dwellings added. In light of these changes, Statistics Canada cautions users of the data to take care in interpreting the data as well as in making comparisons with previous censuses. Also, the 2006 classifications are not expected to agree with the classifications used in administrative data or other sources.


as the likelihood of being institutionalized is lower for seniors who are married or in common law relationships. This is supported by data from the literature which indicates that seniors who are single or divorced / separated are significantly more likely to be living in a nursing home than seniors who are married or in common‐law relationships.10 In 2006, 324,485 Canadians 65 years and older were living in collective dwellings, representing 7.5% of the total senior population. Of these seniors, 274,395 were living in special care facilities, representing 6.3% of the total seniors.11 There were variations in the proportion of seniors in special care facilities in the different provinces and territories. Quebec had the largest proportion of seniors in special care facilities in 2006 at 7.7% followed by Prince Edward Island (7.0%), Alberta and the Northwest Territories (6.6%), and Saskatchewan (6.2%). British Columbia had the smallest proportion (4.9%) among the provinces but Nunavut had the smallest proportion (1.8%) overall (see Figure 1). Figure 1: Proportion of Population 65 years and older in Special Care Facilities by Province and Territory:

Canada, 2006

The proportion of the senior population in special care facilities does not necessarily reflect the share of the senior population in the provinces and territories. Saskatchewan has the largest proportion of seniors among the provinces and territories at 15.4% whereas the province only has 6.2% of seniors in special care facilities. In contrast, the Northwest Territories has a relatively small proportion of seniors (4.8% of the total population) but 6.6% of these seniors are in special care facilities (see Figure 2). For further details, please refer to the data table in Appendix B.

10 Trottier, H., Martel, L., et.al. (2000). Living at home or in an institution: What makes the difference for seniors? Health Reports, Vol. 11 (4), Statistics Canada, Catalogue 82‐003 11 Statistics Canada, 2006 Census, Catalogue no. 97‐554‐XCB2006054

6.3%

5.2%

7.0%

5.0% 5.8%

7.7%

6.1%

5.8%

6.2%

6.6%

4.9%

4.4%

6.6%

1.8%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

Proportion of Population 65+

Geography

Source: Statistics Canada, 2006 Census, Catalogue no. 97‐554‐XCB2006054


Figure 2: Proportion of the Population 65 years and older and Proportion of the Population 65 years and

older in Special Care Facilities by Province and Territory: Canada, 2006

2.1 Characteristics of Senior Movers

Mobility generally decreases with age and seniors change their place of residence less often than non‐seniors. A study that uses data from the 1995 General Social Survey found that 76% of older adults aged 60 years or more who had moved in the previous five years settled within fifty kilometres from their previous residence and many moved no more than ten kilometres.12 More recently, it was found that 38.2% of the population in 2006 had changed their place of residence within the previous five years. During the same period, only 20.4% of seniors 65‐74 years and 17.3% of seniors 75 years and over moved. In addition, most senior movers moved within their province of residence.13 The literature shows that, in general, seniors who are widowed, separated or divorced are more likely to move than those who are married or living with common‐law partners. Seniors who are renters and who live in apartments are more likely to move than those who own their homes and who live in single detached homes. A study by Moore and McGuinness (1997) using data from the 1986 Health and Activity Limitation Survey (HALS) and the 1991 Survey of Aging and Independence (SAI) found that seniors who were still living with their spouse or partner are the most likely to be

12 Che‐Alford, J. and Stevenson, K. (1998). Older Canadians on the Move. Canadian Social Trends, Statistics Canada Catalogue 11‐008‐XPE 13 Statistics Canada 2006 Census, Catalogue no. 97‐556‐XCB2006017

13.7%

13.9%

14.9%

15.1%

14.7%

14.3%

13.6%

14.1%

15.4%

10.7%

14.6%

7.5%

4.8%

2.8%

6.3% 5.2%7.0%

5.0% 5.8%7.7%

6.1% 5.8% 6.2% 6.6%4.9% 4.4%

6.6%1.8%

0.0%

5.0%

10.0%

15.0%

20.0%

0.0%

5.0%

10.0%

15.0%

20.0%

Proportion of Seniors

Proportion of Population

Geography

Population 65+ 65+ in Special Care Facilities



living in stable, owner‐occupied settings and they are the least likely to move. The study also found that widows and those who are divorced or separated are more likely to be movers, since both groups are more likely to have lower incomes and to be renters, both of which are positively correlated to the probability of moving.14 Similarly, a study that used data from the longitudinal Survey of Labour and Income Dynamics (SLID) found that widowed seniors were more likely to move than seniors who were married or in common‐law relationships. The study found that seniors who are married or in common‐law relationships moved at a rate of 7% compared to widowed seniors who moved at a rate of 12%.15 Senior renters are also more likely to move than owners, with renters moving at a rate of 14% versus 7% for owners. One explanation for this trend was that owners felt more settled and stable in their living environment compared to renters. 16 In 2006, only 27.6% of seniors rented their homes17, which may further explain why most seniors would prefer to age in their own homes rather than to move to special care facilities. Of the population 65 years and over in 2006, 55.2% lived in single detached dwellings while 30.7% lived in apartments. The proportion of seniors living in apartments increased by age with 26% of the 65‐74 age group living in apartments and 36% of those over 75 years. This reflects the tendency of seniors to downsize as they age. 18 Lin (2005) found that seniors who live in apartments were almost twice as likely to move compared to those who lived in houses, moving at a rate of 13% versus 7%.19 Using data from the 1995 General Social Survey and the 1991 Survey on Ageing and Independence, a study found that the desire to downsize was the most often cited reason among movers sixty years and older; with 19% of older movers citing this reason.20 Many seniors choose to sell their homes to rent when they downsize (43% in 2001)21, which may increase the likelihood that they will move again in the future considering that renters are more likely to move than owners.

14 Moore, E., and McGuinness, D. (1997). Adjustments of the Elderly to Declining Health: Residential Moves and Social Support. Canadian Studies in Population, Vol. 24(2), pp. 163‐187 15 Lin, J. for Statistics Canada (2005). The Housing Transitions of Seniors. Canadian Social Trends, Catalogue no. 11‐008. 16 Lin, J. for Statistics Canada (2005). The housing transitions of seniors. Canadian Social Trends, Catalogue no. 11‐008. 17 CMHC (2010). 2006 Census Housing Series: Issue 10 – The Housing Conditions of Canada’s Seniors with data from the 2006 Census 18 CMHC (2010). 2006 Census Housing Series: Issue 10 – The Housing Conditions of Canada’s Seniors with data from the 2006 Census 19 Lin, J. for Statistics Canada (2005). The housing transitions of seniors. Canadian Social Trends, Catalogue no. 11‐008. 20 Che‐Alford, J. and Stevenson, K. (1998). Older Canadians on the Move. Canadian Social Trends, Statistics Canada Catalogue 11‐008‐XPE 21 Lin, J. for Statistics Canada (2005). The housing transitions of seniors. Canadian Social Trends, Catalogue no. 11‐008.


Not all seniors who move transition to special care facilities. Some seniors downsize to a smaller home, move in with family, or move to a different location with more amenities and services. Seniors who do transition to special care facilities are generally at a more advanced age and have greater health concerns.


3.0 Seniors’ Transitions to Special Care Facilities

This section looks at seniors’ housing transitions from their private dwellings to special care facilities. It includes a discussion on the different factors that influence a senior’s decision to move to a special care facility, the average age in which this move occurs, patterns of transitions, and the implications of seniors’ transitions on the housing market and on governments.

3.1 Reasons Why Seniors Move to Special Care Facilities

There are a number of factors that may influence a senior’s decision to move from their private home to a special care facility. These include health status, availability of in‐home care, age, income, province of residence, education, marital status and support service needs. Other determinants may include a senior’s education, living arrangement, gender, loneliness, and the presence of home adaptations.

3.1.1 Health Status

Health status is one of the primary reasons seniors move from their private homes to special care facilities. In general, most seniors would prefer to stay in their own homes so it is often something beyond their control which drives them to transition to a special care facility. Key informants suggested that health was the primary driver to moving to a special care facility. One key informant stated that nine out of ten times, seniors do not want to move but a change in their health situation forces them to move. This is supported by the literature presented below, where health status is the most often cited reason for institutionalization. A study using data from a survey conducted by Health and Welfare Canada in 1987 found that poor health was strongly related to entry into an institution. Someone in poor health was twice as likely to live in an institution compared to someone in good health.22 A 2009 study using data from the National Population Health Survey found that those who are healthy are more likely to live independently while those who self‐reported a decline in their health status were more likely to move into institutions.23 Results of interviews with Canadian veterans and their caregivers showed that the primary factors affecting the decision to have a veteran move into a nursing home was the increase of their physical care needs (37%), that the informal caregiver is no longer able to provide care and/or support (34%), an increase in the veteran’s cognitive health care needs (27%), and an increase in their overall health care needs (21%). In addition, other factors that influenced the decision to move to a nursing home included: the

22 Carriere, Y. and Pelletier, L. (1995). Factors Underlying the Institutionalization of Elderly Persons in Canada. 23 Sarma, S., Hawley, G., and Basu, K. (2009). Transitions in Living Arrangements of Canadian Seniors: Findings from the NPHS Longitudinal Data. Social Science and Medicine 68 pp. 1106‐1113


veteran was ready to go into a facility (27%), concerns regarding the veteran’s safety (17%), appropriate formal care services are not available (5%), and a physician recommended facility placement (5%).24 A survey of seniors in the City of Calgary found that 12% of respondents who had moved in the past two years did so because of poor health of the individual or a family member.25 Among seniors with severe disabilities, the odds of institutionalization were very high for those with Alzheimer’s disease or other dementia. It was also very high for those with urinary incontinence and significantly high for those suffering from the effects of a stroke compared to seniors who were not affected by these conditions. When seniors in nursing homes were compared to seniors in private households, it was found that 74.5% of seniors 65 years and older in nursing homes had a severe disability whereas the majority of people in private households (65.8%) had no disability. This same study found that only a very small proportion of seniors living in nursing homes had no disability (9.6%). For this group of seniors, living in a nursing home was associated with two chronic conditions, Alzheimer’s disease or other dementia and urinary incontinence.26 Likewise, a key informant suggested that the timing of the transition from a private dwelling to a special care facility would be different for seniors with Alzheimer’s compared to those with instrumental activities of daily living (IADL)27 and activities of daily living (ADL)28 needs, further emphasizing the fact that the senior’s health status is the primary determinant of moving to a special care facility. A study undertaken for the Winnipeg Regional Health Authority using RAI 2.0 and RAI‐Home Care assessment data for individuals 65 years and older found that cognitive impairment, activities of daily living dependence and bladder incontinence were significantly associated with admission to a special care facility. Nearly two‐thirds of nursing home residents experienced occasional to complete urinary incontinence compared to only one‐quarter (24.8%) of individuals living in private dwellings. In addition, 47.4% of residents of nursing homes had dementia (other than Alzheimer’s disease) whereas neither dementia nor Alzheimer’s were in the top ten most prevalent among individuals in private dwellings. The study also found that the majority of individuals in all three community care settings (private dwellings, supportive housing and assisted living) is independent or have only minor impairment in the performance of ADLs. In contrast, the majority of residents of nursing homes require, at a minimum,

24 Miller, J., Hollander, M., and MacAdam, M. (2008). The Continuing Care Research Project for Veterans Affairs Canada and the Government of Ontario: Synthesis Report. 25 City of Calgary (2008). Survey on Seniors’ Decisions to Relocate. 26 Trottier, H. et. al. (2000). Living at Home or in an Institution: What Makes the Difference for Seniors? Health Reports, Vol. 11, No. 4, Statistics Canada Catalogue no. 82‐003 27 Instrumental Activities of Daily Living (IADL) are secondary level activities (compared to Activities of Daily Living) important to daily living such as cooking, writing and driving. 28 Activities of Daily Living (ADL) are basic tasks that involve bodily issues such as bathing, dressing, toileting, transferring, continence, eating and walking that are done on a daily basis.


extensive assistance with ADL tasks. For example, 65.6% of individuals in private dwellings were independent compared to only 9.5% in nursing homes.29 In addition, the study undertaken for the Winnipeg Regional Health Authority found that based on the number of diseases diagnosed there was little difference in the number of disease diagnoses between those who stayed in their private dwellings and those who moved to nursing homes. For example, of those who had five or more diseases, 28.1% moved from a private dwelling to a nursing home compared to 26.6% who did not move. The study results also show that it is the type of disease that influences a move to a nursing home. For example, among those diagnosed with Alzheimer’s disease and who had the option of moving to a nursing home, 16.4% moved from a private dwelling to a nursing home while only 4.4% did not move. Similarly, among those diagnosed with dementia (other than Alzheimer’s) and who had the option of moving to a nursing home, 30.5% moved to a nursing home while 11.0% did not move. In contrast, there were a larger proportion of non‐movers compared to movers among those who had a choice to move to a nursing home and who had diabetes (21.8% non‐movers vs. 17.8% movers), hypertension (54.6% vs. 49.7%), and coronary artery disease (20.1% vs. 15.7%30).31 The Canadian Institute for Health Information provides data on performance of residents in residential care facilities in four key activities of daily living. These key ADLs are personal hygiene, toileting, locomotion and eating. This data (see Table 2) shows that the largest proportion of residents in residential care facilities are assessed as ‘extensive 1 (3)’, which means that these residents need at least extensive assistance in personal hygiene or toileting and less than extensive assistance in both eating and locomotion. This data also shows that more than a fifth of residents of residential care facilities are assessed as ‘dependent’, meaning they are totally dependent on someone else for eating and/or locomotion. While the proportion of residents who are totally dependent has decreased over the last three years, the proportion that are independent and those needing only supervision have also decreased slightly in the same time period. This shows that although the proportion of residents who are totally dependent is decreasing, a significant proportion of residents in residential care facilities are still in need of extensive assistance, supporting the findings in the literature.

