Health Care in Canada, 2011 A Focus on Seniors and Aging

Health Care in Canada, 2011 A Focus on Seniors and Aging
Health Care in Canada, 2011
A Focus on Seniors and Aging
Who We Are
Established in 1994, CIHI is
an independent, not-for-profit
corporation that provides essential
information on Canada’s health
system and the health of Canadians.
Funded by federal, provincial and
territorial governments, we are guided
by a Board of Directors made up
of health leaders across the country.
Our Vision
To help improve Canada’s health
system and the well-being of Canadians
by being a leading source of unbiased,
credible and comparable information
that will enable health leaders to make
better-informed decisions.
Table of Contents
About the Canadian Institute for Health Information . . . . . . . . . . . . . . . . . . . . . iii
Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v
Want to Know More? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . viii
Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .ix
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Chapter 1: A Profile of Canada’s Seniors Today and Into the Future . . . . .9
Population Aging: Growth in Canada’s Senior Population . . . . . . . . . . . . . 9
Changing Profile of Canada’s Seniors . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Health Status of Canada’s Seniors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Chapter 2: The Sustainability of Canada’s Health Care System . . . . . . . 27
Seniors’ Use of Hospital Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Per Capita Spending on Seniors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Contribution of Population Aging to Increases in Public-Sector
Health Expenditures in Recent Years . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Contribution of Population Aging to Increases in Public-Sector
Health Expenditures in the Near Future . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Chapter 3: Primary Health Care and Prescription Drugs—Key
Components to Keeping Seniors Healthy . . . . . . . . . . . . . . . . . . . . . . . . . . 51
Providing Primary Care to Seniors With Multiple Chronic Conditions . . . . 51
Chronic Disease and Prescription Drug Use in Seniors . . . . . . . . . . . . . . 57
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
Chapter 4: Caring for Seniors in Community Settings . . . . . . . . . . . . . . . 71
Independent Living . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
Chapter 5: Caring for Seniors in Residential Care . . . . . . . . . . . . . . . . . . 89
Living in Residential Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90
Quality Indicators for Seniors in Home and Residential Care . . . . . . . . . 94
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
Chapter 6: Caring for Seniors With Acute Illness . . . . . . . . . . . . . . . . . .
Wait Times in Emergency Departments . . . . . . . . . . . . . . . . . . . . . . . . .
Hospitalizations for Ambulatory Care Sensitive Conditions . . . . . . . . . .
Seniors in Alternate Level of Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Care at the End of Life . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
107
108
112
115
118
119
Health Care in Canada, 2011: A Focus on Seniors and Aging
Looking Forward: Upcoming Challenges . . . . . . . . . . . . . . . . . . . . . . . . . . .127
Summary of Report Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127
Issues on the Horizon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129
Putting the Pieces Together . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141
ii
About the Canadian Institute for Health Information
About the Canadian Institute for
Health Information
The Canadian Institute for Health Information (CIHI) collects and analyzes
information on health and health care in Canada and makes it publicly available.
Canada’s federal, provincial and territorial governments created CIHI as a notfor-profit, independent organization dedicated to forging a common approach
to Canadian health information. CIHI’s goal: to provide timely, accurate and
comparable information. CIHI’s data and reports inform health policies, support
the effective delivery of health services and raise awareness among Canadians
of the factors that contribute to good health.
As of November 1, 2011, CIHI’s Board of Directors consists of the
following members:
Dr. Brian Postl
Chair of the Board, CIHI;
Dean of Medicine, University of Manitoba
Mr. John Wright (ex officio)
President and Chief Executive Officer, CIHI
Dr. Luc Boileau
President and Director General, Institut national de santé publique du Québec
Dr. Marshall Dahl
Consultant Endocrinologist, Vancouver Hospital and Health Sciences Centre
and Burnaby Hospital
Ms. Janet Davidson
President and Chief Executive Officer, Trillium Health Centre
Dr. Chris Eagle
President and Chief Executive Officer, Alberta Health Services
Mr. Donald Ferguson
Deputy Minister, Department of Health, New Brunswick
Dr. Vivek Goel
President and Chief Executive Officer, Public Health Ontario
Mr. Denis Lalumière
Assistant Deputy Minister, Strategic Planning, Evaluation and Quality, ministère
de la Santé et des Services sociaux du Québec
iii
Health Care in Canada, 2011: A Focus on Seniors and Aging
Mr. John McGarry
Private Health Administration Consultant
Dr. Cordell Neudorf
Chair, CPHI Council;
Chief Medical Health Officer, Saskatoon Health Region
Mr. Saäd Rafi
Deputy Minister, Ministry of Health and Long-Term Care, Ontario
Ms. Anne-Marie Robinson
Associate Deputy Minister, Health Canada
Dr. Marlene Smadu
Associate Dean of Nursing, University of Saskatchewan
Mr. Wayne Smith
Chief Statistician, Statistics Canada
Mr. Howard Waldner
President and Chief Executive Officer, Vancouver Island Health Authority
Mr. Graham Whitmarsh
Deputy Minister, Ministry of Health Services, British Columbia
iv
Acknowledgements
Acknowledgements
The Canadian Institute for Health Information (CIHI) wishes to acknowledge
and thank the many individuals and organizations whose work contributed to
the development of this report.
Thank you to the following expert advisors for their review of relevant materials:
Howard Bergman, MD
The Dr. Joseph Kaufmann Professor of Geriatric Medicine; Professor of
Medicine, Family Medicine and Oncology, McGill University and Jewish
General Hospital
Marcus Hollander, PhD
President, Hollander Analytical Services Ltd.—British Columbia, Canada
Pamela Jarrett, MD, FRCPC, FACP
Geriatrician, Associate Professor of Medicine, Dalhousie and Memorial
University; Horizon Health Network—Saint John, New Brunswick, Canada
Anne Martin-Matthews, PhD
Professor, Department of Sociology, University of British Columbia; President,
Research Committee on Aging, International Sociological Association
Cordell Neudorf, MD
Chief Medical Health Officer, Saskatoon Health Region
Heather Orpana, PhD
Senior Research Analyst, Division of Aging and Seniors, Public Health Agency
of Canada
Ron Sapsford
Chief Executive Officer, Ontario Medical Association
Jennifer Verma, MSc, BJH
Director, Policy, Canadian Health Services Research Foundation
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Health Care in Canada, 2011: A Focus on Seniors and Aging
In addition, the following groups contributed to the drug utilization information found
in Chapter 3: Primary Health Care and Prescription Drugs—Key Components to
Keeping Seniors Healthy:
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Alberta Pharmaceutical Funding and Guidance Branch, Ministry of Health
and Wellness
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Manitoba Drug Management Policy Unit, Ministry of Health
Saskatchewan Drug Plan and Extended Benefits Branch, Ministry of Health
New Brunswick Prescription Drug Program, Department of Health
Pharmaceutical Services, Nova Scotia Department of Health
Prince Edward Island Drug Programs, Health PEI
It should be noted that the analyses and conclusions in this report do not
necessarily reflect the opinions of the affiliated organizations.
Health Care in Canada, 2011: A Focus on Seniors and Aging represents a
collaborative effort across much of CIHI. We would like to thank all those who
contributed their expertise and time in various capacities: conducting research,
literature reviews and environmental scans; compiling, analyzing and validating
the data; writing and editing chapters; reviewing content; and providing
generous and ongoing support to the core team.
This report had the guidance, support and leadership of
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•
vi
Jean-Marie Berthelot, Vice President
Jeremy Veillard, Vice President
Kathleen Morris, Director
Kira Leeb, Director
Cheryl Gula, Manager
Acknowledgements
The core project team for this report included
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•
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Michelle Costa, Senior Analyst
Alexey Dudevich, Analyst
Sharon Gushue, Senior Analyst
Jordan Hunt, Program Lead
Hong Ji, Senior Analyst
Derek Lefebvre, Senior Analyst
Mark McPherson, Analyst
Michelle Parker, Senior Program Coordinator
Rob Ranger, Program Lead
The team is grateful for the generous support and assistance from many
areas across CIHI. In particular, we would like to thank Hani Abushomar,
Selina Anggawinata, Ruolz Ariste, Geoff Ballinger, Carol Brule,
Zeerak Chaudhary, Diana Craiovan, Miao Dai, Kinga David,
Mélanie Josée Davidson, Josh Fagbemi, Michael Gaucher, Darren Gerson,
Yana Gurevich, Joanne Hader, Ian Joiner, Norma Jutan, Christopher Kuchciak,
Lacey Langlois, Kathy Lee, Claude Lemay, Alexandra Moses-McKeag,
Ryan Metcalfe, Eric Pelletier, Jeff Proulx, Cheng Qian, Jessica Ramirez
Mendoza, Jocelyn Rioux, Patricia Sullivan-Taylor, Hui Wang, Elena Ward and
Nancy White. We are appreciative, as well, for the contribution of other CIHI
staff members for their work on translation, communications, web design, print
and distribution.
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Health Care in Canada, 2011: A Focus on Seniors and Aging
Want to Know More?
CIHI welcomes comments about this report and would like to know how future
reports can meet your information needs. Please send an email with your
comments to [email protected]
Visit CIHI’s website (www.cihi.ca) for more specific information about any
area of interest or research involving health care in Canada. Highlights and
the full text of Health Care in Canada, 2011: A Focus on Seniors and Aging
are available free of charge in English and French on CIHI’s website.
viii
Executive Summary
Executive Summary
In 2011, the first members of Canada’s baby boom generation will turn age 65.
It is predicted that as early as 2015, seniors (those age 65 and older) will
outnumber youth (those age 14 and younger). Concerns have been raised
that Canada’s health care system will be unable to meet the growing health
care needs of this aging population. Seniors are typically frequent users of
health care services, with the system spending more on them than on any
other segment of the population. Federal, provincial and territorial governments
have all recognized the importance of improving services for seniors. Making
any such improvements first requires an understanding of this diverse and
complex population. Health Care in Canada, 2011: A Focus on Seniors and
Aging describes seniors’ specific needs and the particular ways in which this
population uses the health care system. From this perspective, the report
examines the impact of a growing seniors population on Canada’s health
care system.
The report opens by describing the current demographic shift into an
accelerated period of population aging and the characteristics of today’s
seniors. With the first of the baby boom generation turning age 65 in 2011,
seniors will account for an increasingly larger proportion of the Canadian
population (about 25% by 2036). An examination of the health status of these
seniors shows that, overall, they are living longer than seniors from previous
generations and are healthier than ever before. However, with increasing age,
the differences in capacity to carry out activities of daily living and number of
chronic conditions become more apparent. On these measures, the youngest
seniors (age 65 to 74) appear more similar to adults age 45 to 64.
The report next explores the degree to which aging has contributed to
increases in public health expenditures over the past 10 years and whether
the health care needs of an aging population may become a bigger cost driver
in the near future. While health spending per capita on seniors is more than
four times that of non-senior adults (age 20 to 64 years) in absolute terms,
the rate of spending growth for seniors was actually lower over the past 10
years than the rates for non-senior adults. Over the last decade, population
aging has contributed relatively modestly to rising public-sector health care
spending, adding less than 1% to public-sector health spending each year.
