Tag: Senior Line

Debating profit vs. nonprofit

(photo from Humber Valley Senior Citizens Club)

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In Volume 28 of the Jewish Seniors Alliance’s Senior Line magazine, JSA members Kenneth Levitt and Larry Shapiro debated some of the arguments for and against for-profit long-term-care facilities. They offered their personal opinions in the debate, as JSA does not have a position on this topic. Their views are reprinted here, with permission.

For-profits here to stay
by Kenneth Levitt

The COVID-19 pandemic with its various mutations has caused a justified focus on long-term care (LTC) in Canada. Organizations such as the B.C. Health Coalition, the NDP, unions and other left-leaning activists or progressives, as well as some physicians, have called for the abolition of all for-profit (FP) facilities, recommending that they be taken over by provincial governments or government-approved not-for-profits (NP). This will not happen in the near future. For-profits (FP) are here to stay and, furthermore, provincial governments support them with LTC operating agreements.

The two main issues are profit and quality of care. In British Columbia, there are 27,000 persons in LTC. Approximately one-third are in each of government-operated, NP and FP facilities. When an FP builds or upgrades a facility, there is no government capital fund support. Capital funds for FPs come from investors and shareholders, whereas NPs depend on governments and their own fundraising efforts. FPs have saved governments billions of dollars in capital costs.

In general, residents are financially responsible for their room and board. Their care is paid for by the local funding authority. Should residents pay from their assets (as in the United States) or continue to pay based on income testing? Should residents who are capable contribute more for their room and board? Many NPs raise funds to subsidize care; others permit paid companions to provide extra care for residents. Should investors who put up their own risk capital (with government “ipso facto” approval) be permitted to make a profit? Is it immoral?

FPs did not do well in terms of COVID-19 deaths. Horrendous stories from Ontario and Quebec came to light that noted the squalor and the shameful living conditions of many vulnerable residents. In British Columbia, a number of NPs and FPs had too many COVID infections and deaths. Staff were not exempt from contracting COVID. How do we account for this? When we factor in those facilities with two or more residents per room, the number of COVID-19 infections, complications and deaths increase dramatically for NPs and FPs. In most cases, staff and visitors were responsible for importing the virus. Governments/health authorities were totally unaware, at the outset of the pandemic, of the extent of the problems. However, most care homes planned well, had few infections with a high percentage of vaccinated staff, and are faring well during the pandemic.

It is not just a move to single beds that will solve the problem of COVID and seasonal flu outbreaks, it is the design of the facilities. We need new and upgraded buildings now. It is also imperative that all staff be vaccinated, and that they be supported by management to better prepare for future health crises.

Canada needs FPs. FPs have the capacity to provide needed accommodation for older adults who qualify, and can build more LTC beds faster than governments. They can provide improved efficiency and greater innovation than NPs. The naysayers want to nationalize all private-sector nursing homes in Canada. The National Institute on Aging at Ryerson University in Toronto recently noted, “Some of the FPs are doing well because they have deeper pockets and much better planning procedures than NPs. It is not clear that one class of ownership is better than the other.”

In an April 2021 report, Isobel McKenzie, B.C. Seniors Advocate, criticized FPs for apparently short-changing the number of direct care hours for which they were paid and making a profit by doing so. At the same time, McKenzie noted that capital costs (building maintenance) is one area where FPs outperform NPs.

There is one FP LTC operator in Ontario, Schlegel Villages, that is at the cutting-edge of services and programs for their residents. Schlegel is a family-owned company that has about 5,000 residents and about 5,000 staff in 19 villages. It did not escape COVID-19, but they have excelled in what is known as “best practices”:

  • Their philosophy: a purposeful life for each resident.
  • Each village is accredited.
  • Staff are unionized and pay is the same as at NPs.
  • Owners are committed to providing exceptional care, and are good corporate citizens who are involved in and contribute to the communities they serve.
  • Newer villages are 60% private rooms and 40% with two persons per room. Moving forward, all new construction will be single rooms with ensuites.
  • Each resident has two bathing opportunities per week.
  • Villages have several neighbourhoods, with 32 residents residing in each self-contained neighbourhood that is well-supported by seven staff with a variety of skills.
  • Each village has programs and space open to outside community organizations and they encourage locals to hold events in the available space.

How can we move forward in a constructive way that includes government-operated facilities, not-for-profits and for-profits?