29 Mitchell, L., et.al. (2008). Long Term Care Strategy: An Examination of Clients Across the Care Continuum. Winnipeg Regional Health Authority and Centre on Aging, University of Manitoba. 30 Other groups included those with the option to move to an assisted living facility or supportive housing facility so proportions will not equal to 100%. 31 Mitchell, L., et.al. (2008). Long Term Care Strategy: An Examination of Clients Across the Care Continuum. Winnipeg Regional Health Authority and Centre on Aging, University of Manitoba.


Table 2: ADL Performance Hierarchy of Assessed Residents in Residential Care Facilities, 2007/2008 to 2009/2010

ADL Performance Hierarchy Scale Score 2007/2008 2008/2009 2009/2010

Independent (0) 7.6% 7.9% 7.7%

Supervision (1) 6.7% 6.8% 6.4%

Limited (2) 11.5% 12.8% 12.0%

Extensive 1 (3) 26.0% 26.1% 25.9%

Extensive 2 (4) 12.3% 11.9% 12.5%

Dependent (5) 20.7% 20.5% 21.5%

Total Dependence (6) 15.1% 14.0% 13.9%

Total 100.0% 100.0% 100.0% Source: Continuing Care Reporting System, 2007/2008 to 2009/2010, Canadian

Institute for Health Information Note: The Activities of Daily Living (ADL) Self‐Performance Hierarchy Scale reflects the resident's self‐performance in four key activities of daily living:

personal hygiene, toileting, locomotion and eating. The scale ranges from 0 to 6. Higher scores indicate a greater need for assistance in ADLs

Note: Data is based on a sample of residential care facilities in Newfoundland and Labrador, Nova Scotia, Ontario, Manitoba, Saskatchewan, British Columbia

and Yukon Note: Scores are based on residents who were assessed with the RAI‐MDS 2.0

assessment instrument Note: A description of the different levels of the ADL Hierarchy Scale can be

found in the Appendix

3.1.2 Availability of In‐Home Care

The availability of care in their private residence is one of the major factors that influence a senior’s decision to move to a special care facility. This care may be provided by an informal caregiver, such as a spouse or partner, child, relative or friend. Care may also be formal home care provided by a community organization. In the past, seniors could rely on the informal care provided by family members. Changing circumstances, such as smaller household sizes with fewer or no children and more women in the labour force have resulted in this option being unavailable for many seniors. This has increased the need for publicly‐provided home care. Moore and McGuinness (1997), using data from the Health and Activity Limitation Survey and the Survey on Ageing and Independence, found that transfers to institutions are not always a result of deteriorating health status. Institutionalization is often an unavoidable solution for seniors who live alone and who often have no family who can help them on a daily basis. The study also found that in 1991, 28.2% of seniors 75 years and over who moved cited support reasons, that is, they moved to receive care or support from a relative, due to a decline in health, to be close to family or friends, and/or to be close to services. As many as 18.6% of movers 65‐69 and 19.7% of those


70‐74 moved for support reasons.32 Similarly, literature from the United States showed that the early provision of home care resulted in a lower risk of institutionalization as well as respondents’ greater satisfaction with their lives overall.33 A study using data from the National Population Health Survey (NPHS) from 1994/1995 to 2004/2005 found that publicly‐provided home care reduced the probability of institutionalization by approximately 45%. This study also found that social support reduced the likelihood of a senior being institutionalized by 49% to 62%.34 A study undertaken for Veterans Affairs Canada found that 34.4% of veterans interviewed moved to a nursing home because their informal caregiver could no longer provide the necessary care and/or support. This same study found that over 44% of respondents indicated that they were able to remain in their own homes due to the support and assistance they received from informal caregivers. The services most used by community and supportive housing clients were housekeeping (96%), grounds maintenance (77.5%), and home adaptations (68.5%).35 These data results suggest that the support service requirements of seniors may not necessarily be related to health but may just be a need for assistance with IADLs, which are secondary level activities important to daily living such as cooking, writing and driving. This is supported by some key informants who suggested that some seniors move to residences for seniors or nursing homes not because of their health status but because they needed help with meals and housekeeping. A study that used home care client assessment data to analyze the key characteristics and needs of approximately 1,700 individuals waiting for residential long term care in Toronto found that instrumental activities of daily living needs such as transportation, nutrition and housekeeping were often a key determinant of the care pathway. For example, while transportation is not medically necessary, the lack of transportation can result in social isolation, depression and the inability to perform essential daily tasks which can jeopardize health and independence and eventually result in the institutionalization of the individual.36

32 Moore, E., and McGuinness, D. (1997). Adjustments of the Elderly to Declining Health: Residential Moves and Social Support. Canadian Studies in Population, Vol. 24(2), pp. 163‐187 33 Shapiro, A. and Taylor, M. (2002). Effects of a Community‐Based Early Intervention Program on the Subjective Well‐Being, Institutionalization and Mortality of Low‐Income Elders. The Gerontologist, Vol. 42(3) pp. 334‐341 34 Sarma, S., Hawley, G., and Basu, K. (2009). Transitions in Living Arrangements of Canadian Seniors: Findings from the NPHS Longitudinal Data. Social Science and Medicine 68 pp. 1106‐1113 35 Miller, J., Hollander, M., and MacAdam, M. (2008). The Continuing Care Research Project for Veterans Affairs Canada and the Government of Ontario: Synthesis Report. 36 Williams, P., et. al. (2009). Balancing Institutional and Community‐Based Care: Why Some Older Persons Can Age Successfully at Home While Others Require Residential Long‐Term Care. Healthcare Quarterly, Vol. 12(2) pp. 95‐105


Key informants suggested that the decision to move to a nursing home largely depends on what support services are available in the community. For example, seniors with IADL or ADL needs would be able to age in their own homes if they were provided with proper supports. This is supported by data in the literature that shows 6.8% of residents of private households have severe disabilities (activity limitation and dependence) and 27.4% have moderate disabilities (activity limitation but no dependence or dependence but no limitation).37 It can be inferred that these seniors are able to live in private dwellings in spite of their disabilities due to the presence of some support system, whether informal or formal home care. Key informants also suggested that the decision to move to a special care facility is different for seniors living in urban areas compared to those living in rural areas. This was due, in part, to a lack of organizations providing support services and a lack of housing options for seniors in rural areas. In addition, a lack of public transportation options or transportation for seniors who could no longer drive often resulted in a senior having to move to a nursing home. One key informant found, based on research that they had undertaken, that for seniors in rural areas, the lack of transportation options is often the main reason for moving to a nursing home. This is supported by findings from focus groups of seniors in Atlantic Canada where transportation services emerged as an important issue for seniors in rural areas and seniors with disabilities.38 Similarly, a study of Manitoba seniors found that transportation emerged as a key issue for seniors and that driving was an important mode of transportation for seniors particularly in rural areas. It found that transportation was critical to seniors’ independence, quality of life, and even health.39 Additionally, literature from the U.S. found that households that had at least one senior who could drive were half as likely to select assisted communities, shared housing or supported housing as housing options compared to those without any drivers, even after controlling for other factors that may influence the housing decision.40 The literature reviewed in this section support the idea that the availability of care in their private dwelling has a significant impact on a senior’s decision to move to a special care facility. In some cases, the assistance required is minimal, such as housekeeping or transportation. The care could be provided by informal caregivers such as family or friends or by community organizations as social trends have resulted in the lack of informal caregivers for many seniors. The result is that for many seniors, the choice is

37 Trottier, H. et. al. (2000). Living at Home or in an Institution: What Makes the Difference for Seniors? Health Reports, Vol. 11, No. 4, Statistics Canada Catalogue no. 82‐003 38 Weeks, L, Pottie, S., Cruttendend, K. and Shiner, D. (2007). Seniors’ Housing in Atlantic Canada: Focus Groups with Distinct and Underrepresented Seniors. Atlantic Seniors Housing Research Alliance 39 Kagis, M., Menec, V., and Blandford, A. (2006). Manitoba’s Seniors: A Companion to the Manitoba Fact Book on Aging. University of Manitoba Centre on Aging 40 Schafer, R. (1999). Determinants of the Living Arrangements of the Elderly.


between publicly‐provided homecare, if this is available, or moving to a special care facility.

3.1.3 Age

The literature has shown that age is directly correlated to the likelihood of being institutionalized. A study by Carriere and Pelletier (1995) found that belonging to the oldest age group had the greatest impact on the chances of being institutionalized. Thus, the odds of a person 85 years and over living in an institution were 7.3 times greater than for a person 65‐74 years.41 Similarly, a report by Veterans Affairs Canada (1998) showed that the likelihood of being institutionalized increased with age and that the chances may double in each succeeding five‐year age cohort after age 65.42 A study published by Statistics Canada further supports the theory that the likelihood of being institutionalized increases with age. Using data from the 1996/97 National Population Health Survey from a sample of people aged 65 years and older living in both long term care facilities and private households, it was found that the odds ratio for living in a nursing home increased with age. For people 85 years and older, the odds ratio was 4.96 compared to 1.00 for people aged 65‐69 years. The odds ratio for living in a nursing home for people 70‐74 years was 1.21, 1.45 for seniors 75‐79, and 2.52 for those aged 80‐84 years.43 Likewise, a study using data from the National Population Health Survey (NPHS) found that the probability of moving to an institution or an intergenerational living arrangement increased with age.44

3.1.4 Income

Income is one of the factors that influence a senior’s decision to move from their private dwelling to a special care facility. The literature shows that the effect of income on the probability of being institutionalized is negative. This means that seniors with low incomes are more likely to move to special care facilities. It also implies that as incomes increase, the likelihood of institutionalization decreases.45 Using data from the 1996/1997 National Population Health Survey, it was found that seniors with two or fewer sources of income are more likely to be institutionalized than seniors who have

41 Carriere, Y. and Pelletier, L. (1995). Factors Underlying the Institutionalization of Elderly Persons in Canada. 42 Veterans Affairs Canada (1998). Discussion Paper: Long Term Care Trends in Canada 43 Trottier, H. et. al. (2000). Living at Home or in an Institution: What Makes the Difference for Seniors? Health Reports, Vol. 11, No. 4, Statistics Canada Catalogue no. 82‐003 44 Sarma, S., Hawley, G., and Basu, K. (2009). Transitions in Living Arrangements of Canadian Seniors: Findings from the NPHS Longitudinal Data. Social Science and Medicine 68 pp. 1106‐1113 45 Sarma, S., Hawley, G., and Basu, K. (2009). Transitions in Living Arrangements of Canadian Seniors: Findings from the NPHS Longitudinal Data. Social Science and Medicine 68 pp. 1106‐1113 AND Carriere, Y. and Pelletier, L. (1995). Factors Underlying the Institutionalization of Elderly Persons in Canada.


three or more sources of income (see Table 3). This suggests that seniors who are better off financially are less at risk of being institutionalized, possibly because they have more resources to pay for the help they need in their own homes.46 Based on their experience, key informants stated that household income not only influences the decision to move to a special care facility but it also influences the type of special care facility that a senior moves to, whether they move to a nursing home or a residence for seniors. This is due to the fact that residence in a nursing home is often publicly subsidized while residences for seniors are often not subsidized. Further, admission to a residence for seniors may require a minimum annual household income. For example, a key informant estimates that in Ontario, an annual income of about $30,000 is required for admission. Similarly, the CMHC Seniors Housing Report – Canada Highlights 2011 shows that the average rent for a bachelor unit or private room in a residence for seniors with at least one meal included is $1,909 per month in 2011 (see Table 4). This would mean that a senior living in a residence for seniors would have to have an annual income of at least $22,908. The Seniors Housing Report also shows that Quebec has the lowest average rent ($1,397) and Ontario has the highest ($2,677). This would mean that a senior living in Quebec would need an annual income of at least $16,764 to be able to live in a residence for seniors while a senior in Ontario would need an annual income of at least $32,124.