This result may appear counterintuitive when considering seniors’ use of health
care services; compared with non-senior adults, seniors are proportionately
higher users of hospital and physician services, home and continuing care, and
prescription drugs.
ix
Health Care in Canada, 2011: A Focus on Seniors and Aging
The remaining chapters of the report follow seniors across settings of care,
from primary health care to home and residential care settings. Many seniors
depend on strong primary health care and prescription medications to help
manage an increasingly complex mix of health conditions and protect their
health. While the majority of Canadians (95%) older than age 65 have a regular
family doctor, some reported challenges accessing their doctor when they
needed care. Visits to family doctors are more frequent among seniors with
multiple chronic conditions. Survey findings show that it is the increasing number
of chronic conditions, rather than increasing age, that drives primary health care
use. Data on the use of prescription medication echoes these findings, with the
proportion of seniors taking multiple prescription medications rising in recent
years. Nearly two-thirds of seniors on public drug programs have claims for 5 or
more drugs from different drug classes, and nearly one-quarter have claims
for 10 or more. More than half of seniors on public drug programs regularly use
prescription drugs to treat two or more chronic conditions, and among this group,
the most commonly used medications were for treating high blood pressure and
heart failure (used by 65% of this group).
The vast majority (93%) of seniors live in private households. Although most
prefer to maintain their independence, some require formal and/or informal
support to do so. In terms of formal support, an estimated 1 million Canadians
receive home care at any given time; about 8 out of every 10 of these are
seniors. The services provided to them vary by age and need and include both
home health and home support services. In contrast, most informal care (about
80%) comes from unpaid family members, friends and neighbours. As the time
they spend providing care increases, so does the distress they experience.
Recent data shows that 32% of caregivers who provide more than 21 hours
of care per week report distress in their role—four times the proportion of
distressed caregivers who provide less than 10 hours of informal care per
week. In comparison to home care clients, seniors in residential care are more
likely to be older, unmarried and functionally dependent, more than twice as
likely to show signs and symptoms of possible depression, but almost half as
likely to report daily pain.
As with Canadians of all ages, seniors who become acutely ill may require
care in hospital, where they could encounter issues related to patient flow
and appropriateness of care. Seniors who arrive at the hospital may first make
contact with the emergency department, where they are likely to stay longer
than non-senior adults. Also related to patient flow is alternate level of care
(ALC) stays. Patients are considered ALC patients when they have completed
the acute care phase of their treatment but remain in an acute care bed. Nearly
85% of all ALC patients are age 65 or older and many (35%) are age 85 and
older. As hospitals work toward addressing patient flow issues, the reasons for
hospitalization will likely come into question. For example, questions have been
raised about the appropriateness of receiving end-of-life care in hospitals, given
seniors’ general preference to die in their own homes.
x
Executive Summary
Looking Forward: Upcoming Challenges
The aging of Canada’s population has brought several issues to the forefront
for health care decision-makers. The increasing number of seniors itself will
not threaten Canada’s health care system, but it will require the system to adapt
to meet changing health care needs. Among those challenges: to what extent
the Canadian health care system has met seniors’ needs to date, how it will
likely need to adapt to continue to meet these needs into the future and how
Canadians’ health care needs may change as the population shifts over the
next 20 to 30 years. Analyses such as those presented in this report, across
a wide range of health care services, provide information to help policy-makers
understand seniors’ current needs and to help inform decisions when planning
for the future.
Having a system that is responsive to seniors’ needs will become increasingly
important as Canada’s population ages. To this end, the conclusion of Health
Care in Canada, 2011: A Focus on Seniors and Aging summarizes several
strategies identified by researchers and decision-makers. These include
improving integration of care across the continuum, focusing more on primary
and secondary prevention measures, adopting and making efficient use of
new technologies, and collecting better information to inform decision-making.
Many of these approaches have at least, in part, already been built into existing
provincial and territorial plans. However, as policy-makers will likely have to
make complex decisions in the near future to ensure that Canada’s health care
system is able to accommodate the needs of the rising number and proportion
of seniors in the population, these are areas suggested by experts on which to
focus specific attention.
xi
Introduction
Introduction
Health Care in Canada, 2011: A Focus on Seniors and Aging is the 12th in a
series of annual flagship reports that provides current information on the status
of the health care system and the health of Canadians. Since 2000, the Health
Care in Canada series has served to inform CIHI’s stakeholders—including
policy-makers, health system decision-makers and researchers—on current
priorities in health care. This year’s report focuses on the fastest-growing
segment of the Canadian population: seniors.
As in many developed countries around the globe, Canada’s population is aging.
In 2010, about 14% (4.8 million) of Canadians were seniors (those age 65 and
older).1 By 2036, this proportion will rise to about 25% (10.4 million). 2 In 2011,
the first members of the largest birth cohort in Canada’s recent history—the baby
boom generation—turned age 65.3 As a result, the aging of Canada’s population
has accelerated.2, 3
While Canada’s population is still relatively young compared with that of many
other developed nations,3, 4 its accelerated aging has raised some alarm
bells. Members of the media and the general public have expressed concerns
that Canada’s health care system will be unable to meet the growing health
care needs of an aging population and have called into question the overall
sustainability of the system as a result.5 Research, however, suggests that
population aging has contributed only modestly to increases in health expenditure
to date.6–8 Instead, the evidence points to factors beyond population aging, such
as general population growth and general health service utilization patterns, that
will likely require Canada’s health care system to change and adapt.7–9
Still, the costs and resource needs of health and social care for seniors should
not be underestimated. About 45% of provincial and territorial governments’
health care expenditure in 2009 was spent on seniors,10 yet this group accounts
for only 14% of the population. Seniors are more frequent users of several
sectors of Canada’s health care system11 and utilize the system in different ways
and with different intensity than other age groups. However, today’s seniors are
also redefining aging.12 Available evidence suggests that Canadian seniors are
healthier and more engaged in society than ever before.13, 14 Trends in the use
of health services also suggest that the health care needs of seniors in both
community and institutional settings are rapidly changing.15–17
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Health Care in Canada, 2011: A Focus on Seniors and Aging
As the number and proportion of seniors in Canada’s population grow, the
impact of population aging on public health care expenditures will likely also
grow.18 The effects of an aging population on health care system resources
may be mitigated by promoting a system that is responsive to the needs of
this diverse population. Federal, provincial and territorial governments have all
recognized the importance of improving services for seniors as the Canadian
population ages. Of priority is ensuring that their needs are being met by the
right programs and services at the right time.12
Recommended Priority Areas for
Policy Change in Seniors’ Services
In 2005, the Federal/Provincial/Territorial Ministers Responsible for Seniors
endorsed a framework for action toward healthy aging prepared by the Public
Health Agency of Canada.19 It identified five priority areas for policy and program
change: social connectedness, physical activity, healthy eating, falls prevention
and tobacco control.19 In November 2006, a Special Senate Committee on Aging
was appointed to examine whether seniors’ needs were being appropriately met
by existing health and social programs and services.12
A number of healthy aging strategies and frameworks have since been developed
by provincial governments across Canada.20–27 All underscore the importance of
responding to the growing and complex needs of an aging population across a
wide range of policy areas. In his 2010 Report on the State of Public Health in
Canada,, the Chief Public Health Officer again put forward priority areas for
Canada
action toward healthy aging in Canada, including access to care and services,
knowledge of seniors’ health and improved data.28
Also in 2010, the Canadian Health Services Research Foundation held a series of
roundtable discussions across the country. The discussions with system decisionmakers, care providers and researchers focused on a variety of issues affecting
Canada’s seniors, including the system’s financial sustainability, integrating health
and social care across the care continuum and improving the recruitment and
retention of medical professionals. It was noted that, with seniors living longer and
with more chronic diseases, the current acute care–centred model of health care
delivery may need to be adapted to meet the growing, complex health care needs
of this population. Other recommendations included promoting a positive view of
aging and improving access to health data.9
2
Introduction
Health Care in Canada, 2011: A Focus on Seniors and Aging examines the
impact of a growing seniors population on Canada’s health care system. It
describes Canada’s seniors, discussing not only their health status but also
how they use a wide range of health care services. At its conclusion, the report
summarizes ways in which the system may need to adapt to meet seniors’
current and future needs.
Health Care in Canada, 2011: A Focus on Seniors and Aging is divided into
three parts:
Part 1: Population Aging and Its Impact on the System’s Sustainability
The first section of this report presents information on seniors’ current utilization
of health care services. It considers how healthy Canada’s seniors are by
several measures, while acknowledging the diversity within the seniors cohort.
Part 1 also provides an overview of the impact that aging and other factors
have had on increases in public health expenditures to date for some key
components of the health care system. With Canada’s population set to enter
a period of relatively rapid aging, the system’s future sustainability is discussed.
Part 2: The Health Care Needs of Canada’s Aging Population
As people age, their care needs change. The next four chapters examine
the health and health care needs of Canada’s seniors. Part 2 looks at care
needs along a continuum from community to institutionalized living, as well as
care at the end of life. The description of seniors’ use of primary health care
and prescription medications serves to highlight that, with advancing age,
people develop an increasingly complex mix of health conditions and drug
requirements, both of which need to be managed.
Chapters on long-term care at home and in residential care settings provide
information on how seniors’ needs in these settings are being addressed.
Finally, Part 2 discusses how the system is meeting the needs of seniors
when they become acutely ill, by looking at the care they receive in emergency
departments and acute care hospitals, as well as at the end of life.
Part 3: Looking Forward
The concluding chapter of Health Care in Canada, 2011 highlights four key
areas that have been identified by researchers and decision-makers to consider
in addressing the health care needs of an aging population. To adapt to future
needs, it has been suggested that the system will need to improve integration
of care across the continuum, focus more strongly on primary and secondary
prevention, adopt and efficiently use new technologies, and improve the quality
of available health care information to help policy-makers and other health care
system stakeholders make sound and informed decisions.
3
Introduction
References
1. Statistics Canada, population estimates 1971–2010 (Ottawa, Ont.: Statistics
Canada, 2010).
2. Statistics Canada, Population Projections for Canada, Provinces and
Territories: 2009 to 2036 (Ottawa, Ont.: Statistics Canada, 2010).
3. L. Martel and E. C. Malenfant, Portrait of the Canadian Population in 2006,
by Age and Sex, 2006 Census (Ottawa, Ont.: Statistics Canada, 2007).
4. Organisation for Economic Co-operation and Development, OECD
Factbook 2010: Economic, Environmental and Social Statistics (Paris,
France: OECD, 2010).
5. Canadian Health Services Research Foundation, Sustainability of Canada’s
Healthcare System. Commission on the Future of Health Care in Canada
(Ottawa, Ont.: CHSRF, 2002).