  • The federal government, in partnership with the provinces, needs to develop and to legislate a set of standards of care and service that will be enforced with consequences. This can be done through accreditation, which is currently voluntary. Once the feds have placed standards of care and service into law, each province should enact similar legislation to require that all LTC facilities be accredited. A provincial accreditation body would be responsible for accrediting, monitoring and enforcing standards.
  • Accreditation would ensure every LTC facility is delivering the hours of care and support for which they are receiving funds.
  • Wages and benefits for full-time staff should be uniform for all LTC facilities and part-time staff should be equally entitled to the same wages and benefits.
  • Hours for home care and Better at Home need to be increased. The financial threshold needs to be lowered to allow more persons in need to take advantage of such a service. This has the potential to put less strain on waitlists for LTC admissions.
  • When an FP is for sale, give preference to a quality NP to purchase it or allow a local (new) society to purchase and operate it.
  • Require all LTC facilities that plan to expand to have only single rooms with ensuites.
  • Develop a timetable and a budget for NPs to upgrade/replace current outdated institutional/hospital-style buildings.
  • Healthcare leaders, their boards of directors and seniors should be the ones who are advocating and pushing for changes. The status quo is not acceptable.

To eliminate FPs is specious and politically and/or ideologically motivated and is a short-sighted non-pragmatic position. Canada’s Parliament last year voted against such a proposal put forth by the NDP. The issue is not between the NPs or the FPs. The issue is how to ensure that the interests of the residents come first.

The billions of dollars that would be required to eliminate the FPs can better be used for increased and quantifiable quality programs and services. This would be the best and the most ethical way to honour those lost in the pandemic and to ensure it will never happen again. The issue is how we treat our most vulnerable older adults. After all, is it not a matter of human rights and choices?

No place for profits
by Larry Shapiro

photo - Policy decisions have encouraged raising the profits of private long-term care facilities by replacing union staff with contract workers, which has resulted in creating personnel shortages, declining working conditions and less access to public funding, argues Larry Shapiro
(photo from cdc.gov)

My goal in this debate is to paint a comprehensive picture illustrating conclusively why many of the for-profit long-term-care facilities (LTCFs) are squandering public funds, with little transparency or few accountability requirements to honour any predetermined set of standards in the areas of quality of service, accountability and profit. We need to see profit taken out of long-term care and need new investments in public and nonprofit beds so that we can reduce our dependence on the private, for-profit sector.

Decades of budget cuts, underfunding and privatization by successive governments have resulted in the catastrophic state of the many private care facilities that have been the sites of the loss of a great number of our loved ones. Nobody should be profiting from the care of our senior citizens. Policy decisions going back 20 years have encouraged raising the profits of private LTCFs by replacing union staff with contract workers, which has resulted in personnel shortages, declining working conditions and less access to public funding. The centre of most COVID-19 outbreaks in British Columbia and throughout the rest of the country have been in our LTCFs.

Let us examine the causes and effects of some of the common characteristics of for-profit LTC facilities that negatively affect the quality of care being dispensed to our seniors. Statistically, 67% of LTC in British Columbia is supplied by both nonprofit and for-profit organizations with the remaining 33% being supplied directly by provincial health authorities. The practice of sub-contracting care services occurs when service providers like LTCFs and assisted living facilities, which are contracted by regional health authorities to provide care, proceed to sub-contract with other companies that offer care workers, kitchen staff and maintenance crews.

These sub-contractors are able to bid lower than qualified unionized staff would cost, all to the detriment of the senior residents who are being served by these workers who are receiving lower wages and poorer benefits and who enjoy fewer full-time positions. The prevalence of sub-contracting in elder care began about 22 years ago, when the B.C. government, by virtue of Bills 29 and 94, stripped out no-contracting and job-security provisions from the collective agreements governing healthcare workers. These laws resulted in the loss of 8,000 jobs by the end of 2004. These laws (which were repealed in 2018) provided health-sector employers, including private LTCFs, with unprecedented rights to lay off unionized staff and hire them back as non-union workers through sub-contracted companies. Predictably, this negatively impacted wages and working conditions.

Reduced funding for and access to publicly funded seniors care, from the early 2000s, resulted in the rationing of care. This meant that access to publicly funded care is limited to those with more acute needs, leaving seniors with less complex needs without access to support services that could keep them from deteriorating and requiring institutional care. So, as staffing levels have declined, the care needs of many LTC residents have increased. More of the publicly funded services are being delivered by for-profit companies, often in LTCFs that combine publicly funded and private-pay beds. The latest data shows that more than 35% of beds are run by the for-profit companies. The health authorities pay for the services through block funding, which accounts for the direct care hours that each resident is to receive per day, and the cost of other services and supplies such as meals. There are no restrictions on how operators spend these dollars and health authorities do not perform payroll or expense audits to ensure public funds are actually spent on direct care.