Table 4: Estimated Income Required to Afford the Average Rent for Bachelor Units and Private Rooms in Retirement Homes: Canada, 2011

Average Rent* Estimated Annual Income Prince Edward Island $2,154 $25,848

Nova Scotia $2,263 $27,156

New Brunswick $1,957 $23,484

Quebec $1,397 $16,764

Ontario $2,677 $32,124

Manitoba $1,647 $19,764

Saskatchewan $2,187 $26,244

Alberta $2,178 $26,136

British Columbia $1,977 $23,724

Canada $1,909 $22,908Source: CMHC Seniors' Housing Report ‐ Canada Highlights, 2011, Table 1.2

*Rents include at least one meal

46 Trottier, H., Martel, L., et. al. (2000). Living at Home or in an Institution: What Makes the Difference for Seniors? Statistics Canada Health Reports, Catalogue no. 82‐003

Table 3: Odds Ratios for Income Sources for Seniors Without a Disability in Long Term Care Homes Compared with Seniors with Severe / Moderate Disabilities in Private

Households: Canada, 1996/1997

Income Odds Ratio

Single source* 2.01

Two sources 1.29

Three or more sources** 1.00Source: Trottier et.al. (2000). Living at home or in an institution: What makes the difference for seniors? Health Reports, Vol. 11(4), Statistics

Canada Catalogue no. 82‐003 using data from the 1996/97 National Population Health Survey

*Includes no source of income **Reference category for which odds ratio is

always 1.00


While income influences whether a senior stays in their own home or moves to a special care facility, it may also influence the type of facility a senior moves to. The differences in costs of living in a residence for seniors compared to a nursing home may result in seniors moving into inappropriate facilities due to cost. For example, a senior may choose to live in a nursing home in spite of the fact that they would be better served in an environment with less support services provided, such as a residence for seniors, as it may be more affordable to live in a nursing home due to government subsidies.

3.1.5 Province of Residence

The province or territory wherein a senior lives may also have an effect on whether or not they move to a special care facility. Provincial policies on the delivery of care to seniors have an impact on the institutionalization of seniors. Criteria for entry into a nursing home; funding availability per elderly person; occupancy rates; access to beds; and capture rates are some of the ways through which provincial policies on the delivery of care to seniors may influence the rate of institutionalization of seniors. A study by Carriere and Pelletier (1995), using data from the Survey of Old Age Security and Canadian Pension Plan Retirement Recipients which was conducted by Health and Welfare Canada in 1987 found that most provinces have similar criteria for entry into a nursing home. These criteria looked at the functional status of the individual, the availability of informal support, as well as minimum hours of care required by an elderly person. The differences were seen in the minimum hours of care required by an elderly person. For example, in Quebec, a senior must require a minimum of 1.5 hours of care a day to be considered compared to Alberta which requires a minimum of 1.9 hours of care a day. The authors found that this seemed to lead to a greater likelihood of institutionalization in Quebec.47 This theory is supported by the fact that, in 2006, 7.7% of all seniors in Quebec lived in special care facilities compared to only 6.6% in Alberta.48 In addition to criteria for entry into a nursing home Carriere and Pelletier (1995) found that funding per elderly person and the availability of beds may influence the rate of institutionalization. An examination of provincial budgets found that the higher the average amount budgeted for each elderly person, the greater the likelihood of living in a nursing home. Additionally, the lack of beds and occupancy rates between 98 and 100 percent of existing beds may result in lower institutionalization rates.49

47 Carriere, Y. and Pelletier, L. (1995). Factors Underlying the Institutionalization of Elderly Persons in Canada. 48 Statistics Canada, 2006 Census, Catalogue no. 97‐554‐XCB2006054 49 Carriere, Y. and Pelletier, L. (1995). Factors Underlying the Institutionalization of Elderly Persons in Canada.


Differences in access to a bed50 in a Home for the Aged51 within the residential care facilities category may also influence the rates of institutionalization of seniors in different parts of the country. Data from Statistics Canada shows the proportion of the senior population with access to a bed in a Home for the Aged within the residential care facilities category (see Table 5). This data shows that on average, 4.9% of the senior population have access to a bed but these rates vary widely in the across provinces and territories. Prince Edward Island has the largest proportion of seniors with access to a bed in Homes for the Aged (9.3%) while Quebec has the smallest proportion of seniors with access to a bed (3.6%).

Table 5: Access to Beds in Homes for the Aged: Canada; 2008/2009

Population Aged 65+

Number of Beds*

Population Aged 65+ with access to a bed

Canada 4,335,250 214,368 4.9%

Newfoundland & Labrador 70,260 5,809 8.3%

Nova Scotia 138,215 6,804 4.9%

New Brunswick 107,640 7,411 6.9%

Prince Edward Island 20,190 1,877 9.3%

Ontario 1,649,185 89,295 5.4%

Quebec 1,080,285 39,287 3.6%

Manitoba 161,895 9,742 6.0%

Saskatchewan 149,305 8,514 5.7%

Alberta 353,420 18,583 5.3%

British Columbia 599,810 26,769 4.5%

Territories (combined) 5,065 277 5.5%

Source: Statistics Canada 2006 Census; Statistics Canada Residential Care Facilities ‐ 2008/2009 Catalogue no.83‐237‐X *Number of beds represents beds staffed and in operation which refers to the number of beds that are either

occupied or available for new resident admissions on the last day of the reference period.

Differences in policy among the provinces may also explain variations in the proportion of seniors living in special care facilities as different provincial policies may influence the rates of institutionalization of seniors. Data from the CMHC Seniors’ Housing Report – Canada Highlights shows the proportion of the population aged 75 years and older living in seniors housing52 or residences for seniors (see Table 6). For the period 2009‐

50 Access to a bed refers to the proportion of the seniors population that could potentially be accommodated based on the number of beds. 51 “Homes for the Aged” in the residential care facilities category refers to nursing homes, homes for the aged and other facilities providing services and care for the aged. Not included are homes for senior citizens or lodges where no care is provided. 52 In CMHC’s Seniors’ Housing Report, “seniors housing” refers to private or non‐profit residences where the majority of residents are 65 years and older and have access to additional services (at least an on‐site meal plan). This does not include residences which provide high levels of healthcare such as nursing homes and long term care homes. In addition, residences with less than 10 units were excluded in Quebec, Ontario and the Prairies and with less than 5 units in Atlantic and British Columbia.


2011, an average of 8.4% of people 75 years and older lived in residences for seniors. The proportion living in residences for seniors in the different provinces ranged from an average of 1.3% in Nova Scotia to 17.6% in Quebec. One key informant suggested that the high capture rate53 for seniors housing in Quebec was due to a smaller number of nursing homes compared to the proportion of seniors in the province. On the other hand, in some provinces such as Ontario, nursing homes receive government subsidies while residences for seniors do not, which makes nursing homes more affordable to seniors with lower incomes. This may partly explain the lower capture rate of 4.9% for residences for seniors in Ontario.

Table 6: Trends in the Capture Rate for Seniors Housing: Canada; 2009‐2011

2009 2010 2011 Average

Canada 8.2% 8.4% 8.6% 8.4%

Newfoundland & Labrador 6.0% 6.2% 6.4% 6.2%

Prince Edward Island 9.8% 9.1% 9.6% 9.5%

Nova Scotia 0.8% 1.1% 2.1% 1.3%

New Brunswick ** ** ** **

Quebec 17.3% 17.8% 17.6% 17.6%

Ontario 4.9% 4.8% 5.1% 4.9%

Manitoba 5.0% 4.2% 4.6% 4.6%

Saskatchewan 6.2% 6.3% 7.1% 6.5%

Alberta 5.1% 5.0% 4.9% 5.0%

British Columbia 7.3% 7.9% 8.4% 7.9% Source: CMHC Seniors' Housing Report ‐ Canada Highlights 2009‐2011

Note: The capture rate is the proportion of the population aged 75 years and older living in the survey universe. **not statistically reliable

The discussion in the section on the availability of care has demonstrated that the availability of home care greatly influences the decision to move from a private dwelling to a special care facility. Due to the fact that the availability of home care depends in general on the home care budget of each province, provincial policy may also impact rates of institutionalization in the different provinces. Figure 3 shows that in 2004/2005, the average home care budget in Canada was $1,901 for each person 75 years and older. Prince Edward Island had the smallest per capita budget for home care at $935 while Alberta had the largest at $2,908.54 While the home care budget of each province may influence the rates of institutionalization of seniors, it should be noted that labour costs vary across the country and home care workers may be better paid in

53 The “capture rate” is the proportion of the population aged 75 years and older living in the survey universe. 54 Ascent Strategy Group (2008). Final Report: Trends, Projections and Recommended Approaches to Delivery of Long Term Care in the Province of Prince Edward Island 2007‐2017 using data from the PEI Department of Health dated December 2006.


some provinces compared to others so home care budgets may not be directly comparable. Figure 3: Per Capita Home Care Budgets for Persons 75 years and Older by Province: Canada, 2004/2005

When the data on access to beds in Homes for the Aged, capture rates for residences for seniors and per capita home care budgets are taken together, they illustrate how the policies of the region of residence can significantly impact rates of institutionalization of seniors. Provinces with a larger supply of nursing home beds and units in residences for seniors combined with smaller per capita home care budgets result in higher rates of institutionalization.

3.1.6 Education

The level of education is often believed to influence the decision to move to special care facilities with the assumption that seniors with higher levels of education would have higher incomes, thus resulting in a lower probability of being institutionalized. A study by Carriere and Pelletier (1995) found that the level of education has no significant effect on the likelihood of being institutionalized.55 When the level of education was analyzed in conjunction with the presence of family networks using data from the 1985 General Social Survey conducted by Statistics Canada, it was found that

55 Carriere, Y. and Pelletier, L. (1995). Factors Underlying the Institutionalization of Elderly Persons in Canada AND Sarma, S., Hawley, G., and Basu, K. (2009). Transitions in Living Arrangements of Canadian Seniors: Findings from the NPHS Longitudinal Data. Social Science and Medicine 68 pp. 1106‐1113

$935

$1,209

$1,703

$1,737

$1,798

$2,031

$2,502

$2,609

$2,793

$2,908

$7,895

$0

$2,000

$4,000

$6,000

$8,000

$10,000

Home Care Budget

Geography

Per Capita (75+) Home Care Budget

Source: Ascent Strategy Group (2008). Final Report: Trends, Projections and

Recommended Approaches to Delivery of Long‐term Care in the Province of Prince Edward Island 2007‐2017 using data from the PEI Department of Health dated December 2006

Canada = $1,901


the risk of institutionalization was lower among those with a lower level of education. On average, those who were less educated (in this case, those without a high school diploma) had 2.9 children compared to only 2.2 children for those with more education (with a high school diploma). In addition, those seniors with less education had, on average, 3.0 siblings compared to an average of only 2.4 siblings for the better educated group. This data suggests that less educated seniors have a larger family network to rely on compared to more educated seniors, thus lowering the likelihood of being institutionalized. These findings are supported by the fact that 5.7% of seniors with lower education levels live with relatives compared to only 2.2 percent of better educated seniors. The authors note that their findings do not necessarily suggest that an improvement in the level of education of seniors would increase the likelihood of moving to an institution. It is the extent of family networks that would influence the likelihood of a senior moving to a special care facility. 56 Findings from a report prepared for the Winnipeg Regional Health Authority shows that the largest proportion of individuals who had moved to a special care facility from a private dwelling had no schooling or had an education level of Grade 8 or less (32.2%). Just over one‐quarter (25.6%) of those who moved from private dwellings to special care facilities had an education level of Grades 9‐11 while the smallest proportion of movers had a high school degree (13.8%). On the other hand, the proportion who had a technical, trade or university degree and who moved to a special care facility is slightly higher, at 16.8%.57 While the results of the two studies seem to be conflicting, the findings cannot be directly compared as the studies did not use the same methodology. In addition, the study by Carriere and Pelletier (1995) found that the level of education had no significant effect on the likelihood of institutionalization unless the results were correlated with another variable, such as the presence of family networks. Thus, it can be inferred that level of education may influence the decision to move to a special care facility when taken in conjunction with other variables such as income or the availability of care.

