Integrating Long Term Care into a Community Based Continuum: Shifting from "Beds" to "Places"

To address the growing long term needs of Canada's aging population, governments should expand community based care instead of simply increasing the number of residential care beds.Pour repondre aux besoins grandissants de sa population vieillissante en matiere de soins de longue duree, le Canada doit developper les services de soins communautaires au lieu d'ajouter simplement des lits en etablissement.In Ontario, as in other jurisdictions nationally and internationally, health policy makers face converging challenges. On the demand side is an aging population and the related shift from illness that can be cured on an episodic basis to chronic health and social needs that must be managed over the longer term (IHME 2013) On the supply side are increasingly stretched hospital based health care systems. While recent data show that population aging is not in itself a major health care cost driver (CIHI 2014b) these systems are poorly equipped to respond to chronic care needs. As a consequence, they struggle with persistent problems of inappropriate and costly utilization. In Ontario, more than a decade of concerted effort to achieve transformative change and bend the cost curve has produced little reduction in the number of hospital beds occupied by individuals who no longer require hospital care but cannot be discharged because of a lack of community based care. These individuals, described as alternative level of care (ALC) patients, are disproportionately older and may actually be harmed by lengthy hospital stays, increasing their odds of permanent placement in residential long term care (LTC) (Walker 2011).These system challenges are complicated by the continuing decline in informal caregiving caused by the weakening of the nuclear family, women's growing participation in paid employment, and, particularly in rural areas, the out migration of young adults (and potential caregivers) who are following education and jobs to cities (Fast 2015; Williams, Peckham, Kuluski, Lum, Warrick et al. 2015; Williams, Peckham, Kuluski, Lum, Morton Chang et al. 2015) Given that unpaid family, friends and neighbours provide an estimated 70 to 90 percent of the everyday care that older persons require to remain at home, in the coming years there will be even greater demand placed on formal care systems, which will potentially undermine their sustainability (McNeil and Hunter 2014; Peckham et al. 2014; Peckham, Williams and Neysmith 2014; Warrick et al. 2014; Williams, Peckham, Kuluski, Lum, Warrick et al. 2015; Williams, Peckham, Kuluski, Lum, Morton Chang et al. 2015).How should health care policy makers respond? The conventional wisdom is that the growing number of older persons (as well as children with complex medical needs and adults with disabilities who are also aging) will necessitate a proportional increase in the supply of LTC beds in nursing homes and homes for the aged. Indeed, lengthy wait times for LTC in Ontario have been cited as a reason why hospitals cannot discharge patients more quickly (OLTCA 2012).An alternative view, backed by growing evidence and analysis, is that the real problem is a lack of community based care. As insightful observers in Ontario and elsewhere have commented, older persons overwhelmingly wish to age at home. Nevertheless, because community based care is fragmented and inadequate, care pathways too often lead to hospitals and residential LTC (Donner 2015; Drummond 2012; McNeil and Hunter 2014; Ontario Seniors' Secretariat 2013; Sinha 2012; Walker 2011).In this study, we consider the case of Ontario, Canada's second largest and most populous province. Because residential LTC and home and community care (HC Fierlbeck 2011; Marchildon 2013)