6. R. G. Evans et al., “Apocalypse No: Population Aging and the Future of
Health Care Systems,” presented at SEDAP Conference on Population
Aging, the Health Care System, and the Economy in Burlington, Ontario,
on April 27, 2001.
7. Canadian Institute for Health Information, Health Care Cost Drivers: The Facts.
(Ottawa, Ont.: CIHI, 2011).
8. A. Constant et al., Research Synthesis on Cost Drivers in the Health Sector
and Proposed Policy Options (Ottawa, Ont.: Canadian Health Services
Research Foundation, 2011).
9. Canadian Health Services Research Foundation, Better With Age: Health
Systems Planning for the Aging Population—Synthesis Report (Ottawa,
Ont.: CHSRF, 2011).
10. Canadian Institute for Health Information, National Health Expenditure
Trends, 1975 to 2011 (Ottawa, Ont.: CIHI, 2011).
11. M. Rotermann, “Seniors’ Health Care Use,” Health Reports 16, Suppl.
(2006): pp. 33–45, Statistics Canada catalogue no. 82-003.
12. S. Carstairs and W. J. Keon, Special Senate Committee on Aging Final
Report—Canada’s Aging Population: Seizing the Opportunity (Ottawa, Ont.:
Senate of Canada, 2009), pp. 1–233, accessed from <www.senate-senat.
ca/age.asp>.
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Health Care in Canada, 2011: A Focus on Seniors and Aging
13. National Advisory Council on Aging, Seniors in Canada. 2006 Report Card
(Ottawa, Ont.: National Advisory Council on Aging, 2006).
14. M. Turcotte and G. Schellenberg, A Portrait of Seniors in Canada (Ottawa,
Ont.: Statistics Canada, 2007).
15. Ontario Association of Community Care Access Centres, Submission to
the Standing Committee on Finance and Economic Affairs (Toronto, Ont.:
OACCAC, 2011).
16. M. J. Hollander and M. J. Prince, “Organizing Healthcare Delivery Systems
for Persons With Ongoing Needs and Their Families: A Best Practices
Framework,” Healthcare Quarterly 11, 1 (2008): pp. 45–54.
17. J. P. Hirdes, “Long-Term Care Funding in Canada: A Policy Mosaic,” Journal
of Aging & Social Policy 13, 2 (2001): pp. 69–81.
18. Organisation for Economic Co-operation and Development, OECD
Economic Outlook (Paris, France: OECD, 2010).
19. Public Health Agency of Canada, Healthy Aging in Canada: A New Vision,
A Vital Investment—From Evidence to Action. A Background Paper Prepared
for the Federal, Provincial and Territorial Committee of Officials (Seniors),
2006, accessed from <www.phac-aspc.gc.ca/seniors-aines/alt-formats/pdf/
publications/pro/healthy-sante/haging_newvision/vision-rpt_e.pdf>.
20. Premier’s Council on Aging and Seniors’ Issues, British Columbia, Aging
Well in British Columbia: Report of the Premier’s Council on Aging and
Seniors’ Issues (Victoria, B.C.: Premier’s Council on Aging and Seniors’
Issues, 2006), accessed from <http://www.seniorsbc.ca/shls/pcasi/>.
21. Government of Alberta, Aging Population Policy Framework
(Edmonton, Alta.: Government of Alberta, 2010), pp. 1–41, accessed
from <www.seniors.alberta.ca/Seniors/AgingPopulation/docs/
AgingPopulationFramework.pdf>.
22. Government of Alberta, Alberta Health and Wellness, Continuing Care
Strategy: Aging in the Right Place (Edmonton, Alta.: Government of Alberta,
2008), pp. 1–22, accessed from <www.health.alberta.ca/documents/
Continuing-Care-Strategy-2008.pdf>.
6
Introduction
23. Ministry of Health and Long-Term Care, Ontario’s Aging at Home Strategy:
Questions and Answers (Toronto, Ont.: Government of Ontario, 2011),
accessed from <www.health.gov.on.ca/english/public/program/ltc/34_
strategy_qa.html>.
24. Province of New Brunswick, Being There for Seniors: Our Progress in
Long-Term Care. Part I of Implementing “Be Independent. Longer.” New
Brunswick’s Long-Term Care Strategy (Fredericton, N.B.: Province of New
Brunswick, 2009), pp. 1–28, accessed from <http://www.gnb.ca/0182/pdf/
LongTermCare-e.pdf>.
25. Seniors’ Secretariat of Nova Scotia, Strategy for Positive Aging in Nova
Scotia (Halifax, N.S.: Government of Nova Scotia, 2005), accessed from
<www.gov.ns.ca/scs>.
26. Nova Scotia Health, Continuing Care Strategy for Nova Scotia: Shaping the
Future of Continuing Care (Halifax, N.S.: Government of Nova Scotia, 2008).
27. Department of Health, Prince Edward Island, Prince Edward Island’s
Healthy Aging Strategy (Charlottetown, P.E.I.: Department of Health, 2009),
accessed from <http://www.gov.pe.ca/photos/original/doh_agingstrat.pdf>.
28. D. Butler-Jones, The Chief Public Health Officer’s Report on the State
of Public Health in Canada, 2010: Growing Older—Adding Life to Years
(Ottawa, Ont.: Public Health Agency of Canada, 2011).
7
As the first of the baby boom
generation turns age 65 in 2011,
seniors will account for an increasingly
larger proportion of the Canadian
population (about 25% by 2036).
Chapter 1
A Profile of Canada’s Seniors Today
and Into the Future
Understanding the health status of seniors in Canada can help inform decisions
about how best to meet seniors’ current and future health care needs. In many
ways, seniors’ health status determines their service needs. And changes in the
collective health status of seniors at the population level can point to emerging
areas of need.
This chapter describes the changing demographics and profiles the diverse
health status of Canada’s seniors population. It examines variations in life
expectancy, functional capacity, multi-morbidity and income distribution.
It highlights that, by several population measures, today’s seniors are living
longer and are healthier than ever before. Findings for some measures show
that the youngest seniors are actually more similar to non-senior adults,
underscoring the diversity within the cohort.
Population Aging: Growth in Canada’s
Senior Population
Population aging describes an upward shift in the age structure of a population,
as a function of birth and death rates and migratory patterns to and within
countries. In Canada, population aging has occurred over many decades,
mainly as the result of both increasing life expectancy and declining fertility
rates.1 And for many regions in Canada, population aging is also due to the
out-migration of youth.1
Seniors (those age 65 or older) now account for a growing proportion of the
Canadian population. Between 1986 and 2010, the number and proportion
of Canadian seniors increased from 2.7 million to 4.8 million and from 10%
to 14% of the population. 2 Between 2011 and 2031, all members of the baby
boom generation—Canada’s largest birth cohort (born between 1946 and
1965)—will turn 65.1, 3, 4 As a result, both the number and proportion of seniors in
the population will climb.1, 4 After 2031, population aging is expected to continue,
but at a less rapid pace.4
Health Care in Canada, 2011: A Focus on Seniors and Aging
As early as 2015, the proportion of seniors in the population will surpass the
proportion of youth.4 The working-age segment of the population (those age
15 to 64) is projected to decrease over the next 25 years.4 At the same time,
the labour force participation rate is expected to rise, the result of sustained
population growth due to ascending birth rates and projected moderate
immigration levels.5
Figure 1: Composition of the Population, by Age, Canada, 1971 to 2051
Historical Data
Projected Data
80%
Proportion of Total Population
70%
60%
50%
40%
30%
20%
10%
0%
1971
1991
2010
2031
2051
Year
Age <15
Age 15–64
Age 65+
Notes
Population projections assume a medium population growth scenario based on historical growth and
related demographic factors, such as total fertility rate, life expectancy at birth, international immigration,
emigration and interprovincial migration.
Birth rates are projected to increase after 2031 as a result of rising fertility rates since 2002 and as
more immigrant women and women from birth cohorts following the baby boom generation become of
childbearing age. Higher-than-expected immigration levels into the future would also have the effect of
elevating birth rates and expanding the labour force; however, interpretation of this factor independent
of others that contribute to population growth dynamics is cautioned.
Sources
Statistics Canada 2010, population estimates, 1971 to 2010, and population projections, 2009 to 2036.
10
Chapter 1: A Profile of Canada’s Seniors Today and Into the Future
Defining Seniors
In Canada, age 65 is generally understood to be the defining age for seniors. 3, 6
It is at this age when many Canadians begin to receive social services, such as
government pensions.7 At one time, 65 was considered the mandatory age for
retirement in Canada; however, this is no longer the case in most provinces
and territories,8 with many people working well into their 60s and beyond.
The Organisation for Economic Co-operation and Development (OECD) also
defines seniors as age 65 and older, allowing for comparability across member
countries, although there is some variation.9
Among researchers and others, however, there is no true consensus on this
definition. Some argue that rising life expectancies worldwide mean that age 65
can no longer be regarded as the start of older age.10 They also assert that,
since seniors age differently, combining all people age 65 and older into one
cohort results in a group so diverse there is no longer a common experience
across it.11
Many of the analyses in this report are restricted to those age 65 and older.
Comparisons are made with younger adults and, where possible, with subgroups
of the age 65 and older cohort—those age 65 to 74, 75 to 84, and 85 and older.
Variation in Aging Across Canada
The populations of all provinces and territories across Canada are aging.
However, population aging has not been uniform across jurisdictions. The
Atlantic provinces currently have the highest proportions of seniors (ranging
from 15% to 16%), while the territories account for the lowest (3% to 8%). By
2031, the greatest increases will have occurred in both the Atlantic provinces
and in the territories.
11
Health Care in Canada, 2011: A Focus on Seniors and Aging
By 2031, the proportion of seniors will have nearly doubled in the Atlantic
provinces and nearly tripled in the territories. In absolute terms, the greatest
number of seniors will continue to reside in Ontario and Quebec, the most
populous provinces in Canada. In 2010, all provinces except Alberta had
population proportions of seniors within 2% of each other; by 2031, this
range will have increased to about 10% for all provinces.
Figure 2: Current and Projected Proportions of Seniors, by Province/Territory,
Canada, 2010 and 2031
Proportion of the Total Population Age 65+
35%
30%
25%
20%
15%
10%
5%
0%
B.C.
Alta.
Sask.
Man.
Ont.
Que.
N.B.
N.S.
P.E.I.
N.L.
Y.T.
N.W.T.
Nun.
Province/Territory
2010
2031
Note
Population projections assume a medium population growth scenario based on historical growth and
related demographic factors, such as total fertility rate, life expectancy at birth, international immigration,
emigration and interprovincial migration.
Sources
Statistics Canada 2010, population estimates, 1971 to 2010, and population projections, 2009 to 2036.