3.1.7 Marital Status

Marital status is one of the determinants of moving to special care facilities for seniors. Being married decreases the likelihood of moving to a special care facility as a spouse or partner would be able to provide some care and assistance as well as companionship. These are factors which the literature has suggested could greatly influence a senior’s health and wellbeing, thus delaying or helping avoid institutionalization.

56 Carriere, Y. and Pelletier, L. (1995). Factors Underlying the Institutionalization of Elderly Persons in Canada. 57 Mitchell, L., et.al. (2008). Long Term Care Strategy: An Examination of Clients Across the Care Continuum. Winnipeg Regional Health Authority and Centre on Aging, University of Manitoba.


A study by Trottier et al. (2000), using data from the 1996/1997 National Population Health Survey shows that seniors who are single are fourteen times more likely to be in a nursing home compared to seniors who were married or in common‐law relationships even if they do not have a disability. The findings also indicate that seniors who were separated or divorced were twelve times more likely to be in a nursing home compared to seniors who were married or in common‐law relationships (see Table 7).58 Similarly, a study conducted by Sarma, et. al. (2009) using the first six cycles of the National Population Health Survey microdata found that being married decreases the probability of moving to either an intergenerational living arrangement or an institution. In contrast to the first study undertaken by Trottier, et. al. (2000), the study by Sarma, et. al. (2009) found no difference in the probability of institutionalization among single, widowed, divorced or separated seniors.59

3.1.8 Other Factors

There are a number of other factors that may influence the decision of a senior to move from a private dwelling to a special care facility. These include gender, living arrangements, loneliness or the need for social support, and un‐adapted housing or housing with physical barriers that limits independent living. Although these factors may influence a senior’s decision to move, they are generally correlated to the health status of a senior and the availability of in‐home care. In general, these are therefore not the primary factors that influence a senior’s decision to move to a special care facility. Living Arrangement

The living arrangement of an individual is one of the factors that influence the decision to move to a special care facility. A study of clients across the care continuum in Winnipeg found that the highest proportion of individuals who moved to a nursing home lived alone. The data shows that 46.7% of individuals living alone in private

58 Trottier, H., et.al. (2000). Living at Home or in an Institution: What makes the difference for seniors? Health Reports, Vol. 11(4), pp. 49‐61 59 Sarma, S., Hawley, G., and Basu, K. (2009). Transitions in Living Arrangements of Canadian Seniors: Findings from the NPHS Longitudinal Data. Social Science and Medicine 68 pp. 1106‐1113

Table 7: Odds Ratios for Marital Status for Seniors Without a Disability in Long Term Care Homes Compared with Seniors with Severe / Moderate Disabilities in Private

Households: Canada, 1996/1997

Marital Status Odds Ratio

Married / Common‐law 1.00

Single 14.04

Widowed 6.70

Separated / Divorced 12.08Source: Trottier et.al. (2000). Living at home or in an institution: What makes the difference for seniors? Health Reports, Vol. 11(4), Statistics

Canada Catalogue no. 82‐003, Table 3 using data from the 1996/97 National Population Health

Survey *Reference category for which odds ratio is

always 1.00


dwellings moved to a nursing home compared to only 28.5% who lived with a spouse and 24.8% who lived with others.60 Gender

In spite of the fact that there are a greater proportion of women in special care facilities, gender has no effect on the housing transitions of seniors.61 Key informants stated that couples generally stay in their own homes until a spouse passes away. Due to the differences in life expectancy62, the survivors are often women. One key informant noted, based on data from the Census that the gap between the average life expectancy of men and women is narrowing. Recent data from Statistics Canada shows that in 2006‐2008, the life expectancy at birth for men was 78.5 years, which was up 0.2 years from 2005‐2007 data. Life expectancy at birth for women increased by 0.1 years, to 83.1 years, during the same period. Additionally, during the 1996 to 1998 period, the gap in life expectancy at birth between men and women was 5.6 years. In the 2006 to 2008 period, this gap narrowed to 4.6 years.63 This suggests that men will soon live almost as long as women, with more elderly couples rather than elderly widows. For example, population projections in Manitoba suggest that the gap between men and women is narrowing for the population 75 to 84 years.64 Loneliness

Another factor that may influence a senior’s decision to move to a special care facility is loneliness or the need for social support. According to some key informants, seniors sometimes opt to move to retirement homes because their friends have moved to retirement homes and they decide that it is a lifestyle that they like. This is particularly true for those who have lost their spouse or partner as a move to a retirement home may be a way to reconnect with friends as well as to receive some assistance, such as meal preparation. It should be noted that when key informants suggested this determinant of moving, they were referring only to a move to a residence for seniors and not a move to a nursing home. Un‐adapted Housing

The layout of a home and the presence of physical barriers may impact a senior’s decision to move to a special care facility as it may limit the ability of a senior to continue to live independently. The review of literature did not find a study where the lack of home adaptations directly resulted in a senior’s move to a special care facility

60 Mitchell, L., et.al. (2008). Long Term Care Strategy: An Examination of Clients Across the Care Continuum. Winnipeg Regional Health Authority and Centre on Aging, University of Manitoba. 61 Sarma, S., Hawley, G., and Basu, K. (2009). Transitions in Living Arrangements of Canadian Seniors: Findings from the NPHS Longitudinal Data. Social Science and Medicine 68 pp. 1106‐1113 62 “Life expectancy” is the average number of years of life remaining at birth or at another age. It is based on age‐specific mortality rates and calculated using three‐year data. 63 Statistics Canada (2011). Deaths 2008. Catalogue no. 84F0211XWE. 64 Centre on Aging, University of Manitoba (2006). Manitoba’s Seniors: A Companion to the Manitoba Fact Book on Aging.


although a study by CMHC found that home adaptations improved the quality of life of seniors and their family members. These adaptations lessened the risk of falls and injuries and increased seniors’ access to their home and the outdoors.65 One key informant suggested that the physical ability of a senior and the way their home was laid out, whether there were stairs for example, influenced the course that a senior would follow. Another key informant suggested that the homes that were currently being built were “peter pan homes,” that is, homes that people could not grow old in and that a change in thinking was necessary.

3.1.9 Summary of Determinants of Moving to Special Care Facilities

There are a number of reasons why seniors move from their private dwellings to special care facilities. The health status of a senior is the primary determinant although this is closely related to the availability of care. If a senior has access to support services in their home, whether these are publicly‐provided or from informal caregivers, the likelihood of moving to a special care facility is greatly decreased. Other factors that influence a senior’s decision to move to a special care facility include age, income, marital status and education but these are all influenced by the health status of the senior as well as the availability of care in their private dwelling. Gender seems to be a determinant of moving to special care facilities but it is more a result of longer life expectancy for women rather than an independent factor that influences a senior’s decision to move. As the gap in life expectancy between men and women narrows, there may be more men moving to special care facilities or more couples seeking alternatives to institutionalization. The narrowing of the gap in life expectancy may also result in a need for special care facilities that allow a couple to stay together even if the two partners have different needs. In addition, the policies and programs in the senior’s province of residence influence their decision to move. Regions with a larger supply of beds in special care facilities may result in higher rates of institutionalization. In addition, policies around payment for accommodation influences whether a senior moves to a residence for seniors or a nursing home. Further, provincial and territorial budgets for home care are factors in the rates of institutionalization as these determine the availability and access to care in the community. The following figure provides a summary of the factors that influence a senior’s decision to move to a special care facility. A senior’s health status and the availability of care, in general, are the primary factors that influence this decision. Age, income, province of residence, education, marital status, gender, living arrangements, loneliness or social

65 CMHC (2008). Research Highlight: Adapting Homes to Extend Independence – A Case Study of 13 Frail Seniors in Quebec City Suburbs.


support and un‐adapted housing are secondary factors that influence the decision to move.

3.2 Timing of the Transition to Special Care Facilities

This section discusses the average age at which seniors move to special care facilities and the proportion of the seniors’ population in special care facilities.

3.2.1 Average Age of Seniors in Special Care Facilities

Data from the Canadian Institute for Health Information (see Table 8) shows that the average age of residents in residential care facilities66 is 83, with more than 50% of residents being 85 years and older. This has been the average age of residents for the past three years, with the average age for male residents being a little less than that of female residents. Key informants agreed that the average age of residents in special care facilities was between 80 to 85 years. A study in Prince Edward Island found that about 70% of people admitted to nursing homes are over the age of 80.67 The data in Table 8 also shows that 68.6% of residents in residential care facilities are female. This may be explained by the fact that women tend to live longer than men. In addition, the literature and key informants state that, generally, couples are more likely to live in a private residence than in a special care facility. There is a higher probability for a senior to move to a special care facility after they lose their spouse or partner, particularly if they were relying on this partner for care or if there is no one else that they can rely on for care, as is discussed in the previous sections of this report.

66 According to Statistics Canada, “Residential Care Facilities” include all facilities in Canada with four or more beds providing assistance such as counseling, custodial, supervisory, personal, basic nursing and/or full nursing care to at least one resident. These are facilities that are funded and approved by provincial or territorial departments of health or social services. Excluded are those facilities providing active medical treatment (general and allied special hospitals). The category “special care facilities” includes residential care facilities. 67 Ascent Strategy Group (2008). Final Report: Trends, Projections and Recommended Approaches to Delivery of Long‐term Care in the Province of Prince Edward Island 2007‐2017.

•Health Status

•Availability of In‐Home CarePrimary Factors

•Age, income, education, marital status, gender, social support, living arrangements, province of residence, un‐adapted housing

Secondary Factors

Decision to move to a special care

facility


Table 8: Average Age of Residents in Residential Care, 2007‐2010

2007‐2008 2008‐2009 2009‐2010

Average Age 83 83 83

Male 80 80 80

Female 84 84 84

% Younger than 65 6.3% 6.6% 4.8%

% 85+ 52.4% 51.6% 57.3%

% Female 68.6% 68.6% 68.6% Source: Continuing Care Reporting System, Canadian Institute for Health

Information Note: Data is based on a sample of residential care facilities in Newfoundland &

Labrador, Nova Scotia, Ontario, Manitoba, Saskatchewan, British Columbia & Yukon

The data from the Canadian Institute for Health Information also demonstrates that the average age of residents in residential care facilities varies across the provinces and territories (see Table 9). Residents of residential care facilities in Newfoundland and Labrador are, on average, the youngest, at 77 years while residents in Nova Scotia are the oldest, at 86 years. In addition, residential care facilities in Saskatchewan and Manitoba have the largest proportion of residents over the age of 85, at 62.6% and 62.5% respectively.