A report from the Seniors Advocate exposed the fact that most direct care (67%) is delivered by care aides, the lowest paid care workers. For-profit care companies generate profits by underpaying the workers who provide most of the direct care, despite receiving funding based on the assumption they pay union rates contained in the master collective agreement (industry standard). Operators are not monitored to ensure that they are providing the number of care hours for which they are being paid. Without adequate oversight and reporting, companies also make profits by understaffing, which impacts the amount and quality of care that residents receive.

Many LTCFs have a combination of publicly subsidized and private-pay beds, but the co-located private-pay beds are not consistently included in the calculation of care hours delivered. This practice results in publicly funded care hours used to cross-subsidize the care of private-care residents who pay out-of-pocket (for the generation of greater profits) and, at the same time, exacerbates staffing shortages, as companies use the same staff to cover both publicly funded and private-pay beds, which should have their own dedicated staff.

Notwithstanding that the last period for which data is available is 2017-2018, it is noteworthy that while receiving, on average, the same level of public funding, contracted not-for-profit LTCF operators spent $10,000 more per resident per year than did for-profit providers. In addition, and not surprisingly, the for-profit LTCFs failed to deliver 207,000 funded direct-care hours while the nonprofit LTCFs exceeded direct-care hour targets by delivering an additional 80,000 hours of direct care beyond what they were funded to deliver.

Low staffing levels and resulting poor working conditions deteriorate the quality of care, as low staffing places both workers and residents under increased stress and reduces the amount of time care workers can spend with residents. The combination of low pay and understaffing makes it difficult to recruit and retain staff. There is adequate proof that staffing levels and staffing mix are key predictors of resident health outcomes and care quality, and that care provided in for-profit long-term care facilities is generally inferior to that provided by public- and nonprofit-owned facilities.

The B.C. government’s long-standing reliance on attracting private capital into the seniors care sector has benefited corporate chains with the ability to finance and build new facilities. In the decade between 2009 and 2018, British Columbia invested less than one half of one percent of the total healthcare capital spending (which is not very much money). More than one-third of all publicly subsidized and private-pay long-term care and assisted living spaces are controlled by large corporations, while the balance is owned by either nonprofit agencies or health authorities.

Corporate chain consolidation in seniors care has become popular among investors in this sector because the business is real estate-focused, resulting in care facilities being treated and traded as financial commodities. This being the case, the care chains are prone to engage in risky business practices. These chains are routinely bought and sold after using debt-leveraged buyouts, ultimately leaving the chains with debt-servicing costs that revenues, including the government funding, cannot cover, resulting in financial crisis and creating disruptions that undermine the quality of relational care due to high staff turnover.

The evidence is clear: profit-making has no place in seniors care. Public dollars are flowing into profits not into frontline care as intended.

Let us strive to provide the care and support for our parents, grandparents, siblings and others who gave us so much and for whom we care so much. Nobody should be profiting from the care of our seniors and that, dear readers, is why profit should be eliminated from long-term care.

Kenneth Levitt is a past president of Jewish Seniors Alliance, former chief executive officer of Louis Brier Home and Hospital, and a past chair of Camp Miriam. In 1985, he co-edited, The Challenge of Child Welfare, the first textbook on child welfare in Canada. Larry Shapiro studied accounting and worked at major firms as well as with the federal government. In 1977, he studied real estate and opened his own business. Since moving from Montreal to Vancouver, Shapiro has been an active member of the JSA board.

Peer service reinvented

To say that COVID-19 has wreaked havoc on British Columbians would be an understatement. The virus has disrupted anything that we would call the normal activities of daily life. Most of us have had to make major compromises: where we go, what we do and how we can avoid getting the terrible virus. These adjustments have had a major impact on Jewish Seniors Alliance clients, who are already compromised by loneliness and isolation.

How we serve our clients and how we support our volunteers has undergone major changes – let’s give it the label “reinventing peer services.” In order to better understand what has taken place, I interviewed Charles Leibovitch, JSA senior peer support services coordinator, and Grace Hann, JSA trainer of volunteers of senior support services.

In the beginning

By mid-March 2020, the first sign of COVID-19 began to show its ugly head. The lockdown left clients and volunteers absolutely unprepared. Persons who were already isolated and lonely found themselves even more isolated and lonelier. As time progressed, clients were cut off from family members who might have supported their relatives through personal contact and social events. This was especially devastating for persons without family.