Future growth in Canada’s senior population is also expected to vary by
area. On average, Canada’s smaller cities and rural regions are projected
to experience faster population aging than larger cities and the regions
immediately bordering them. As younger adults leave to find work in urban
centres, rural areas are projected to have higher proportions of older residents,
although the majority of seniors will continue to live in urban centres.1, 5
The aging of rural populations will likely be compounded by the majority of
immigrants continuing to settle in urban areas.5
12
Chapter 1: A Profile of Canada’s Seniors Today and Into the Future
Population Aging Around the World
Canada’s population remains younger than those of many industrialized
countries, despite population aging.9 There are no benchmarks against which
to formally determine whether a population is “aged.” However, by comparison,
countries such as Japan and Italy may be considered aged societies, with
seniors accounting for more than one-fifth of their total populations in 2010
(23% and 21%, respectively) and expected to account for close to one-third
by 2031 (32% and 28%, respectively).9
In the early stages of the transition, Canada may look to other nations to
anticipate the economic impact of population aging.12 In 2010, Japan and Italy
had fewer working-age adults (2.63 and 2.96, respectively) to support every
senior, lower than the number for Canada (4.46) and the average for OECD
countries (4.12). i, 13 Although some suggest that this indicates a higher health
care cost burden for the working-age population in Japan and Italy than in
Canada, data on health expenditures suggests a different interpretation.
Despite its younger population, Canada had higher total health care spending,
both as a percentage of gross domestic product (10.3%) and per capita ii
($4,024), than Japan (8.5% and $2,878, respectively) or Italy (9% and $3,059)
in 2008.14
Changing Profile of Canada’s Seniors
Although most seniors are in the youngest age range of this group (65 to 74),
the proportion of the most elderly seniors (85 and older) is growing rapidly. In
2010, about 53% of seniors were between age 65 and 74, 33% were between
age 75 and 84 and 13% were 85 and older. This latter group accounted for 2%
of the total population of Canada in 2011.
In 2031, those age 85 or older will account for a similar proportion of all seniors
but 3% of the total population of Canada. By 2052, these proportions will have
nearly doubled: the eldest seniors (age 85 and older) will account for 24% of
all seniors and 6% of the total population. And after 2031, the proportion of the
youngest seniors (age 65 to 74) will decline.4
Most seniors are women, especially among the older age groups. For example,
women accounted for 52% of seniors age 65 to 74 and 60% of seniors age
75 and older in 2010. Women will continue to outnumber men into the future;
however, this gender split will become more even as the age gap in life
expectancy narrows for men and women.3
i.
ii.
The old-age support ratio compares the number of working-age adults (age 20 to 64) relative to the
number of seniors (65 and older).13 It does not adjust for labour force participation rates among seniors
or working-age adults.
Per capita data is in U.S. dollar purchasing power.
13
Health Care in Canada, 2011: A Focus on Seniors and Aging
Life Expectancy
Life expectancy at birth in Canada and worldwide has been increasing for
many decades.15 In particular, life expectancy at age 65 has been rising in most
developed countries.15 This is attributed to a combination of factors that impact
health status both before and after people reach age 65, including advances in
medical care, improved public health (such as decreased smoking rates), higher
educational attainment and per capita income and increases in total health
care spending.15, 16 In fact, research in Canada also shows a reduction in the
difference in income-related mortality for some diseases, including ischemic
heart diseases.17, 18
Life expectancy has continued to increase for Canadians of both
sexes since 1961. While life expectancy among women at age 65
remains greater than that for men, there is some evidence that this
gap is beginning to narrow.
Figure 3: Life Expectancy at Age 65, by Sex, Canada, 1961 to 2006
22
Additional Years of
Life Expectancy at Age 65
20
18
16
14
12
10
1961 1966 1971 1976 1981 1982 1983 1984 1985 1986 1991 1996 2001
2006
Year
Women
Men
Source
Organisation for Economic Co-operation and Development, OECD.StatExtracts > Health: Health Status, 2011
<http://stats.oecd.org/index.aspx>.
14
Chapter 1: A Profile of Canada’s Seniors Today and Into the Future
In 2006, Canadian women who had reached age 65 were expected to live
86.1 years on average, while men were expected to live 82.9 years. By 2036,
it is projected that women will live until age 87.3 and men until age 84.0.4 This
difference between the sexes in life expectancy at age 65 has persisted since
at least the early 1900s.19 Researchers have suggested that it is driven, in
part, by men’s historically higher exposure to modifiable risk factors, such as
smoking and alcohol consumption.15, 20 However, life expectancy at age 65 has
increased at a faster rate for men than for women since the late 1980s, due to a
sharp decline in cardiovascular mortality for men over this same period.15 As a
result, the gender gap in life expectancy has narrowed.
Disparity in Life Expectancy for
Canada’s Aboriginal Populations
While life expectancy is increasing for both men and women across Canada,
there remain distinct populations who are not experiencing equal gains. For
example, life expectancy among Inuit seniors is, on average, significantly lower
than that for the general Canadian population.21 Although most Aboriginal
Canadians continue to live in urban centres and have a diverse socio-economic
profile, many First Nations, Inuit and Métis communities are located in
geographically isolated areas and have higher levels of poverty than other areas
of Canada. 22, 23
Socio-Economic Status
Socio-economic status—defined as income and education—is among the
known non-medical or social determinants of health that also affects when and
how health care is used.24
Differences in life expectancy at age 65 were seen when socio-economic status
was taken into account. Compared with those from poorer neighbourhoods,
senior men living in Canada’s wealthiest neighbourhoods had longer
life expectancies. In 2000–2001, men age 65 and older in the highest
neighbourhood income tercile iii could expect to live 1.1 years longer than
senior men in the lowest tercile.25 In contrast, senior women from the wealthiest
neighbourhoods did not live longer than their counterparts in the poorest
neighbourhoods. In fact, they lived 0.2 years less on average.25 More research
is required to understand why patterns in life expectancy at age 65 differ for
men and women by socio-economic status.
iii. Neighbourhood income terciles are derived by dividing the range of incomes in neighbourhoods
belonging to a census enumeration area into three equal parts: lowest, middle and highest income.
15
Health Care in Canada, 2011: A Focus on Seniors and Aging
Generally, studies show that socio-economically disadvantaged seniors have
poorer health status than their wealthier and more educated counterparts,
although this effect lessens with increasing age.iv, 26 Older adults age 60 to 69
from lower socio-economic groups are less likely to engage in health-promoting
behaviours, such as screening for colorectal cancer.27 Older adults age 50
and older from lower socio-economic groups are also more likely to engage
in health-harming behaviours, such as smoking. 28 The reasons for these
behaviours are complex and the research in general is inconclusive for older
adults. Low-income seniors are also more likely to live in neighbourhoods with
fewer health-promoting features.26 And despite universal access to health care
in Canada, seniors with fewer personal resources, including health, wealth
and social support, are also more likely to experience barriers to accessing
health care.26
Income
Overall, seniors’ income from all sources has grown over time. Average total
income increased for both seniors familiesv and unattached seniors between
1998 and 2008.29, 30 As well, fewer Canadian seniors and seniors families were
considered low income or fell below low-income cut-offs between 1998 and
2007.31 Fewer seniors also relied on public income-security programs for
their income, such as Old Age Security (OAS) and the Guaranteed Income
Supplement (GIS). The proportion of seniors’ total income from the OAS and
the GIS declined between 1998 and 2008.32 Instead, more relied on retirement
savings and other income sources.vi, 32
Although income has increased generally across Canada, the income gap in
retirement between the sexes has remained. In 2008, the mean after-tax income
from all sources for women older than age 65 was 65% that of men, unchanged
from the mid-2000s. In 2008, this translated to an annual income difference of
$13,300 ($24,800 versus $38,100).32
iv. The lessening of this effect may be due, in part, to a survival effect for seniors of low income who are
also in good health. Low-income seniors in good health may be more likely to outlive their counterparts
in poor health and, therefore, may also increasingly comprise this socio-demographic group with age.
v. “Seniors families” are those in which the major income earner is age 65 and older.
vi. Caution must be used when interpreting these statistics. Changing characteristics of the financial system,
such as unemployment rates and the performance of investment markets, also impact these trends.
16
Chapter 1: A Profile of Canada’s Seniors Today and Into the Future
Health Status of Canada’s Seniors
Seniors are now living longer on average than they did a decade ago.15 For
health system planning, it is important to understand whether or not these
added years are lived in good health. Although life expectancy is a useful
indicator, it measures quantity—not quality—of life.33 Other measures of health
status can be used to better understand how healthy Canada’s seniors are
during these additional years of life.34 Two indicators with similar methodology
and inclusion and exclusion criteria—functional status and multi-morbidity—are
discussed here. vii Together, they illustrate that Canada’s seniors are generally
healthy well into their later years. They also show that the health status of
younger seniors appears more similar to that of adults younger than age 65.
Declines in health status and higher health care use are more likely to be driven
by chronic disease than by age itself.37
Functional Capacity
Functional capacity is an indicator of one’s ability to carry out everyday
tasks. It provides a measure of independence, which is of particular concern
to seniors’ health and quality of life. Functional capacity takes into account
both basic activities of daily living (ADLs)—walking, bathing, toileting, eating
and dressing—and instrumental activities of daily living (IADLs)—shopping,
housekeeping, food preparation, etc.34, 35
Overall, there is great variability in the reported limitations in functional capacity
of seniors, underscoring the diversity in health status within this large group. In
a 2008–2009 survey, the majority of Canadians younger than age 85 did not
report any limitations in functional capacity. However, by age 85, the majority
had at least mild limitations. The youngest group of seniors reported limitations
similar to those reported by adults age 45 to 64.
vii. These measures of disease and disability were chosen because they are based on comparable
survey instruments with similar methodology and sampling populations. As used here, chronic disease
comorbidity is a measure of chronic disease prevalence. Limitation in functional capacity is a proxy
measure for disability severity.
17
Health Care in Canada, 2011: A Focus on Seniors and Aging
With age, losses of functional capacity become more common and more
severe. Most people with a limitation in functional capacity younger than age
85 reported only mild limitations. However, one-quarter (25%) of all seniors
85 and older reported a moderate (15%), severe (5%) or total (5%) limitation in
functional capacity.
Figure 4: Self-Reported Functional Capacity Limitation, by Age Group, Canada,
2008–2009
60%
Mild Limitation
50%
Moderate Limitation
Severe Limitation
Proportion
40%
32%
Total Impairment
30%
20%
10%
0%
10%
2%
4%
45–64
19%
15%
6%
2%
5%
5%
65–74
75–84
85+
Age Group
Notes
Bar values for age groups 45 to 64, 65 to 74 and 75 to 84 that were less than 1% were not labelled.
All bar values were above zero.
Figure does not include data for the territories. Analyses exclude individuals living on Indian Reserves and
on Crown Lands, institutional residents, full-time members of the Canadian Forces and residents of certain
remote regions.
Data was collected between December 2008 and November 2009.
Source
Canadian Community Health Survey—Healthy Aging, 2008–2009, Statistics Canada.