Table 9: Average Age of Residents in Residential Care Facilities, 2009‐2010

Average Age % 85+

Newfoundland & Labrador 77 36.7%

Nova Scotia 86 50.3%

Ontario 83 56.3%

Manitoba 84 62.5%

Saskatchewan 83 62.6%

British Columbia 83 58.7%

Yukon 78 37.3%

Total 83 57.3% Source: Continuing Care Reporting System, Canadian Institute for

Health Information Note: Data is based on a sample of residential care facilities in Newfoundland & Labrador, Nova Scotia, Ontario, Manitoba,

Saskatchewan, British Columbia & Yukon

Data in Table 10 from Statistics Canada’s Residential Care Facilities shows that more than three quarters of residents in these facilities are seniors. In addition, a large proportion are 85 years and over, with the proportion increasing from 39.5% in 2003/2004 to 41.6% in 2008/2009. The proportion of residents in the other age groups has been quite consistent in the past four years, with the proportion of residents increasing with age.


Table 10: Residents on books in Residential Care Facilities (Homes for the Aged68) by Age: Canada 2003/2004 to 2007/2008

Age Group 2003/2004 2004/2005 2006/2007 2008/2009

65‐69 5,431 3.0% 5,418 2.9% 5,784 2.9% 6,471 3.1%

70‐74 10,092 5.6% 10,084 5.3% 10,380 5.3% 10,552 5.1%

75‐79 19,395 10.8% 18,630 9.8% 19,931 10.2% 19,871 9.7%

80‐84 32,072 17.9% 34,526 18.2% 33,794 17.2% 34,478 16.8%

85+ 70,899 39.5% 73,718 38.9% 78,890 40.2% 85,440 41.6%

Total 65+ 137,889 76.9% 142,376 75.2% 148,779 75.8% 156,812 76.3%

Total All Ages 179,424 100.0% 189,325 100.0% 196,261 100.0% 205,442 100.0%Source: Statistics Canada, Residential Care Facilities 2003/2004 to 2008/2009, Catalogue no. 83‐237

A report by the Association Quebecoise D’Etablissements de Sante et de Services Sociaux (AQESSS) using data from the Ministry of Health in Quebec shows that in 2009, changes in housing arrangements occurred at 85 years or older. The proportion of seniors living in a private home decreased from 96.4% for seniors 65‐74 years to 83.2% for those 75‐84 years to a low of 60.9% for those aged 85 years and older.69 Key informants were not aware of data that specifically showed the average or median age at which seniors’ transitions to special care facilities occurred but it can be inferred from the data presented above as well as the experience of five key informants that this transition generally occurs between 80 and 85 years. Key informants suggest that, in the future, seniors’ moves may come even later in life due to the increasing life expectancy, particularly, disability‐free life expectancy. Key informants also suggest that the narrowing gap in life expectancy of men and women may allow seniors to live in their own homes longer, thus delaying the move to a special care facility. It may also result in more couples moving, as opposed to individuals. As discussed in the previous section on the determinants of moving to special care facilities, age alone does not determine whether a senior will move from their private dwelling to a special care facility. Other factors, such as health status and the availability of care in the community, in association with age, influence a senior’s decision to move. The fact that most seniors are admitted to special care facilities in their 80’s is primarily a result of health status, which naturally deteriorates with age.

68 “Homes for the aged” are nursing homes, homes for the aged and other facilities providing services and care for the aged. Not included are homes for senior citizens or lodges where no care is provided. 69 Association Quebecoise D’Etablissements de Sante et de Services Sociaux (AQESSS) (2011). 6 Cibles pour Faire Face au Vieillissement de la Population.


3.2.2 Proportion of Seniors in Special Care Facilities

Key informants were not aware of data that would show the proportion of the seniors’ population moving from private dwellings to special care facilities each year. Data was available on the number of nursing home admissions for some provinces. In Quebec, the number of seniors being admitted to nursing homes increased from 27,708 in 1991 to 37,099 in 1995 but decreased to 35,519 in 2005 (see Table 11). The data also shows that the proportion of seniors aged 65 to 74 years who were being admitted to nursing homes in Quebec decreased from 26.4% of all admissions in 1991 to only 16.3% in 2005. In contrast, the proportion of seniors 85 years and older being admitted to nursing homes in Quebec increased from 32.8% of all admissions in 1991 to 42.9% of all admissions in 2005. This suggests that seniors being admitted to nursing homes in Quebec are being admitted at a later age compared to two decades ago.

Table 11: Trends in the Number of Nursing Home Admissions by Age: Quebec, 1991‐2005

Age Range 1991 1995 2000 2005

65‐74 7,304 26.4% 6,991 18.8% 6,842 19.2% 5,775 16.3%

75‐84 11,302 40.8% 15,617 42.1% 14,430 40.5% 14,505 40.8%

85+ 9,102 32.8% 14,491 39.1% 14,332 40.3% 15,239 42.9%

Total 65+ 27,708 100.0% 37,099 100.0% 35,604 100.0% 35,519 100.0%Source: Conseil des aines Quebec (2007). Etat de Situation sur les Milieux de vie Substituts pour les Aines en Perte D'Autonomie

A report that looked at the current state of long term care services in Prince Edward Island found that the number of nursing home admissions in the province increased from 2000 to 2004 then decreased to 2006 (see Table 12). The study also found that approximately 70% of people being admitted to nursing homes in Prince Edward Island are over the age of 80. On average, admissions to nursing homes were 35% male and 65% female. The care needs of those being admitted have also increased over the past years, with the majority of nursing home residents having a dual diagnosis such as a chronic illness combined with a physical limitation, disability or cognitive impairment.70 Research and key informant consultations were not able to identify data showing the proportion of the seniors’ population transitioning to special care facilities each year in the past decade. It can be inferred from the data available that only a small

70 Ascent Strategy Group (2008). Final Report: Trends, Projections and Recommended Approaches to Delivery of Long‐term Care in the Province of Prince Edward Island 2007‐2017

Table 12: Average Nursing Home Admissions: Prince Edward Island; 2000‐2006

Year Ave. Admissions

2000 389

2001 369

2002 395

2003 387

2004 423

2005 366

2006 350 Source: Ascent Strategy Group (2008). Trends, Projections and Recommended Approaches to

Delivery of Long‐Term Care in the Province of Prince Edward Island,

2007‐2017


proportion of seniors move to special care facilities each year. This is supported by the fact that only 6.3% of the senior population in 2006 lived in special care facilities. In addition, approximately 1.7% of seniors in Prince Edward Island and 3.3% of seniors in Quebec moved to nursing homes in 2005/2006.

3.3 Patterns of Transition to Special Care Facilities

This section looks at the patterns of transitions from private dwellings to special care facilities and how these patterns are likely to change in the future, particularly as a result of the aging of the baby boomer cohort.

3.3.1 Typical Course from Private Dwellings to Special Care Facilities

Litwak and Longino (1987) suggested that there are three kinds of moves among retirees in a modern society. The first move is undertaken right after retirement and is primarily for amenity reasons. The second move is done to be near a primary caregiver when the senior becomes moderately disabled and can no longer manage without help. The third move is to an institution when the senior’s needs are too much for the caregiver to handle.71 The first move is undertaken by relatively healthy, younger seniors who have enough retirement income and are often married. These seniors would, in general, plan this move for years and may have vacationed at and visited this location. This move is undertaken for amenity and lifestyle considerations.72 The second move is undertaken when the senior begins to require help with household tasks such as shopping, cooking and cleaning. A spouse or partner often helps with these tasks so the need for assistance is exacerbated when the spouse or partner passes away. It is at this phase that the senior moves to be closer to their children or relatives. The Litwak and Longino (1987) study supports this theory by analyzing the mobility patterns of people 60 years and over who moved to Florida from New York, New Jersey, Pennsylvania and Ohio. Their examination showed that only 15.5% of those moving to Florida were 75 years or older while 40.6% of those moving north from Florida were 75 years and older. In addition, 47.8% of those moving north from Florida were widowed whereas only 17% of those moving to Florida were widowed.73 The third move is a move to an institution and occurs when the support needs of the senior become too great for the informal caregiver to handle. The authors support this

71 Litwak, E. and Longino, C. (1987). Migration Patterns Among the Elderly: A Developmental Perspective. The Gerontologist, Vol. 27(3), pp. 266‐272 72 Litwak, E. and Longino, C. (1987). Migration Patterns Among the Elderly: A Developmental Perspective. The Gerontologist, Vol. 27(3), pp. 266‐272 73 Litwak, E. and Longino, C. (1987). Migration Patterns Among the Elderly: A Developmental Perspective. The Gerontologist, Vol. 27(3), pp. 266‐272


theory by showing that 11.2% of those moving north from Florida were institutionalized compared with only 1.2% of those moving south to Florida.74 Litwak and Longino (1987) found that there are a number of variances to this pattern. For example, a senior household with lower incomes may not have the option of moving for amenity or lifestyle reasons. In addition, for seniors with no children or younger relatives who may be able to provide some assistance, moving to an institution may be their only option, particularly if there are no formal supports available in the community. Another deviation from the pattern is with immigrants. The study found that some groups of immigrant seniors tended to live with their children or relatives despite their relatively good health.75 In contrast to Litwak and Longino’s theory, key informants felt that there was no typical pattern in the housing transitions of seniors. They felt that each individual had a unique pattern but that these were most often influenced by the senior’s health status. This is similar to Litwak and Longino’s (1987) premise on the motivations for the second and third moves, which are influenced by the health status of the senior. Key informants also suggested that a senior’s financial situation largely influenced the housing transition pattern followed. Moving to a residence for seniors, for example, would require an average annual income of about $23,000 and stays at residences for seniors are often not subsidized by the government. Thus, seniors with lower incomes stay in their own homes for as long as possible then move to a nursing home, which is often subsidized by the government, when they can no longer live independently. Some key informants also suggested that the availability of home care or informal care influenced what pattern of transition a senior followed. An informal caregiver, such as a child or relative, or the availability of formal home care in the community allows seniors to stay in their own homes longer, if not permanently.

3.3.2 Changes in the Patterns of Transition

Key informants stated that they expected patterns of seniors’ housing transitions to change as a result of the aging of the baby boomers. There was no data to support this theory, particularly since the oldest of the baby boomers would only be reaching retirement age this year (2011). But baby boomers’ attitudes and the changes that have occurred, such as staying in the workforce longer and a focus on staying healthy longer, suggest that changes will be experienced in this sector as well. Key informants suggested that baby boomers would not accept institutionalization as their only option

74 Litwak, E. and Longino, C. (1987). Migration Patterns Among the Elderly: A Developmental Perspective. The Gerontologist, Vol. 27(3), pp. 266‐272 75 Litwak, E. and Longino, C. (1987). Migration Patterns Among the Elderly: A Developmental Perspective. The Gerontologist, Vol. 27(3), pp. 266‐272


and that they would find creative ways of being cared for collectively in their community. A survey in the spring of 2010 found that even if baby boomers lost their autonomy due to health issues, 78% would still want to remain in their own homes, with help from both public and private service providers.76 Some key informants also suggested that the influence of baby boomers is already becoming evident in housing for seniors as they have higher expectations in terms of the accommodation and level of service that their parents will receive.

3.4 Housing Preferences and Actual Transition Patterns

This section looks at the housing preferences of seniors and whether their stated intentions regarding housing transition match the actual transition patterns.