In many situations, volunteers were their primary contact; their lifeline! Being alone undermines one’s mental health. Being alone exaggerates one’s fear of COVID-19. Most of the clients were cut off from community programs, like adult day care. Spouses who usually spent time with their spouse in a long-term care facility were also cut off. Simple activities like going for a walk and sitting on a bench were curtailed. Elders had depended on having that human connection – having that human touch makes us feel needed and whole.

Volunteers meet challenge

The changing scene called for quick action, initiated by Grace and Charles. Instead of personal visits, the telephone would become the prime instrument of contact between volunteers and their clients. It was necessary to contact the volunteers quickly. Support for the volunteers would be provided by Zoom. This necessitated a steep learning curve for volunteer and client. After all, making and keeping the connection was critical. The three services – peer support, friendly visits and friendly phone calls – had to be reassessed in terms of the neediest clients. Each of the three services’ volunteers had different levels of training by Grace.

In some situations, a certified peer support volunteer was assigned to a person who ordinarily would have had contact with a friendly visitor or a friendly phone caller. Moving from in-person contact to impersonal contact was a major transition – almost like reinventing how support was to be provided. The JSA volunteers made the transition like veterans, with the extraordinary help of Grace and Charles. There was an increase in the contacts between volunteers and clients and an increase in Zoom online meetings to support the very special work being carried out by the volunteers.

Supporting the volunteers

Grace and Charles organized many activities, including outdoor picnics, weekly webinar seminars, a Chanukah party with a singalong and group support meetings every three weeks. The spirit and esprit de corps by the volunteers has been amazing. Volunteers will send cards to their clients as an additional way to keep in contact. Who doesn’t like to receive mail?

Next steps

Challenging times require challenging solutions. Charles and Grace rose to the challenge and proved that, with dedication, imagination and determination, obstacles can be overcome. When the COVID-19 vaccine has been fully distributed, we will establish a “new normal.” This will present JSA, Grace, Charles and the volunteers with a new set of issues and situations. And, as the song goes, “we shall overcome” – they will face these challenges with creativity, empathy and caring.

Ken Levitt is a past president of Jewish Seniors Alliance, former chief executive officer of Louis Brier Home and Hospital, and a past chair of Camp Miriam. In 1985, he co-edited The Challenge of Child Welfare, the first textbook on child welfare in Canada. A version of this article originally appeared in the March 2021 issue of Senior Line.

We must plan for our death

While our ultimate death is a certainty, when and how we will die is unknowable. And though death is inevitable, it remains a taboo subject for most. None of us knows what the future will bring. It is better to be prepared, so that if you become unable to make medical care decisions, your designated family members and healthcare providers, if you have talked to them, will have the knowledge and confidence to make those decisions for you.

As long as you are capable of understanding and communicating effectively with your doctor, nurse or other healthcare provider, you will be asked to make your own healthcare treatment decisions. But a serious accident or illness can result in you being incapable of making your own healthcare decisions at the time care is needed. This is why thinking about your preferences and talking to your future decision-makers now is so important. Making an advance care plan is a choice that will help alleviate some of the stress your family and friends could face if they are required to make important decisions for you, including who, exactly, you want your doctor to approach to learn about your wishes.

Advance care planning begins by thinking about your beliefs, values and wishes regarding future healthcare treatment and talking about them with selected family members or friends, as well as your doctor. When people you trust know what is important to you, it will be easier for them to make treatment decisions on your behalf.

Healthcare providers will always offer medically appropriate healthcare based on clinical assessment. They will want to ensure that any symptoms like pain, dizziness, nausea, bleeding or infection are understood and addressed. As long as you can understand and communicate, your healthcare provider will explain the medically appropriate care best for you, including any risks, benefits or alternatives. They will also ask if you have any questions and if you wish to accept or refuse the proposed healthcare treatment.

Some of the hardest decisions deal with the use of life support and life-prolonging medical interventions. These can include a ventilator to help with breathing, tube feeding, kidney dialysis, or CPR to restart the heart and lungs. If you were to have a life-threatening illness or injury, would you want to accept or refuse CPR? All, some, or no life support or life-prolonging medical interventions? A trial period of life support and life-prolonging medical interventions, allowing a natural death to occur if your condition is not improving?