The most common reported functional capacity limitation across all ages was
an inability to perform housework without assistance: 14% of all seniors were
unable to do so. Other common functional capacity limitations among seniors
included the inability to
•
•
•
Shop without assistance (10%);
Go places without help (10%); and
Prepare meals (5%).36
Inabilities to perform ADLs were rare in those age 84 or younger but became
more common over the age of 85. More than 1 in 10 seniors older than age 85
could not
•
•
•
18
Bathe or shower without help (15%);
Walk without help (11%); or
Use the washroom easily (10%).36
Chapter 1: A Profile of Canada’s Seniors Today and Into the Future
Multiple Chronic Conditions
In the 2008 Canadian Survey of Experiences With Primary Health Care, about
three out of every four Canadian seniors (76%) reported having at least 1 of
11 chronic conditions, viii compared with one in every two adults age 45 to 64
(48%). About one-quarter (24%) of seniors reported being diagnosed with three
or more of these conditions (known as multi-morbidity). With increasing age,
the likelihood of having at least one chronic condition also increased. However,
this likelihood did not increase for those older than age 84.37
Interestingly, older seniors, age 75 or more, did not always report higher rates
of health care use than younger seniors. Rather, higher utilization was reported
among those with a higher number of chronic conditions, regardless of age.37
This finding is supported by other research showing that, regardless of age,
the more chronic conditions seniors had, the less likely they were to report good
health. In 2009, 74% of seniors with only one chronic condition reported good
self-perceived health, compared with only 27% of those with four or more.38
Health Behaviours
Several factors can affect health status beyond functional capacity and chronic
conditions. Successful aging—the maintenance of physical and cognitive
function, and engagement with life—is at least partly within the control of
individuals through their lifestyle choices or health behaviours.26 Much research
has shown that socio-economic status affects lifestyle choices.
Healthy lifestyle choices have been shown to positively impact health and
quality of life into old age.39 For example, even in older age, choosing not to
smoke or stopping if already started,40 maintaining a healthy body weight and
exercising regularly can all help protect heart health.41 Overall, there were fewer
senior smokers in 2010 than in 1994–1995.3, 42 Obesity rates among seniors age
65 to 74 have also declined. In contrast, rates of obesity among seniors age 75
and older have risen, as has occurred in the general population age 1 to 64.43
Women age 75 or older are more likely to be obese than men of the same age,
in part because they are also more likely to be physically inactive.ix, 3
Rising rates of obesity and low levels of physical activity among adults and the
middle-to-eldest seniors threaten to increase chronic disease prevalence and
morbidity into the future. In particular, the risk of developing high blood pressure
and osteoarthritis is highly correlated with obesity.44 And physical inactivity
increases an individual’s susceptibility to a number of chronic conditions and
mental health problems.3
viii. The 11 chronic conditions are arthritis, asthma, cancer, chronic pain, depression, diabetes, emphysema
or chronic obstructive pulmonary disease (COPD), heart disease, high blood pressure, a mood disorder
other than depression and stroke.
ix. While obesity can result from physical inactivity, it can also reduce the possibility of engaging in
physical activity.3
19
Health Care in Canada, 2011: A Focus on Seniors and Aging
Conclusion
Both medical and non-medical determinants of health were profiled in this
chapter to illustrate that a wide range of factors have important effects on
seniors’ health and resource needs. Available data suggests that, overall,
today’s seniors are living longer than seniors from previous generations and
with improved health and functional status. The demographic shift to an older
population in Canada will mean that the number of seniors affected by chronic
conditions and functional limitations will likely grow, even if the proportion of
seniors affected remains the same.
Research has shown that the number of chronic conditions a person has is
more important than age in determining health care resource use.37 As such,
health promotion and disease prevention efforts may become increasingly
important as Canada’s population ages. Preventing, delaying or reducing the
severity of chronic conditions may not only enhance quality of life as people
age, but likely also help ease demand on limited health care resources.
Chapter 2: The Sustainability of Canada’s Health Care System summarizes
seniors’ current use of health care system resources. The relative contribution
of population aging to increases in public expenditures on health care is
provided. Taken together, this information can inform the debate about the
sustainability of Canada’s health care system, in light of the aging population.
20
Chapter 1: A Profile of Canada’s Seniors Today and Into the Future
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31. Statistics Canada, Income in Canada: 2007 (Ottawa, Ont.: Statistics
Canada, 2009).
32. A. Milan and M. Vézina, “Senior Women,” Women in Canada: A GenderBased Statistical Report (Ottawa, Ont.: Statistics Canada, 2011), catalogue
no. 89-503-X.
33. Statistics Canada, Life Expectancy for Overall Population. Comparable
Health Indicators 2004: Healthy Canadians (Online Definitions) (Ottawa,
Ont.: Statistics Canada, 2004), accessed from <http://www.statcan.gc.ca/
pub/82-401-x/2002000/considerations/hlt/4064222-eng.htm>.
34. K. Christensen et al., “Ageing Populations: The Challenges Ahead,”
The Lancet 374, 9696 (2009): pp. 1196–1208.
35. W. B. Applegate et al., “Instruments for the Functional Assessment of Older
Patients. Current Concepts in Geriatrics,” New England Journal of Medicine
322, 17 (1990): pp. 1207–1215.
36. Statistics Canada, 2008–2009 Canadian Community Health Survey—
Healthy Aging (public use microdata file [PUMF]) (Ottawa, Ont.:
Statistics Canada, 2011).
37. Canadian Institute for Health Information, Seniors and the Health Care
System: What Is the Impact of Multiple Chronic Conditions? (Ottawa, Ont.:
CIHI, 2011).
23
Health Care in Canada, 2011: A Focus on Seniors and Aging
38. P. L. Ramage-Morin et al., “Health-Promoting Factors and Good Health
Among Canadians in Mid-to-Late Life,” Health Reports 21, 3 (2010): pp. 1–9,
Statistics Canada catalogue no. 82-003-X.
39. L. Martel et al., “Healthy Aging,” Healthy Today, Healthy Tomorrow?
Findings From the National Population Health Survey (Ottawa, Ont.:
Statistics Canada, 2005).
40. J. A. Critchley and S. Capwell, Smoking Cessation for the Secondary
Prevention of Coronary Heart Disease (John Wiley & Sons, Ltd., 2009).
41. R. McPherson et al., “Canadian Cardiovascular Society Position
Statement—Recommendations for the Diagnosis and Treatment of
Dislipidemia and Prevention of Cardiovascular Disease,” Canadian Journal
of Cardiology 22, 11 (2006): pp. 913–927.
42. Statistics Canada, Health Indicator Profile, Annual Estimates, by Age Group
and Sex, Canada, Provinces, Territories, Health Regions (2007 Boundaries)
and Peer Groups, Occasional (CANSIM Table 105-0501) (Ottawa, Ont.:
Statistics Canada, 2010).
43. M. Tjepkema, “Measured Obesity,” Adult Obesity in Canada: Measured
Height and Weight (Ottawa, Ont.: Statistics Canada, 2004).
44. K. Wilkins, “Incident Arthritis in Relation to Excess Weight,” Health Reports
15, 1 (2011): pp. 23–37, Statistics Canada catalogue no. 82-003-X.
24
Although population aging
has contributed to increases in
public-sector health spending,
its impact to date has been
relatively modest.
Chapter 2
The Sustainability of Canada’s
Health Care System
Debate about the sustainability of the Canadian health care system has been
ongoing for several years. For many, it was brought to the forefront in 2002 with
the publication of Senator Kirby’s The Health of Canadians—The Federal Role1
and Commissioner Romanow’s Building on Values: The Future of Health Care
in Canada.2 These reports set the stage for the 2003 First Ministers’ Accord on
Health Care Renewal and the 2004 First Ministers’ 10-Year Plan to Strengthen
Health Care. As these agreements between the federal and jurisdictional
governments expire in 2014, sustainability once again is gaining prominence
in the public debate.
This chapter details the resources utilized—both physical and financial—
to provide a wide range of health care services across the country. It draws
on the definition of sustainability suggested by the Commission on the Future
of Health Care in Canada:
Sustainability means ensuring that sufficient resources are available
over the long term to provide timely access to quality services that
address Canadians’ evolving health needs.2
There has been a great deal of attention paid to the perceived impact
that Canada’s aging population will have on the sustainability of the health
care system.3–5 This chapter begins with a snapshot of seniors’ utilization
of hospital services—one of the largest components of the health care
system—to illustrate that, on average, seniors use more care than younger
adults. It then explores the degree to which the aging of the population has
contributed to increased costs over the last 10 years for hospitals, physicians
and drugs. Quantitative analysis of the role of aging as a cost driver allows
better understanding of its importance relative to other cost drivers. The results
can inform the debate about potential cost pressures related to Canada’s
aging population.
Health Care in Canada, 2011: A Focus on Seniors and Aging
While the analysis shows that aging has not been the major driver of increased
public-sector health care expenditures to date, the chapter concludes with
a discussion of whether the health care needs of an aging population may
become a bigger cost driver in the near future. The chapters that follow
present detailed information on health care needs and the services provided
as Canadians age, as understanding both needs and service delivery are key
to sustaining the health care system.
Seniors’ Use of Hospital Care
Of all the components of Canada’s health care system, hospitals receive the greatest
share (37.3%) of public-sector health care dollars.6 Compared with other age groups,
seniors use a disproportionate amount of hospital services. For example, although
they make up only 14% of the population,7 in 2009–2010, 40% of acute hospital stays
were for patients age 65 and older.i Seniors use hospital services not only more often
than other age groups but also in different ways.
Figure 5 shows comparative information on hospital use for seniors and
younger adults across different types of hospital care. Overall, in 2009–2010,
utilization rates for inpatient services, including acute, complex continuing
and rehabilitation care, were significantly higher for seniors than for non-senior
adults. And among seniors, utilization increased with increasing age for all care
types except outpatient services.
i.
28
Excludes obstetrical cases, cadaveric donors, non-Canadian residents and records with a most
responsible diagnosis for mental health (ICD-10-CA diagnosis code with a prefix of F or G30).
Chapter 2: The Sustainability of Canada’s Health Care System
Compared with rates for younger adults, the rate of hospital discharges for
seniors is higher for all care types examined. For inpatients, the discharge
rate per 100,000 seniors is 4.9 times higher for acute care, 22 times higher
for complex continuing care and 11.6 times higher for rehabilitation.
Figure 5: Rate of Hospital Discharges per 100,000 Population, by Type of Hospital
Care, Seniors Versus Non-Senior Adults, 2009–2010
Rate of Hospital Discharges per 100,000 Population
Type of Care
Adults
Age
20–64
Seniors
All Seniors
Age 65–74
Age 75–84
Age 85+
4,395
21,693
15,316
25,764
36,986
603
786
498
902
1,648
Inpatient Complex
Continuing Care**
45
991
401
1,207
2,804
Inpatient
Rehabilitation††
66
763
441
993
1,443
7,609
21,809
20,792
25,608
16,152
29,485
44,043
35,114
49,955
64,277
Acute
Inpatient*, §
Inpatient
Mental Health†, §
Outpatient‡, §
Emergency
‡, ‡‡
Notes
* Acute Inpatient population excludes obstetrical cases, cadaveric donors, non-Canadian residents and
records with a most responsible diagnosis for mental health (ICD-10-CA diagnosis code with a prefi x
of F or G30).