3.4.1 Seniors’ Housing Preferences

The majority of seniors would prefer to remain in their own homes for as long as possible. A survey of Atlantic Canadian seniors found that 88% of respondents have no plans to move from their current dwelling.77 When offered a home care alternative, 90% of Canadian veterans chose to remain at home rather than move to a long‐term care facility.78 The majority of older adults and seniors have no plans of moving. As one key informant stated, when seniors move from their private dwelling to a special care facility, it is usually not because they want to but because they have to due to a change in their health status or care needs. In addition, many are unaware of the housing and care options available to them. Thus, when the need to move arises, they are unprepared to make an informed decision. Another key informant suggested that many seniors are still unaware of the difference between a nursing home and a residence for seniors. They see these as one and the same and the challenge for seniors housing providers is overcoming the negative perception associated with residences for seniors. The results of a survey of seniors in Atlantic Canada showed that only 12.6% of respondents indicated that they had plans to move. Of those planning to move only 22.8% said they planned to move in the next twelve months while 62.3% indicated that these moving plans were six to ten years into the future. Of the respondents indicating that they planned to move, the majority (53.4%) said that their primary choice of accommodation would be senior citizen housing. The smallest proportion of respondents (10.2%) chose a nursing or a special care home.79

76 Association Quebecoise D’Etablissements de Sante et de Services Sociaux (AQESSS) (2011). 6 Cibles pour Faire Face au Vieillissement de la Population. 77 Shiner, D. (2007). Report on the Atlantic seniors Housing and Support Survey 78 Pedlar, D., Lockhart, W., and Macintosh, S. (2009). Canada’s Veteran’s Independence Program: A Pioneer of “Aging at home”. Healthcare Papers, Vol. 10(1) pp. 72‐77 79 Shiner, D. (2007). Report on the Atlantic seniors Housing and Support Survey


A study undertaken for Veterans Affairs Canada using data from interviews with veterans showed that 65.5% of all cognitively capable respondents would prefer to live in their own home or in the home of a family member. A further 19.6% would prefer to live in an assisted living or supportive housing environment while only 14.9% would prefer to live in a nursing home.80 Data from a survey of older adults and seniors (aged 53 to 97) conducted in Prince George, British Columbia showed that if a single detached home was not an option, respondents’ housing preferences included seniors housing (63.9%), congregate housing (36.7%), garden suites (26.1%), and residential care facilities (21.1%). Respondents were also asked whether they would like to be put on a wait list for seniors housing and a large majority (81.9%) did not want to be put on a wait list. This was in spite of the fact that more than half of the respondents (57.1%) indicated that they expected to change housing situations within the next ten years due to health concerns.81 The authors of the study did not offer a possible explanation for the respondents’ resistance to be put on a wait list but one possible explanation is that the respondents were still hoping that they would not need to move from their homes. The literature shows that housing preferences of senior Americans are similar to that of senior Canadians. A quarter (26%) of respondents of a national mail survey, most of whom (96%) did not live in retirement housing, indicated that they had plans to move into either a retirement community without health‐care services, a retirement community with health‐care services, or a nursing home. Considering that previous studies showed that approximately 80% of older Americans would prefer to stay in their own homes, these results seem high. The authors felt that this may be due to the fact that although older Americans would prefer to stay in their own homes, they realize that they may need to move in the future due to their care needs.82

3.4.2 Seniors’ Actual Housing Transitions Patterns

Key informants were not aware of any study that looked at whether seniors’ stated intentions regarding housing transitions matched actual transition patterns although one key informant stated that seniors’ intentions are to age in place. They do not plan to move and a move is triggered by a health event not by any desire to move to a special care facility.

80 Miller, J., Hollander, M., and MacAdam, M. (2008). The Continuing Care Research Project for Veterans Affairs Canada and the Government of Ontario. Study 2: A Cost‐Effectiveness Study of Home Care, Supportive Housing and Facility Care 81 Wagner, S., Shubair, M., and Michalos, A. (2010). Surveying Older Adults’ Opinions on Housing: Recommendations for Policy. 82 Gibler, K, Moschis, G., and Lee, E. (1998). Planning to Move to Retirement Housing. Financial Services Review, Vol. 7 pp. 291‐300.


The literature shows that when seniors who are currently living in a nursing home are asked about their housing preferences, 75% of respondents chose a nursing home. On the other hand, when seniors living in the community and receiving care in the community were asked about their housing preferences, 98.2% chose living in their own home or in the home of a relative and not one respondent chose a nursing home.83 This suggests that although the large majority of seniors living in a nursing home chose this facility, it was not because it was their first choice. They may have chosen it because it was familiar or they may have felt that it was their only option in view of their care needs. A study conducted in the United States using data from the Asset and Health Dynamics of the Oldest Old (AHEAD) survey, which collected data over a five‐year period, analyzed the responses to a question that asked respondents their expectations of moving to a nursing home within five years. The study found that expectations were strongly associated with actual nursing home placement and that level of expectations had the same effect on nursing home placement regardless of race and gender.84 Respondents who indicated that there was some chance that they would move to a nursing home had a greater likelihood of actually moving to a nursing home than those who indicated that there was absolutely no chance or very little chance of their moving to a nursing home within five years. Akamigbo and Wolinsky (2006) found that high expectations of nursing home placement were associated with advanced age, being a high school graduate, prior nursing home use, low income, low assets, low self‐rated health status, incontinence, and low ADL and IADL levels.85 This suggests that the respondents’ expectations reflected their personal risk profiles rather than their housing preferences. In general, seniors would like to age in their own homes or, at the very least, in the home of a family member. In spite of this, many seniors do realize that as they age, their health will deteriorate and there is a good chance that they will need to move to some form of seniors housing that offers support services. As the study by Akamigbo and Wolinsky (2006) demonstrates, seniors’ expectations of their living arrangements in the future are largely based on their personal profile. This means that in spite of the fact that most seniors would like to age in their own home, for someone whose health status is not good and who does not have access to home care; the expectations of transitioning to a special care facility are quite high.

83 Miller, J., Hollander, M., and MacAdam, M. (2008). The Continuing Care Research Project for Veterans Affairs Canada and the Government of Ontario. Study 2: A Cost‐Effectiveness Study of Home Care, Supportive Housing and Facility Care 84 Akamigbo, A., and Wolinsky, F. (2006). Reported Expectations for Nursing Home Placement Among Older Adults and Their Role as Risk Factors for Nusing Home Admissions. 85 Akamigbo, A., and Wolinsky, F. (2006). Reported Expectations for Nursing Home Placement Among Older Adults and Their Role as Risk Factors for Nursing Home Admissions.


3.5 Implications of Seniors’ Transitions to Special Care Facilities

This section discusses government initiatives that aim to meet the current and projected needs of the aging population and the extent to which these needs are being met.

3.5.1 Implications for Governments

The transition of seniors from private dwellings to special care facilities has several implications for the different levels of governments and agencies. These include implications for ‘aging at home’ programs, the need for special care facilities, and a re‐examination of services provided in special care facilities to meet the changing needs of residents. Aging at Home

The literature and key informant interviews show that most seniors would like to age in their own homes. Research also shows that with appropriate support services, seniors can stay in their private dwellings longer and, in some instances, completely forego the need to move to special care facilities. Many provincial governments have put in place ‘Aging at Home’ or ‘Aging in Place’ programs that allow seniors to age in their own homes. These programs facilitate aging at home by providing support services and assisting with design modifications to seniors’ homes to make them accessible. For example, Ontario’s Aging at Home strategy provides funding for a series of services that include enhanced home care and community support services like meals, transportation, shopping, snow shovelling, friendly visiting, adult day programs, homemaking services and caregiver support. These services are aimed at reducing seniors’ use of hospitals, visits to the emergency room and preventing early entry to special care facilities.86 Another example is Manitoba’s Home care program which provides post‐acute recovery services at home, maintenance or palliative home care to functionally disabled or frail individuals who need help to remain at home, and services to individuals awaiting personal care home placement.87 In spite of these initiatives, there is still a great demand for home care services for seniors. Key informants have suggested that these government initiatives are not able to keep up with the demand and many seniors are still going into special care facilities when they could potentially age at home if they had access to appropriate services. Additionally, key informants suggest that the aging of the baby boomers will put even more pressure on these programs as there will be an even greater desire to avoid institutionalization. A study of services for seniors in Quebec suggests that if publicly‐

86 Ascent Strategy Group (2008). Final Report: Trends, Projections and Recommended Approaches to Delivery of Long‐term Care in the Province of Prince Edward Island 2007‐2017 87 Kagis, M., Menec, V., and Blandford, A. (2006). Manitoba’s Seniors: A Companion to the Manitoba Fact Book on Aging. University of Manitoba Centre on Aging.


provided home care services are not increased, the demand for nursing home beds will put a great strain on the province’s coffers in the near future.88 The literature shows that in integrated care models where the most appropriate services can be selected from across the health and social care continuum, there is a tendency to use lighter care IADL supports instead of health care. For example, case managers associated with the Veterans Independence Program use negotiated budgets to purchase the most appropriate home and community care services for seniors assessed as being eligible for nursing home placement to allow them to age at home. This program has been successful in substituting community supports such as housekeeping and grounds maintenance for residence in nursing homes.89 Similarly, a study conducted for the Regional Geriatric Program (RGP) of Eastern Ontario found that the “overall divert rate” for Champlain, estimated on the basis of service‐by‐service delivery in the private home was just over 14% while supportive housing divert rates were estimated at about 33%. Individuals were considered “diverts” if the direct cost to the Local Health Integrated Network (LHIN) of their home and community care package for a thirteen‐week period was equal to or less than the direct cost to the LHIN of a bed in a nursing home for the same period. The study also found that IADLs, such as meal preparation and housekeeping, were key drivers of nursing home wait lists in Champlain. As discussed in previous sections of this report, while these support service needs are not necessarily health care needs, the inability of individuals to perform these everyday tasks could lead to a loss of independence and institutionalization. In addition, the study found that the challenges for seniors and their caregivers of coordinating and managing services resulted in placement in a nursing home as the default option.90 Programs that support home adaptations may also help extend seniors’ independence. Although the literature did not show a direct correlation between the lack of home adaptations for seniors and the decision to move to a special care facility, a study did find that home adaptations improved the quality of life of seniors by increasing feelings of safety, improving access and helping maintain dignity and privacy.91 Need for Beds in Special Care Facilities

In spite of the desire to age at home and the home care programs that are helping to make this possible, the literature suggests that there will still be a need for beds in special care facilities. A study undertaken for the Ontario Long Term Care Association

88 Association Quebecoise D’Etablissements de Sante et de Services Sociaux (AQESSS) (2011). 6 Cibles pour Faire Face au Vieillissement de la Population. 89 Williams, P. et.al. (2009). Balancing Institutional and Community‐Based Care: Why Some Older Persons Can Age Successfully at Home While Others Require Residential Long‐Term Care. Healthcare Quarterly Vol. 12(2) pp. 95‐105 90 Williams, P. and Watkins, J. (2009). The Champlain Balance of Care Project: Final Report. 91 CMHC (2008). Research Highlight: Adapting Homes to Extend Independence – Case Study of 13 Frail Seniors in Quebec City Suburbs.


estimates that by 2035, 238,000 Ontarians will be in need of long‐term care compared to approximately 98,000 today. This is based on utilization patterns in the past in addition to taking into account the aging of baby boomers. There are currently 76,904 nursing home beds in Ontario, which includes for‐profit, non‐profit, municipal, and Eldcap beds. As of April 2010, there were 24,033 people on the wait list for these beds with an average wait of between 80 and 165 days. In addition, the study estimates a gap of approximately 57,000 nursing home beds by 2035 based on the growth in supply assuming the current ratio between supply and demand is maintained.92 Similarly, a study undertaken for Prince Edward Island shows that the province’s population 75 years and older will grow from 9,430 in 2007 to an estimated 15,784 in 2027, an increase of 67%. The impact of this growth will not be experienced as much in admissions to nursing homes in the near future since the majority of seniors entering these facilities are 80 years or older. The impact of the baby boomer population will be noticeable after 2027. It is estimated that the population 75 years and older will grow to approximately 20,000 by 2037. Based on these population projections, the demand for nursing home beds in Prince Edward Island is expected to grow from 1,064 in 2007 (with actual beds at 1,012 in 2007) to 1,604 in 2027.93 Likewise, in Quebec, a shortfall of 7,124 nursing home beds may occur by 2017 if the current funding priorities in terms of home care are maintained. These estimates are based on the current number of nursing home beds (33,900 in 2009) and an annual admission rate of 30%.94 A study from the Manitoba Centre for Health Policy that included projecting the future need for nursing home beds found that Manitobans will use between 29.1% to 49.0% more nursing home beds by 2030/2031. The difference in usage is due to the fact that the study used two projection models. One model assumes that the current per capita rates of use are as low as they can get and that no further reductions in per capita use will occur, thus future nursing home use will rise proportionally with population growth. This model projects a need for 13,366 nursing home beds by 2030/2031, a 49.0% increase from the number of beds in 2007/2008. The second model assumes that the per capita use of nursing home beds will continue to decrease and projects that by 2030/2031, there will be a need for 11,573 beds in Manitoba, an increase of 29.1% from 2007/2008 levels. The second model also projects that the need for nursing home beds

92 The Conference Board of Canada (2011). Elements of an Effective Innovation Strategy for Long Term Care in Ontario. 93 Ascent Strategy Group (2008). Final Report: Trends, Projections and Recommended Approaches to Delivery of Long‐term Care in the Province of Prince Edward Island 2007‐2017 94 Association Quebecoise D’Etablissements de Sante et de Services Sociaux (AQESSS) (2011). 6 Cibles pour Faire Face au Vieillissement de la Population.