Your advance care plan should at a minimum include these three things:

  • Having conversations with selected family members, friends, your family doctor and, if applicable, your spiritual leader, about your beliefs, your values and your wishes.
  • Writing down your beliefs, values and wishes for future healthcare treatment.
  • Writing down the contact information for the people who qualify to be on your temporary substitute decision-maker list (see below), or, if you prefer, the contact information for the representative you have chosen and named in an enhanced representation agreement, which is the one that allows you to name a person to make personal-care decisions and some healthcare decisions, including decisions to accept or refuse life support or life-prolonging medical interventions for you. (If you choose to have a representative agreement, I recommend you seek legal advice).

Bear in mind that your health and personal circumstances will change over time. As long as you are capable, you may change or cancel your advance care plan at any time and for any reason. Be sure to notify your doctor and your family members/friends of all changes you make.

Palliative care

When thinking about what to cover in your advance care plan, you might want to expressly include your wish to receive palliative care if you are suffering from a serious illness or condition. Palliative care is specialized medical care that focuses on providing patients with relief from the symptoms, pain and stress of a serious illness, whatever the diagnosis. The goal of palliative care is not to prolong life, nor to shorten it. The goal is to improve quality of life for both the patient and the family, and can be provided in a variety of locations, including the patient’s home, in a hospice, in a residential care facility or in a hospital.

Palliative care is provided by a team of doctors, nurses and other specialists who work with a patient’s other doctors to provide an extra layer of support. While often associated with end-of-life situations, palliative care is appropriate at any age and at any stage in a serious illness and can be provided alongside other appropriate treatments.

Many people choose to stay at home right to the end of their lives while receiving in-home palliative care from specialized healthcare providers. But if you are in the last few months of your life and feel that you are no longer able to manage at home, a hospice may be a good option for you. Hospices are meant to feel more like a home than a hospital. They are designed and furnished to provide a peaceful, homelike environment for you and your family while you receive end-of-life palliative care.

For more information on the delivery of palliative care in each of these settings, search the B.C. Health Ministry website or contact your local health authority.

Medical assistance in dying

Medical assistance in dying (MAiD) was made legal in Canada in 2016. It provides eligible patients who are experiencing intolerable suffering due to a grievous and incurable medical condition the option to end their life with the assistance of a doctor or nurse practitioner.

If your beliefs and values allow you to consider MAiD in the face of intolerable suffering, you should start by speaking with your doctor or your local health authority. For a variety of reasons, not all doctors will provide MAiD, and no one is required by law to do so. For some, MAiD may conflict with their personal beliefs or professional ethics. However, a patient can expect to be provided with information on how to access this service. Healthcare providers must not discriminate against patients with beliefs or values different from their own, and must provide an effective transfer of care to another healthcare professional who does offer MAiD.

To be eligible for MAiD, a patient must meet all of the following criteria:

  • be registered under B.C. Medical Services Plan
  • be at least 18 years old and capable of making healthcare decisions
  • have made a voluntary request for medical assistance in dying that was not made under any external pressure. This request must be in writing and signed and dated in front of two independent witnesses
  • have given informed consent after having been informed of the other means that are available to relieve their suffering, including palliative care, and
  • on assessment by two independent doctors or nurse practitioners, are determined to have a grievous and incurable medical condition, which means they have a serious and incurable illness, disease or disability; they are in an advanced state of decline that cannot be reversed; the illness, disease, disability or state of decline causes enduring physical or psychological suffering that is intolerable and cannot be relieved under conditions that the patient considers acceptable; their natural death becomes reasonably foreseeable. (On Feb. 24, 2020, the Liberal government of Canada introduced a bill to further amend the Criminal Code to, among other things related to MAiD, allow eligible persons to pursue a medically assisted death whether their natural death is reasonably foreseeable or not.)

A patient who has requested MAiD must be given the opportunity to withdraw their request throughout the process, including immediately before the medical assistance is administered, and this withdrawal need not be in writing or in any other particular form. Just an indication of a change of mind will do. And be aware that only patients who are themselves capable of giving consent can request MAiD. A request by a substitute decision-maker or by way of an advance directive is not valid.

Start the discussion

There is much more information available on end-of-life options than touched on in this article, and many matters not covered herein, but there is enough here to allow you to begin a conversation with those in your life who you want to make decisions for you when you cannot.

This is a lot to cover in one conversation. You can have as many conversations as you need – just get started before unwelcome circumstances make it too late. You will be doing yourself and your loved ones a big favour.

Tony DuMoulin is a founder of the law firm of DuMoulin Boskovich, where he practised commercial and real estate law for 40 years. He has a long history of involvement in Jewish organizations and municipal projects. DuMoulin is on the executive board of Jewish Seniors Alliance, in whose magazine, Senior Line, this article originally appeared in July 2020, Vol. 27(2).