† Inpatient Mental Health population (Discharge Abstract Database and/or Hospital Morbidity Database
records) excludes obstetrical cases, cadaveric donors, non-Canadian residents, acute inpatient
records where the most responsible diagnosis is not a mental health diagnosis (ICD-10-CA diagnosis
code without a prefi x of F or G30) and facilities not designated as mental health or acute inpatient.
No exclusions applied to Ontario Mental Health Reporting System records.
‡ Outpatient and Emergency populations exclude non-Canadian residents.
§ Acute Inpatient, Inpatient Mental Health and Outpatient fully cover all provinces and territories.
** Inpatient Complex Continuing Care fully covers Ontario.
†† Inpatient Rehabilitation fully covers Ontario and partially covers Newfoundland and Labrador,
Nova Scotia, P.E.I., New Brunswick, Manitoba, Saskatchewan, Alberta and B.C.
‡‡ Emergency fully covers Ontario and Alberta and partially covers Nova Scotia, P.E.I., Manitoba,
B.C. and Yukon.
Sources
Discharge Abstract Database, Hospital Morbidity Database, National Ambulatory Care Reporting System,
Ontario Mental Health Reporting System, Continuing Care Reporting System and National Rehabilitation
Reporting System, 2009–2010, Canadian Institute for Health Information; Alberta Ambulatory Care
Reporting System, 2009–2010, Alberta Health and Wellness.
29
Health Care in Canada, 2011: A Focus on Seniors and Aging
Seniors are heavier users of hospital services and also stay longer once
admitted to hospital. For example, seniors’ overall average length of stay in
acute inpatient care is roughly 1.5 times that of non-senior adults (nine days
versus six). A similar pattern is seen in emergency department use, with
seniors having a 4-hour median stay compared with 2.5 hours among younger
adults. This may be due in part to seniors using emergency departments for
conditions that could be treated in other settings, such as primary care. For
example, in 2008–2009, 9% of all seniors’ visits to emergency departments in
Ontario were for ambulatory care sensitive conditions, compared with only 3%
for non-senior adults.8 Alternatively, owing to their advanced age and/or the
presence of comorbid conditions, seniors may be held longer for observation
to ensure that they are healthy enough for discharge. In contrast, in inpatient
complex continuing and rehabilitation care settings, seniors have shorter
lengths of stay than non-senior adults. ii Figure 6 provides a detailed breakdown
by type of care.
ii.
30
Patients who died in these institutions (about one-third of all patients) were included in the analysis.
Chapter 2: The Sustainability of Canada’s Health Care System
Seniors stay longer than younger adults in emergency departments and
in acute and mental health care settings. However, younger adults remain
longer in inpatient complex continuing and rehabilitation care, as well as in
outpatient settings.
Figure 6: Average Lengths of Stay, by Type of Care, Seniors Versus
Non-Senior Adults, 2009–2010
Average (Median) Overall Length of Stay
Type of Care
Seniors
Adults
Age 20–64
All Seniors
Age 65–74
Age 75–84
Age 85+
Acute Inpatient*
(Days)
6 (3)
9 (5)
8 (4)
9 (5)
10 (6)
Inpatient Mental
Health†, § (Days)
20 (8)
26 (16)
28 (15)
26 (18)
21 (18)
149 (31)
79 (29)
84 (29)
85 (30)
70 (28)
34 (23)
27 (20)
26 (17)
26 (19)
29 (23)
,§
Inpatient Complex
Continuing Care**
(Days)
Inpatient
Rehabilitation†† (Days)
Outpatient‡, § (Hours)
5.0 (4.0)
4.6 (3.1)
4.7 (3.1)
4.6 (3.0)
4.5 (3.0)
Emergency‡, ‡‡ (Hours)
n/a (2.5)
n/a (4.0)
n/a (3.3)
n/a (4.2)
n/a (5.3)
Notes
*
Acute Inpatient population excludes obstetrical cases, cadaveric donors, non-Canadian residents and
records with a most responsible diagnosis for mental health (ICD-10-CA diagnosis code with a prefi x
of F or G30).
† Inpatient Mental Health population (Discharge Abstract Database and/or Hospital Morbidity Database
records) excludes obstetrical cases, cadaveric donors, non-Canadian residents, acute inpatient
records where the most responsible diagnosis is not a mental health diagnosis (ICD-10-CA diagnosis
code without a prefi x of F or G30) and facilities not designated as mental health or acute inpatient.
No exclusions applied to Ontario Mental Health Reporting System records.
‡ Outpatient and Emergency populations exclude non-Canadian residents.
§ Acute Inpatient, Inpatient Mental Health and Outpatient fully cover all provinces and territories.
** Inpatient Complex Continuing Care fully covers Ontario.
†† Inpatient Rehabilitation fully covers Ontario and partially covers Newfoundland and Labrador,
Nova Scotia, P.E.I., New Brunswick, Manitoba, Saskatchewan, Alberta and B.C.
‡‡ Emergency fully covers Ontario and partially covers Nova Scotia, P.E.I., Manitoba, B.C. and Yukon.
n/a: not available; the emergency department length of stay was generated from the Emergency
Department Wait Time Indicators in CIHI Portal, which provides only the median length of stay.
Sources
Discharge Abstract Database, Hospital Morbidity Database, National Ambulatory Care Reporting System,
Ontario Mental Health Reporting System, Continuing Care Reporting System and National Rehabilitation
Reporting System, 2009–2010, Canadian Institute for Health Information; Alberta Ambulatory Care
Reporting System, 2009–2010, Alberta Health and Wellness.
31
Health Care in Canada, 2011: A Focus on Seniors and Aging
Seniors are heavy users of hospital services, measured not only by number of
visits but also by resource use during those visits. Resource Intensity Weights
(RIWs) are derived from hospital case cost data and serve as standardized
estimates of the relative resources used by hospital inpatients compared with
those used in a typical case.9 Hospital planning staff can use RIWs to gain a
better understanding of the relative costs associated with treating patients of
varying clinical and demographic backgrounds.
In 2009–2010, the overall average RIW for inpatients in acute care hospitals
was almost 70% higher for seniors, compared with non-senior adults (2.09
versus 1.23). In addition, for specific conditions and procedures, there are
significant differences in resource use between senior and non-senior acute
care patients. Figure 7 presents the relative resource use for the conditions
that seniors are most often treated for in acute care hospitals. Data is also
presented on several of the procedures identified as priorities under the 2004
First Ministers’ 10-Year Plan to Strengthen Health Care. Most jurisdictions have
targeted wait time reductions for these priority procedures. (See Chapter 6 for
further discussion on seniors and wait times.)
32
Chapter 2: The Sustainability of Canada’s Health Care System
In the graph below, bars that exceed 1.00 indicate conditions for which
acute care hospitals used, on average, more resources to treat seniors than
to treat non-senior adults. Conversely, bars that fall below 1.00 indicate
conditions for which acute care hospitals used, on average, fewer resources
to treat seniors than to treat non-senior adults.
Respiratory
Priority
Procedure
Figure 7: Comparison of Average Acute Care Hospital Resource Use in Treating
Seniors and Non-Senior Adults, for Selected Conditions and Procedures,
2009–2010
Unilateral Knee Replacement
Unilateral Hip Replacement
Influenza/Acute Upper Respiratory Infection
Chronic Obstructive Pulmonary Disease
Viral/Unspecified Pneumonia
Cardiac
Percutaneous Coronary Intervention
Heart Failure
Unstable Angina/Atherosclerotic Heart Disease
Angina (Except Unstable)/Chest Pain
Other
Myocardial Infarction/Shock/Arrest
Dementia
Palliative Care
0.00
1.00
Ratio of Average RIW of Seniors Versus Non-Senior Adults
Notes
The ratios presented are calculated as the average RIW of seniors divided by the average RIW of nonsenior adults, in acute inpatient care hospitals in Canada in 2009–2010.
All conditions and procedures listed except three—influenza/acute upper respiratory infection, cataract
surgery and dementia—are among the top reasons for seniors being in acute inpatient care in 2009–2010.
Cataract surgery was the top day procedure performed on seniors. See Chapter 6 for further information.
Data was grouped using the CMG+ 2011 methodology.
Sources
Discharge Abstract Database, Hospital Morbidity Database, 2009–2010, Canadian Institute for
Health Information.
33
Health Care in Canada, 2011: A Focus on Seniors and Aging
In addition to using more hospital care than other segments of the population,
seniors are high users of several other sectors of Canada’s health care system,
including the following:
•
Continuing care: In 2009–2010, 95% of people in residential care and 85%
of people in hospital-based continuing care were age 65 and older;10
•
•
Home care: In 2009–2010, 82% of home care clientsiii were age 65 and older;11
•
Prescription drugs: In 2009, provincial and territorial governments spent an
average of $1,311 per senior compared with $170 per adult age 20 to 64 for
prescription drugs (this difference is explained, in part, by seniors’ heavier
reliance on public sources of financing while younger adults use more private
insurance and out-of-pocket payments);6 and
Family physicians: In 2009, the share of seniors who frequently (10 times
a year or more) visited their family physician was almost double the share
of frequent visitors among non-senior adults iv (9.7% versus 5.5%).12
Seniors are also more dependent on income and social support provided by
governments at all levels. According to Statistics Canada, in 2008, seniors
families reported median government transfers of $24,100, compared with
$2,900 for all other families.13
Greater and more resource-intensive service use translates into increased
health spending incurred by the provincial and territorial governments. As
shown above, seniors are more frequent users of several sectors of Canada’s
health system, and their pattern of use is different compared with that of
other age groups. These, coupled with the expected growth in both number
and proportion of seniors in Canada’s population,14 highlight the importance
of understanding the impact that population aging has on increases in health
expenditures. To help inform the debate, the following section provides detailed
information on per capita health spending for two groups: seniors and younger
adults age 20 to 64. In addition, an analysis is presented of the relative
contribution of aging to increases in public-sector health care spending over
the past 10 years.
iii. Based on available data from the Home Care Reporting System.
iv. Adults age 18 to 64.
34
Chapter 2: The Sustainability of Canada’s Health Care System
Per Capita Spending on Seniors
In 1998, total provincial and territorial government per capita health expenditure
on Canadians age 65 and older ($6,374) was five times greater than that for
adults age 20 to 64 ($1,282). Eleven years later, it was 4.5 times greater: $11,196
compared to $2,494.6 While the ratio was relatively stable for the first six years of
this trend, it dropped sharply between 2004 and 2009 (see Figure 8).
Overall, the ratio of per capita health spending on seniors to younger
adults decreased between 1998 and 2009. The decline was most noticeable
between 2004 and 2009.