will be modest until 2020 / 2021 which is when the oldest of the baby boomers will reach age 75 years. 95 It should be noted that the preceding studies based the estimates for the need for nursing home beds on current utilization rates. Programs to facilitate aging at home and baby boomers’ search for alternatives to institutionalization may result in a different utilization rate of nursing home beds than what has been experienced in the past. Greater Health Care Needs of Residents in Special Care Facilities

In addition to the increase in demand for beds in special care facilities, the literature shows that in the future, seniors being admitted into special care facilities will have greater health care needs compared to previous residents. A Veterans Affairs Canada study found that institutional populations are now characterized by later admission ages and a larger proportion of patients with Alzheimer’s disease and other dementias.96 Similarly, Smith (2004) found that the number of seniors requiring tube feeding, dialysis and catheters in nursing homes in Ontario is increasing.97 In 2007, an estimated 450,000 Canadians over 65 years had dementia and 260,000 of these seniors had Alzheimer’s disease. The Canadian Alzheimer’s Society estimates that by 2031, 750,000 Canadians will have dementia.98 Using data from the Canadian Institute for Health Information and their population estimates, the Conference Board of Canada estimates that in 2035, there will be 133,659 residents of nursing homes in Ontario with dementia or Alzheimer’s disease.99 Data reported by the Canadian Institute for Health Information (see Table 13) shows that the proportion of residents in residential care facilities who were admitted from a hospital increased from 39.9% in 2007/2008 to 42.8% in 2009/2010. The proportions diagnosed with dementia, hypertension, and diabetes increased as well during the same period. On the other hand, the proportion of residents in residential care facilities who were admitted with a diagnosis of cancer, with total dependence in activities of daily living (ADL) and severe cognitive impairment decreased in the same time period.

95 Doupe, M. et.al. (2011). Population Aging and the Continuum of Older Adult Care in Manitoba. Manitoba Centre for Health Policy, University of Manitoba 96 Veterans Affairs Canada (1997). Literature Review: Care Trends for Seniors 97 Smith, M. (2004). Commitment to Care: A Plan for Long‐Term Care in Ontario 98 Ascent Strategy Group (2008). Final Report: Trends, Projections and Recommended Approaches to Delivery of Long‐term Care in the Province of Prince Edward Island 2007‐2017 99 The Conference Board of Canada (2011). Elements of an Effective Innovation Strategy for Long Term Care in Ontario.


Table 13: Selected Health Characteristics of Residents in Residential Care Facilities: Canada, 2007‐2010

2007‐2008 2008‐2009 2009‐2010

Admitted from Acute / Other Hospital 39.9% 44.4% 42.8%

Diagnosis of Dementia 54.0% 55.1% 56.2%

Diagnosis of Hypertension 43.7% 45.8% 51.3%

Diagnosis of Cancer 9.3% 8.8% 8.9%

Diagnosis of Diabetes 19.0% 20.5% 22.9%

Total Dependence in ADLs 15.1% 14.0% 13.9%

Severe Cognitive Impairment 33.8% 31.4% 31.2%

Source: Continuing Care Reporting System, Canadian Institute for Health Information Note: Data is based on a sample of residential care facilities in Newfoundland & Labrador, Nova

Scotia, Ontario, Manitoba, Saskatchewan, British Columbia & Yukon

This suggests that seniors entering special care facilities may have greater care needs than seniors in the past, particularly since admissions occur at a later age when health status may be worse. In addition, the health issues being experienced by residents of special care facilities seem to be changing, perhaps as a result of lifestyle changes and medical advances. Effects of Changes in Life Expectancy

The population of Canada is living longer and this trend is expected to continue. In addition, the gap in life expectancy between men and women is narrowing. Between 1921 and 2005, average life expectancy at birth rose from 58.8 to 78.0 years for men and from 60.6 to 82.7 years for women. The gap between the sexes was less than two years in 1921 and increased to more than seven years in 1976 then gradually narrowed to 4.7 years in 2005. By 2031, the average life expectancy in Canada is projected to be 81.9 years for men and 86.0 for women, a gap of 4.1 years.100 Considering that seniors living with a spouse or partner are less likely to move to an institution, the narrowing gap in life expectancy between men and women may result in a smaller proportion of the senior population moving to special care facilities. It may also result in a need for accommodations for couples as opposed to individuals, which was suggested by one of the key informants interviewed, and accommodations that allow couples with various degrees of care needs to stay together. In addition to life expectancy, disability‐free life expectancy (DFLE) is a factor that may influence seniors’ transitions from private dwellings to special care facilities. DFLE takes into account quality of life of an individual and includes data on mortality, long‐term institutionalization and activity limitations in the population and represents a comprehensive index of population health status. The emphasis is not exclusively on the length of life of an individual but also on their quality of life. In 1996 the DFLE at

100 Statistics Canada (2010). Demographic Change: Life Expectancy. Healthy People, Healthy Places Catalogue no. 82‐229‐X


birth in Canada was 68.6 and 11.7 years at age 65, which means that Canadians can expect to live disability‐free for another 11.7 years after age 65. The DFLE at birth for men was 66.9 years and 70.2 years for women. 101 In 2001, data for life expectancy that took into account quality of life was called ‘health‐adjusted life expectancy’. This was the number of years in full health that an individual can expect to live given the current morbidity and mortality conditions. Health‐adjusted life expectancy uses the Health Utility Index (HUI) to weigh years lived in good health higher than years lived in poor health. In 2001, the health‐adjusted life expectancy at birth of men was 68.3 and 70.8 years for women.102 Although the data used is not exactly the same, it can be inferred that the disability‐free life expectancy of both men and women in Canada have increased. It can also be assumed that due to medical advances, this trend will continue. This may partly explain why seniors are transitioning to special care facilities at an advanced age. If this trend continues, the demand for special care facilities may decrease, particularly if care can be provided in a senior’s home.

3.5.2 Summary

The aging of the population has significant socio economic implications. Since the majority of seniors would prefer to age in their own homes, there will be increasing pressure for programs that facilitate aging in place, including home care programs and programs that support informal caregivers. The aging of the baby boomers will increase the demand for these programs as information on this population group suggests that they will look for alternatives to institutionalization. In spite of the desire to age at home, there will still be a number of seniors who will require special care facilities. This number is expected to increase as a result of the increase in the number of seniors. In addition, some studies suggest that the population entering special care facilities will have higher care needs due to the prevalence of certain health conditions, such as dementia, and the advanced age at which seniors move to special care facilities. Data also suggest that there may be a need to consider providing accommodation in special care facilities for couples rather than just individuals as the gap in life expectancy between men and women narrows.

101 Statistics Canada (2011). Health Status – Data tables and maps. Health Indicators Catalogue no. 82‐221‐X 102 Statistics Canada (2010). Summary Tables: Health‐adjusted life expectancy by sex 2001. Using data from CANSIM table 102‐0121. Accessed from: http://www40.statcan.ca/l01/cst01/hlth67‐eng.htm


4.0 Gaps in Information

This section discusses the gaps in data and information that were identified in the literature review on seniors’ transitions from private dwellings to special care facilities and presents recommendations to addressing these gaps. The section also identifies areas for further research that are related to seniors’ housing transitions.

4.1 Gaps in Data and Information

The review of the current state of knowledge on seniors’ housing transitions from private dwellings to special care facilities identified a number of data and information gaps. Common Terms and Definitions

One of these gaps is the lack of common terms and definitions across the country. As one key informant stated, this may cause confusion among policy and decision‐makers. Further, the lack of common terms and definitions may affect the consistency of data across the different provinces and territories. It is recommended that a set of common terms and definitions around special care facilities be developed. Consistent Data

Another gap that was identified was the lack of consistent data on seniors moving from private dwellings to special care facilities throughout the provinces and territories. Some provinces had data on admissions to nursing homes while others did not. In addition, some data was available for the population 65 years and older while other data was only available for the population 75 years and older. Data from Statistics Canada was also difficult to compare to data from other sources such as the provincial ministries of health and CMHC’s survey of seniors housing. It is recommended that standards for the collection of data on admissions to special care facilities be developed to ensure consistent data throughout the country. These standards should include specific age ranges and different categories for special care facilities, such as nursing homes and residences for seniors. Data on the Proportion of Seniors Moving to Special Care Facilities

Data was not available on the proportion of the senior population moving each year from private dwellings to special care facilities by age categories. Some of this information could be estimated by using the number of seniors being admitted to nursing homes but this data was not always available. In addition, different sources of population estimates challenged the uniformity of data throughout the country. It is recommended that data be gathered on the number of seniors entering special care facilities each year across all provinces and territories. This can then be compared to annual population estimates from Statistics Canada to compute the proportion of the senior population moving to special care facilities each year. To be able to determine the proportion moving from private dwellings to special care facilities, authorities


collecting data on admissions to special care facilities can go further by recording the senior’s dwelling type prior to the move to a special care facility. This would allow researchers and policy‐makers to pinpoint the actual number of seniors moving from private dwellings to special care facilities. It is further recommended that in collecting data on special care facilities as part of the Census or another survey, residents of special care facilities or their proxies be asked to identify their dwelling type and/or living arrangement the previous year or in the last five years. This would be similar to the question asked on mobility and would give further information on the number or proportion of the seniors population moving from private dwellings to special care facilities as well as the living arrangement of this population prior to a move to a special care facility. This information is important in forecasting the need for special care facilities in the future. Data on Characteristics of Seniors in Special Care Facilities

Some data is available on the characteristics of residents in residential care facilities from the Canadian Institute for Health Information (CIHI). This data is from a sample of residential care facilities in a number of provinces. Unfortunately, the sample does not include all provinces and territories. Further, the provinces chosen for the sample are not consistent from year to year. Understanding the population in special care facilities is particularly important in the development of programs and policies to meet the needs of this population. Thus, having complete and consistent data on the characteristics of this population is essential. It is recommended that the data gathered by CIHI on the profile of residents in residential care facilities be gathered from a sample of residential care facilities from all provinces and territories to provide an overall picture of residents in residential care facilities. Agencies can go further by gathering data not only on residents of residential care facilities but on residents of all special care facilities, differentiating between the population in nursing homes and the population in residences for seniors as the needs of these resident groups may be different. Data on Nursing Homes and Residences for Seniors

Statistics Canada collects data on the number of people in collective dwellings by age and this data is available from certain topic‐based tabulations. For the 2006 Census, a new category was added called ‘special care facilities’ which included nursing homes, residences for seniors and other special care facilities. This data, available for the 2001 as well as the 2006 Census from topic‐based tabulations on the Statistics Canada website, does not differentiate between nursing homes and residences for seniors. However, an inquiry confirmed that data was available for the different types of special care facilities as a custom tabulation order from Statistics Canada.


The review found that in some cases, it was difficult to find the same type of data (e.g. number of admissions, number of residents, and characteristics of residents or people admitted) for nursing homes and residences for seniors separately. Beginning to address this challenge, Statistics Canada has made changes to both the definitions and the profile form for the 2011 Census to better reflect the nature of the different types of special care facilities.103 Collective dwellings data from the 2011 Census now distinguishes between nursing homes and residences for seniors. Going forward, it is recommended that the same type of data, such as the examples listed above, be gathered on a regular basis and be made available for both nursing homes and residences for seniors separately. This data would be useful in comparing the population of these two types of special care facilities as well as determining the current and future need for these types of special care facilities. Examining the trends for residences for seniors and nursing homes separately would allow projections for the need for each type of facility. This is important because these facilities serve clients with different needs, and differentiating between nursing homes and residences for seniors would have an impact on policy and funding decisions. Collecting and analyzing this data from Statistics Canada would be a good first step but further research would be beneficial, particularly if data can be gathered at a more regular basis than every five years.