Figure 8: Ratio of Provincial/Territorial Government per Capita Health Spending on
Seniors Versus Non-Senior Adults, 1998 to 2009
Ratio of Provincial/Territorial Government Spending
per Senior Versus Non-Senior Adult ($)
5.2
5.0
4.8
4.6
4.4
4.2
4.0
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
Note
Mostly, provincial and territorial governments pay for health care provided to seniors, including prescription
drugs. Younger adults are more reliant on private sources, such as insurance and out-of-pocket payments.
Source
National Health Expenditure Database, 2011, Canadian Institute for Health Information.
35
Health Care in Canada, 2011: A Focus on Seniors and Aging
Differential annual growth rates in major spending categories may explain,
at least in part, why the ratio of per capita spending on seniors to younger
adults has recently decreased. Over the past 11 years, per capita provincial
and territorial government drug spending on younger adults grew faster than
spending on seniors. Even though the reverse was true for per capita hospital
and physician spending, the total per capita growth rate for non-senior adults
surpassed that for seniors. Similarly, as a share of total public-sector health
spending, expenditures on institutions other than hospitals (such as long-term
care institutions) was actually declining—forecast at almost 10% in 2010,
compared with 12% in 1999.15
Unadjusted for inflation, total per capita spending on seniors grew, on average,
5.3% annually during this period. The growth rate of total per capita spending
on non-senior adults was higher, at 6.2% (see Figure 9).
From 1998 to 2009, provincial/territorial per capita drug spending and total
health spending on seniors increased at a slower pace than spending on
non-senior adults. However, per capita hospital and physician spending on
seniors increased faster.
Figure 9: Average Annual Rates of Growth in per Capita Provincial/Territorial
Government Health Spending on Hospitals, Physicians, Drugs and
Total, 1998 to 2009
12%
Average Annual Growth Rate
10%
8%
6%
4%
2%
0%
Hospitals
Physicians
Seniors (Age 65+)
Drugs
Non-Senior Adults (Age 20–64)
Source
National Health Expenditure Database, 2011, Canadian Institute for Health Information.
36
Total
Chapter 2: The Sustainability of Canada’s Health Care System
Contribution of Population Aging to Increases in
Public-Sector Health Expenditures in Recent Years
After adjusting for inflation, public-sector health spending has increased
considerably faster than public revenues over the past 10 years: 4.3% versus
only 2.3%, annually.16 To better understand what is driving health care costs,
CIHI’s report Health Care Cost Drivers: The Facts provides a retrospective
analysis of macro health care cost drivers between 1998 and 2008.17 It explores
the underlying drivers of specific spending categories, including hospitals,
physicians and prescription drugs. The study’s results can contribute to the
debate about the future fiscal sustainability of the health care system in the
context of Canada’s aging population. The results show that, overall, although
population aging contributed to spending increases, its impact to date has been
relatively modest.
The study first looked at drivers of increases in public-sector health
expenditures overall. The average annual growth rate in public-sector health
spending between 1998 and 2008 was 7.4%.17 Explanatory factors that were
included in the study’s analytical framework included population growth, aging,
price and volume effects. Their relative contributions to the overall growth in
spending were assessed. Population growth added 1% to public-sector health
spending each year, while population aging was a small contributor, adding
0.8% annually.17 Price effects were a more significant driver.
Although there are no measures of total health sector inflation, it can be
perceived in relation to general inflation. Inflation for the entire economy
averaged 2.8% per year during this period.17 However, measures of the growth
in labour compensation in the health sector—a major input into the provision of
health care—exceeded this rate. Finally, the contribution of a residual, “other”
category, was 2.8% each year.17 The “other” category includes factors such
as increases in service utilization, changes in technology and health sector
inflation above the rate of general inflation.
37
Health Care in Canada, 2011: A Focus on Seniors and Aging
From 1998 to 2008, population growth and aging contributed differently to
public-sector health spending growth in different jurisdictions. The impact
of population aging relative to population growth was more pronounced in
Atlantic Canada and Quebec.
Figure 10: Contribution of Population Growth and Aging to Growth in Provincial/
Territorial Government Health Spending, by Individual Province and
Territory, 1998 to 2008
3.0%
2.5%
Percentage Increase
2.0%
1.5%
1.0%
0.5%
-1.0%
Canada
Y.T.
N.L.
P.E.I.
N.S.
N.W.T./Nun.
-0.5%
N.B.
Que.
Ont.
Man.
Sask.
Alta.
B.C.
0.0%
Population Aging
Population Growth
Source
Canadian Institute for Health Information, Health Care Cost Drivers: The Facts. (Ottawa, Ont.: CIHI, 2011).
Overall, the cost drivers study found substantial variation across jurisdictions
in the contributions of population aging and growth to total public-sector health
spending (see Figure 10). The impact of population aging relative to growth was
more apparent in the Atlantic region and Quebec than in Ontario and Western
Canada. Details on drivers of cost increases specific to hospitals, physicians
and prescription drugs are presented below.
38
Chapter 2: The Sustainability of Canada’s Health Care System
Drivers of Public-Sector Spending on Hospitals
Total public-sector spending on hospitals grew steadily between 1998 and
2008, adding on average about 6.7% a year. Population growth and population
aging each contributed only 1% per year. The biggest contributing factor to
the growth in spending on hospitals was price effects. Labour compensation
accounts for about 60% of hospital budgets. The growth in hospital wage rates
exceeded annual general price inflation during the period.17 Trends in shifting
from inpatient to outpatient procedures helped mitigate utilization as a driver.
Drivers of Public-Sector Spending on Physicians
The average annual growth of roughly 6.7% in spending on physicians was
explained by two major factors. One was the average annual growth of 3.6%
in fees for physician services. This was due partially to general inflation over the
10-year period and partially to a rise in fees for service, which outpaced inflation.
Over the study period, physicians’ compensation grew faster than the average
pay in the economy and also faster than pay in the health and social sector.17
The other factor responsible for growth in public-sector spending on physicians
was Canadians’ increasing use of physician services. Utilization per capita
adjusted for aging accounted for average annual increases of 1.5%. For
example, the number of consultations and diagnostic and therapeutic services
per 100,000 population provided by medical specialists increased notably. From
1998–1999 to 2008–2009, consultations increased by 16%; diagnostic and
therapeutic services increased by 49%. For surgical specialists, consultations,
major surgery and diagnostic and therapeutic services all showed higher-thanaverage rates of increase.18
In addition to these two main factors, growth in population (1%) and population
aging (0.6%) contributed modestly to the total growth in public-sector spending
on physicians.17 Spending on physicians for treating seniors (unlike spending
on other major categories) grew faster than that for the general population
because of changes to fee schedules. Between 1998 and 2008, a number of
jurisdictions implemented higher fees or fee premiums for consultations and/or
visits by seniors. Age premiums v contributed to the rising cost of visits to family
physicians in all provinces and territories.18
v.
An age premium is the difference between a regular physician fee and a higher fee for consultation
and/or visit by a senior.
39
Health Care in Canada, 2011: A Focus on Seniors and Aging
Drivers of Public-Sector Spending on Prescription Drugs
Between 1998 and 2007, retail spending on prescription drugs in Canada grew
from $8 billion to $19 billion,19 an average annual growth rate of 10.1%. In 2010, just
less than half of spending for prescription drugs (forecast at 46%) came from the
public purse,vi a share that has grown over the last decade.19 The main cost driver
was growth in the volume of drugs consumed by Canadians, which increased
spending at an average annual rate of 6.2%. For example, among five major
drug classes profiled, volume increases in spending on cholesterol-lowering and
gastrointestinal drugs accounted for average annual increases of 12.9% and 8.4%,
respectively. For both drug classes, the rapid growth in consumption was due, at
least in part, to changes in treatment guidelines.19
Changes in drug mix were responsible for average annual growth in drug
spending of 2.0% between 1998 and 2007. Mix effects include both changes
in the selection of drug type (for example, ACE inhibitors versus beta-blockers
to treat hypertension) and individual drugs within drug classes (for example,
ramipril use among ACE-inhibitor users), after adjusting for population aging.19
Initial use of higher-cost drugs, or switching from lower- to higher-cost drugs,
can both contribute to the mix effect.
Population growth and population aging each contributed 1% to the growth in
retail spending on prescription drugs from 1998 to 2007.17 But their individual
effects were substantially smaller than those of either drug volume or mix. It is
also worth noting that, on average, prices of existing drugs decreased over the
study period. The contribution of price changes to the total growth in retail drug
spending was negative.
The cost driver analyses above highlight that, to date, aging has had a relatively
modest effect on increases in public-sector health expenditures. However,
the impact of aging does vary across spending categories and, for certain
categories, it may be greater than the overall trend. For example, between
1998 and 2008, aging was responsible for 2.3% of average annual growth
in spending on long-term institutional care (see Figure 11).17
vi. Not including drugs prescribed to hospital inpatients.
40
Chapter 2: The Sustainability of Canada’s Health Care System
A recent CIHI study examined the drivers of increases in four categories
of public-sector health expenditure. Aging was found to be a stable and
modest driver of increases in public-sector health expenditure for hospitals
(1%), physicians (0.6%) and drugs (1%) over the study period. Aging had a
greater effect on expenditures for long-term institutional care.
Figure 11: Contribution of Aging to Average Annual Growth for Hospitals,
Physicians, Drugs and Long-Term Care Institutions, 1998 to 2008
10%
9%
8%
Average Annual Growth
7%
8.1%
6%
5%
4%
4.7%
2.1%
5.1%
3%
2.3%
2%
1.0%
1.0%
0.6%
1%
1.0%
1.0%
1.0%
1.0%
0%
Hospitals
Physicians
Drugs*
Population Growth
Population Aging
Long-Term
Institutional Care
Other
Note
* The time frame for growth in public-sector spending on drugs is 1998 to 2007.
Source
Canadian Institute for Health Information, Health Care Cost Drivers: The Facts. (Ottawa, Ont.: CIHI, 2011).
41
Health Care in Canada, 2011: A Focus on Seniors and Aging
Contribution of Population Aging to Increases in
Public-Sector Health Expenditures in the Near Future
Canada is not the only country with an aging population. Because of
its relevance globally, the Organisation for Economic Co-operation and
Development (OECD) has developed projections of the impact of population
aging on health spending in its member countries. The projection methodology
used by the OECD is different from that used by CIHI in that it estimates the
share of gross domestic product (GDP) allocated to health and long-term care.
CIHI’s report Health Care Cost Drivers: The Facts focused on public-sector
health expenditure, which represents about 70% of total health spending in
Canada.15 Although the OECD projections are not directly comparable with
those from the cost driver analyses, they do allow for international comparisons
of the possible future effects of aging on health system sustainability.