4.2 Areas for Further Research

The environment scan and key informant consultations have also identified some areas for further research to better understand seniors’ transitions from private dwellings to special care facilities. Narrowing Gap in Life Expectancy

One area that may warrant further research is the effect of the narrowing of the gap in life expectancy between men and women. One key informant felt that this would result in couples living longer together. The question may be whether these senior couples will opt to continue to live in their own homes and receive care there or whether they would jointly move to a special care facility. If it is the former, the demand for services that allow aging at home will be greater but the demand for beds in special care facilities would decrease. If it is the latter, the accommodation and services provided in special care facilities would have to be altered to suit this new trend. Impact of Increasing Disability‐Free Life Expectancy

Another area that may merit further research is the impact that increasing disability‐free life expectancy would have in the use of special care facilities. Research shows that

103 http://www12.statcan.gc.ca/census‐recensement/2011/dp‐pd/index‐eng.cfm


at present, the average age at which seniors move to special care facilities is between 80 and 85 years. This suggests that until the age of 80, most seniors are able to live in their private dwellings. If the disability‐free life expectancy continues to increase, particularly as a result of changes in behaviour and medical advances, would this result in a decrease in the demand for special care facilities as some seniors would be able to avoid this option altogether while others would not need to move until they are much older? Also, would this result in changing care needs of residents of special care facilities? Implications for Communities

Some research has been done on the effects of the aging population on communities in terms of aging at home. This is important as the majority of seniors would like to remain in their own homes and/or in their own communities rather than moving to special care facilities. The research presented in the previous sections indicate that a small proportion of seniors will still move to special care facilities and it is anticipated that this trend will continue in the future. Further research may look into how communities can become more age‐friendly and to promote aging at home, which may result in a decrease in the proportion of seniors moving to special care facilities in spite of the increase of the proportion of seniors in the population. The research could further examine the feasibility of developing community‐based special care facilities to allow seniors who need this level of care to at least remain in their own community if not in their own home. Implications for the Housing Market

Research has been conducted on the implications of the aging population on the housing market but the environment scan and key informant consultations did not identify studies that looked directly at the effect of seniors’ transitions from private dwellings to special care facilities on the housing market. Further research can be conducted to examine the implications of seniors’ transitions to special care facilities on the housing market in different parts of the country. The research could further differentiate between the implications for urban areas compared to rural areas and areas that receive a large proportion of immigrants each year compared to those that have low immigration levels. Balance of Care

Another area that may merit further research is the Balance of Care (BoC) model which seeks to set evidence‐based benchmarks for the most appropriate mix of community‐based and institutional resources at the local level needed to support an aging population.104 While several studies have already looked at the proportion of clients on the wait list of nursing homes that could safely and cost‐effectively be supported in their own homes or in supportive housing in their communities, this is an area that may warrant further research, particularly since funding priorities would have to be re‐

104 Williams, P. and Watkins, J. (2009). The Champlain Balance of Care Project: Final Report.


examined to accommodate the growing seniors population. Current service levels for home care would not be able to meet the demand, particularly as needs increase due to the aging of the baby boomers. In addition, current processes and funding priorities result in placement in nursing homes as the default option for many seniors.

4.3 Summary of Recommendations

The following is a summary of recommendations to address the data and information gaps that have been identified as well as recommendations for areas for further research.

4.3.1 Addressing Data Gaps in Collaboration with Others

Addressing the data gaps that have been identified involves modifying how data is gathered and the type of data being collected. Considering that data collection is undertaken by different government agencies and different jurisdictions, it is necessary to find a collaborative way of addressing the data gaps that have been identified. The following is recommended: 1) Develop a set of common terms and definitions around special care facilities.

2) Develop standards for the collection of data on admissions to special care facilities to ensure consistent data throughout the country. These standards should include specific age ranges and different categories for special care facilities, such as nursing homes and residences for seniors.

3) Collect data on the number of seniors entering special care facilities each year across all provinces and territories. This data can then be compared to annual population estimates from Statistics Canada to calculate the proportion of the senior population moving to special care facilities each year.

Modify the way data is collected, specifically:

4) In collecting data on admissions to special care facilities, authorities should go further by recording the senior’s dwelling type or living arrangement prior to the move to a special care facility.

5) In collecting data on special care facilities as part of the Census or another survey, residents of special care facilities or their proxies be asked to identify their dwelling type and/or living arrangement the previous year or in the last five years.

6) The data gathered by the Canadian Institute for Health Information (CIHI) on the profile of residents in residential care facilities should include a sample of residential care facilities from all provinces and territories to provide an overall picture of residents in residential care facilities.

7) The data gathered on the characteristics of seniors in special care facilities should be gathered on a regular basis to allow for trends analysis. It should also continue to


differentiate between populations in nursing homes and in residences for seniors, as the needs of these resident groups may be different, in order to provide a more solid base for policy and funding decisions.

8) Gather the same type of data, such as number of admissions, number of residents, and characteristics of residents or people admitted, and make this data available for nursing homes and residences for seniors separately.

4.3.2 Recommendations for Future Research

It is suggested that further research be undertaken on the following topics to better understand the implications of seniors’ housing transitions from private dwellings to special care facilities. 9) Implications of the narrowing gap in life expectancy of men and women for special

care facilities.

10) Effect of the increasing disability‐free life expectancy on the need for special care facilities.

11) Implications for communities of the aging population and the feasibility of developing community‐based alternatives to special care facilities.

12) Balance of Care studies that examine the feasibility of home and community care as an alternative to institutionalization.


5.0 Conclusion

This report presents a synthesis of the findings from a review of literature, data collection and key informant consultations on seniors’ housing transitions from private dwellings to special care facilities. The research found that the primary determinants of moving to a special care facility are health status and the availability of care in the home. There are other factors that influence a senior’s decision to move from their private home to a special care facility but they are generally correlated with health status and the presence or absence of care in the home. It was also found that only a small proportion of seniors reside in special care facilities and, if given the choice, most seniors would prefer to age in their own homes. Moving to a special care facility is often a last resort for seniors who need assistance. The literature shows that, in some cases, the assistance required is not even healthcare‐related but lower level needs such as housekeeping and meal preparation. Wait lists for nursing homes often include individuals who would be better served in their own homes if an alternative to institutionalization existed. The research also shows that this transition often does not happen until much later in life, often at age 80 or older. Trends indicate that this age of transition will increase further in the future. The research process also identified some gaps in data and information. This report provides recommendations on how to address these gaps and identifies areas that merit further research. There are a number of government initiatives that facilitate seniors’ aging at home, and research has shown that this is a step in the right direction as the majority of seniors would prefer this option to being institutionalized. It is also the more cost‐effective response, which is particularly important in times of limited resources and increasing numbers of seniors. Then again, there will still be a small number of seniors who will require care in special care facilities. It is important to examine the current and future needs of this population to ensure that resources are provided to meet these needs.


Appendix A: Questions Asked During the Consultations Filling Data Gaps

1) Are you aware of any reports or studies, including recent or upcoming studies that would provide data (such as data from surveys or the Census) or additional information that is related to the following topics?

The determinants of moving to special care facilities for seniors

The average age that seniors move to special care facilities

The proportion of the seniors population that moved from private dwellings to special care facilities each year in the past decade (preferably by age 65‐74, 75‐84, 85+)

The typical course / courses by which seniors move from private accommodations to special care facilities (for example, moving from a private home to a retirement home to a long‐term care home)

Changes in the patterns of transition over time, particularly as a result of the aging of the baby boomers

Seniors’ stated intentions regarding housing transitions and how these match their actual transition patterns

Implications of seniors’ transitions on housing

Your Opinions

2) Based on your expertise and experience in seniors housing, what is your opinion on the following topics?

Reasons why seniors move from their private homes to collective dwellings

Age at which seniors usually move from private dwellings to collective dwellings / special care facilities

Whether the average or median age when seniors move to special care facilities has changed in the last decade

The proportion of the seniors population that moved from private dwellings to collective dwellings each year in the past decade (preferably by age group: 65‐74, 75‐84, 85+)

Whether there is a typical course / courses by which seniors move from private dwellings to collective dwellings (for example, private housing to a retirement home then to a long term care home or directly from a private dwelling to a nursing home or long term care home)

The factors that determine what course a senior will follow to transition from a private dwelling to a collective dwelling


Changes in the patterns of seniors’ transitions from private dwellings to collective dwellings over time and as a result of the aging of the baby boomers

Whether stated intentions on housing transitions match actual transition patterns

Implications of seniors’ transitions to special care facilities

If possible, please provide us with your research or data on the topics that you have chosen to provide your opinion on. Additional Information

3) Do you have any additional information, including any reports or studies that would provide information on the topics discussed above?

4) Do you have any recommendations of other key informants that we should contact with regard to this study?

5) Would it be alright for us to use your name and/or organization’s name in our report in connection with the information you provided?


Appendix B: Data Tables

Proportion of the Senior Population in Special Care Facilities by Age and Geography; 2006

Geography Total Seniors Population Population in Special Care Facilities

Total Pop 65+ 65‐74 75+ Total Pop 65‐74 75+ 65+

Canada 31,612,895 4,335,250 13.7% 2,288,360 7.2% 2,046,890 6.5% 299,375 30,970 10.3% 243,425 81.3% 274,395 6.3%

Newfoundland & Labrador 505,470 70,260 13.9% 39,680 7.9% 30,580 6.0% 4,020 455 11.3% 3,195 79.5% 3,650 5.2%

Prince Edward Island 135,850 20,190 14.9% 10,810 8.0% 9,380 6.9% 1,590 170 10.7% 1,245 78.3% 1,415 7.0%

Nova Scotia 913,460 138,215 15.1% 73,290 8.0% 64,925 7.1% 7,595 790 10.4% 6,150 81.0% 6,940 5.0%

New Brunswick 729,995 107,640 14.7% 56,850 7.8% 50,790 7.0% 7,535 835 11.1% 5,425 72.0% 6,260 5.8%

Quebec 7,546,130 1,080,285 14.3% 583,705 7.7% 496,580 6.6% 92,410 11,010 11.9% 72,700 78.7% 83,710 7.7%

Ontario 12,160,285 1,649,185 13.6% 868,185 7.1% 781,000 6.4% 108,425 10,585 9.8% 90,035 83.0% 100,620 6.1%

Manitoba 1,148,400 161,895 14.1% 78,930 6.9% 82,965 7.2% 10,310 935 9.1% 8,430 81.8% 9,365 5.8%

Saskatchewan 968,160 149,305 15.4% 70,890 7.3% 78,415 8.1% 10,140 850 8.4% 8,415 83.0% 9,265 6.2%

Alberta 3,290,350 353,420 10.7% 189,330 5.8% 164,090 5.0% 24,865 2,425 9.8% 20,815 83.7% 23,240 6.6%

British Columbia 4,113,485 599,810 14.6% 313,395 7.6% 286,415 7.0% 32,120 2,850 8.9% 26,830 83.5% 29,680 4.9%

Yukon 30,375 2,280 7.5% 1,470 4.8% 810 2.7% 130 20 15.4% 80 61.5% 100 4.4%

Northwest Territories 41,460 1,970 4.8% 1,235 3.0% 735 1.8% 210 40 19.0% 90 42.9% 130 6.6%

Nunavut 29,475 815 2.8% 585 2.0% 230 0.8% 25 0 0.0% 15 60.0% 15 1.8%


Note: "Special care facilities" refers to nursing homes, residences for senior citizens, and chronic and long‐term care and related facilities


Appendix C: ADL Hierarchy Scale The ADL (Activities of Daily Living) Hierarchy Scale groups activities of daily living according to the stage of the disablement process in which they occur. Early loss ADL’s (e.g. dressing) are assigned lower scores than late loss ADL’s (e.g. eating). The ADL Hierarchy Scale ranges from 0 (no impairment) to 6 (total dependence). The four items used to score the hierarchical ADL‐scale (0‐6) are: personal hygiene, toileting, locomotion, and eating.

Independent (0) (in all 4 ADLs)

Supervision (1) – at least supervision in one ADL (and less than limited assistance in all four ADLs)

Limited (2) – Limited assistance in one or more of the four ADLs (and less than extensive assistance in all four ADLs)

Extensive 1 (3) – At least extensive assistance in personal hygiene or toileting (and less than extensive assistance in both eating and locomotion)

Extensive 2 (4) – Extensive assistance in eating or locomotion (total dependence in neither of the two)

Dependent (5) – Total dependence in eating and/or locomotion

Total Dependence (6) – Total dependence in four ADLs

Source: interRAI Status and Outcome Scales accessed from www.interrai.org on August 26, 2011


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