In 2010, the OECD projected an increase in spending on aging-related health
and long-term care in selected member countries from 2010 to 2025. The
OECD projected that, during this time frame, the share of Canadian GDP spent
on health and long-term care will increase by 1.9 percentage points vii (pp).20
Health and long-term care will contribute 1.4 pp and 0.5 pp, respectively, to this
increase (see Figure 12).
vii. Percentage points are the unit for the arithmetic difference in two percentages.
42
Chapter 2: The Sustainability of Canada’s Health Care System
Projected increases in the share of GDP diverted toward health and
long-term care spending vary substantially among 19 comparable OECD
countries. Results show that Canada’s total projected age-related increase
of 1.9 percentage points is similar to the overall 1.8 percentage point average
across the countries included.
Figure 12: Projected Changes (in GDP Percentage Points) in Health and Long-Term
Care Spending, 19 Selected OECD Countries, 2010 to 2025
3.0
GDP Percentage Points
2.5
2.0
1.5
1.0
0.5
Japan
Ireland
Greece
Italy
Spain
Luxembourg
Canada
Finland
New Zealand
Netherlands
Germany
Portugal
Austria
United Kingdom
United States
France
Belgium
Sweden
Australia
0.0
OECD Country
Health Care
Long-Term Care
Source
Organisation for Economic Co-operation and Development, OECD Economic Outlook, Vol. 2010/2
(Paris, France: OECD, 2010).
In absolute terms, the projected increase is not insignificant. In dollar terms, 1.9 pp
of GDP would equate to about $30.9 billion in 2010, or $905 per Canadian.21, 22
This amount would translate approximately to a 1.5% average annual increase
in public health expenditure. Canada differs only slightly from other comparable
countries in that 1.9 pp is just above the 1.8 pp average for the 19 OECD countries
included.20 The projected total age-related spending increases range from 0.9 pp
of GDP in Australia to 2.7 pp in Japan.
43
Health Care in Canada, 2011: A Focus on Seniors and Aging
The projections of growth in health and long-term care spending are influenced
by demographic variables such as fertility rates and migration estimates. Some
demographic variables are particularly important to the Canadian context, such
as the old-age support ratio. This is the ratio of the number of working-age
adults (those age 20 to 64) to the number of seniors (those age 65 and older)
in a given population. A higher ratio means that more working-age adults are
available to support each senior. viii In 2010, Canada had a favourable position
on this measure: there were 4.46 working-age adults for every Canadian senior;
the OECD average was 4.12. 23 However, by 2025, Canada is expected to have
only 2.84 working-age adults per senior, while the OECD average will be 3.00.23
Uneven changes in the old-age support ratio across OECD countries may
explain, at least in part, why growth in health and long-term care spending in
Canada is expected to be above average. The aging of the Canadian population
is expected to occur faster than in many other countries, not including Japan.
In Canada, the proportion of persons age 65 and older is expected to go from
12% to 22% in 33 years, while the same transition will take 69 years in the
United Kingdom, 61 years in France, 54 years in Germany and more than
50 years in the U.S. The reason for the faster rise in proportion is because
Canada had a strong baby-boom in the 1950s and 1960s, followed by a sharp
decline in fertility rates.24
viii. However, this measure used by the OECD has a limitation: it does not account for labour force
participation rates among seniors or working-age adults.
44
Chapter 2: The Sustainability of Canada’s Health Care System
Conclusion
This chapter has shown that seniors are relatively high users of many health
care services. For example, utilization rates for inpatient services, including
acute, complex continuing and rehabilitation care, were significantly higher
for seniors than for younger adults. And among seniors, hospital utilization
increased with age. The majority of Canadians receiving residential care and
hospital-based continuing care were seniors. This group was also significantly
more likely to be taking prescription medication and visiting family physicians,
in comparison with younger adults. As a result of this greater use, per capita
public-sector health care spending on seniors has been higher than spending
on non-senior adults, although there is some evidence to suggest that the gap
has narrowed in recent years.
Considering such findings, as Canada’s population enters a period of relatively
rapid aging, many have called into question the ongoing sustainability of
Canada’s health care system. Analyses of the drivers of increases in publicsector health expenditures over the last decade showed that the contribution
of aging has been relatively modest. To date, system-level cost drivers such as
inflation and increased utilization have played bigger roles in health spending
increases. However, projections from the OECD suggest that, between now and
2025, population aging will have a bigger impact on health and long-term care
spending in Canada relative to its average impact across OECD countries.
The health care system’s sustainability cannot be determined only by
calculating future revenues and expenditures. Priorities identified by Canadians
must also be taken into account. Health system stakeholders—including policymakers, health care providers, researchers and even the general public—have
become involved in the discourse. 25, 26 Such calls to work toward addressing
sustainability are not new, as experts have been raising population aging as
an issue for many years.
45
Chapter 2: The Sustainability of Canada’s Health Care System
References
1. M. J. L. Kirby, The Health of Canadians—The Federal Role. Volume
Six: Recommendations for Reform (Ottawa, Ont.: The Standing Senate
Committee on Social Affairs, Science and Technology, 2002).
2. R. J. Romanow, Building on Values: The Future of Health Care in Canada—
Final Report (Saskatoon, Sask.: Commission on the Future of Health Care
in Canada, 2002).
3. H. Mackenzie and M. Rachlis, The Sustainability of Medicare (Ottawa, Ont.:
The Canadian Federation of Nurses Unions, 2010).
4. Canadian Health Services Research Foundation, Myth: Canada’s System
of Healthcare Financing Is Unsustainable (Ottawa, Ont.: CHSRF, 2007).
5. M. Lee, How Sustainable Is Medicare? (Ottawa, Ont.: Canadian Centre
for Policy Alternatives, 2007).
6. Canadian Institute for Health Information, National Health Expenditure
Trends, 1975 to 2011 (Ottawa, Ont.: CIHI, 2011).
7. Statistics Canada, Annual Demographic Estimates: Canada, Provinces
and Territories (Ottawa, Ont.: Statistics Canada, 2010).
8. Canadian Institute for Health Information, Seniors’ Use of Emergency
Departments in Ontario, 2004–2005 to 2008–2009 (Ottawa, Ont.:
CIHI, 2010).
9. Canadian Institute for Health Information, DAD Resource Intensity Weights
and Expected Lengths of Stay for CMG+ 2008 (Ottawa, Ont.: CIHI, 2008).
10. Canadian Institute for Health Information, Quick Stats: Continuing Care
Reporting System, 2009–2010 (Ottawa, Ont.: CIHI, 2011).
11. Canadian Institute for Health Information, Quick Stats: Home Care
Reporting System, 2009–2010 (Ottawa, Ont.: CIHI, 2011).
12. Statistics Canada, Canadian Community Health Survey 2009—Annual
Component (Ottawa, Ont.: Statistics Canada, 2009).
47
Health Care in Canada, 2011: A Focus on Seniors and Aging
13. Statistics Canada, Income of Canadians, last modified 2011, accessed on
September 13, 2011, from <http://www.statcan.gc.ca/daily-quotidien/100617/
dq100617c-eng.htm>.
14. Statistics Canada, Population Projections for Canada, Provinces and
Territories, 2009 to 2036 (Ottawa, Ont.: Statistics Canada, 2010).
15. Canadian Institute for Health Information, National Health Expenditure
Trends, 1975 to 2010 (Ottawa, Ont.: CIHI, 2010).
16. Statistics Canada, Consolidated Federal, Provincial, Territorial and Local
Government Revenue and Expenditures, Annual (Dollars) (CANSIM Table
385-0001), last modified 2011, accessed on July 27, 2011, from <http://
cansim2.statcan.gc.ca/cgi-win/cnsmcgi.exe?Lang=E&amp;CNSM-Fi=CII/
CII_1-eng.htm>.
17. Canadian Institute for Health Information, Health Care Cost Drivers:
The Facts. (Ottawa, Ont.: CIHI, 2011).
18. Canadian Institute for Health Information, “Health Care Cost Drivers:
Physician Expenditure Trends Perspective” (PowerPoint presentation)
(Ottawa, Ont.: CIHI, 2011).
19. Canadian Institute for Health Information, “Health Care Cost Drivers: Drug
Expenditure Trends Perspective” (PowerPoint presentation) (Ottawa, Ont.:
CIHI, 2011).
20. Organisation for Economic Co-operation and Development, OECD
Economic Outlook, Vol. 2010/2 (Paris, France: OECD, 2010), accessed
from <http://dx.doi.org/10.1787/eco_outlook-v2010-2-en>.
21. Statistics Canada, Gross Domestic Product, Expenditure-Based, Annual
(CANSIM Table 380-0017) (Ottawa, Ont.: Statistics Canada, 2011),
accessed on August 23, 2011, from <http://www40.statcan.ca/101/cst01/
ECON04-eng.htm>.
22. Statistics Canada, Canada’s population estimates (Ottawa, Ont.: Statistics
Canada, 2011).
23. Organisation for Economic Co-operation and Development, Pensions at
a Glance 2011: Retirement-Income Systems in OECD and G20 Countries
(Paris, France: OECD, 2011), accessed from <http://dx.doi.org/10.1787/
pension_glance-2011-en>.
48
Chapter 2: The Sustainability of Canada’s Health Care System
24. W. Smith, What’s New, What’s Different About Canadian Demographics?
(unpublished presentation: Statistics Canada, 2011).
25. Canadian Medical Association, Health Care Transformation in Canada
(Ottawa, Ont.: CMA, 2010).
26. The Conference Board of Canada, The Canadian Alliance for Sustainable
Health Care, last modified 2011, accessed on June 6, 2011, from
<http://www.conferenceboard.ca/CASHC/default.aspx>.
49
In 2009, about two-thirds of
seniors on public drug programs
were claiming 5 or more drug
classes, and nearly one-quarter
were claiming 10 or more.
Chapter 3
Primary Health Care and Prescription
Drugs—Key Components to Keeping
Seniors Healthy
The number of chronic conditions—not age—accounts for the greater use of
primary health care services among seniors.1 Chronic disease management
will therefore become increasingly important as the number and proportion of
Canada’s seniors grow over the next 25 years.
As they age, many seniors develop a progressively more complex mix of
health conditions. They will likely need both strong primary health care and
appropriate prescription medications to help manage these conditions, and
to protect their health for as long as possible.
The information in this chapter will show how two key components of Canada’s
health care system—primary health care and prescription medications—are
currently being used to support seniors in managing their chronic conditions.
Providing Primary Care to Seniors With Multiple
Chronic Conditions
Primary health care involves both the treatment of illness and health promotion
and prevention activities. It is often the first point of contact with the health
system. In most cases, primary health care encompasses a wide range of
medical and allied health services and providers. Primary health care providers
may also help patients navigate through the continuum of care, by providing a
system coordination function. 2
Family Physicians
Family physicians are the most common point of first contact for primary health
care services. And seniors are more likely than younger Canadians to have
a family physician. In 2009–2010, the majority of those older than 65 (95%)
reported having a regular family physician, compared with 83% of non-senior
adults3 (see Figure 13).
Health Care in Canada, 2011: A Focus on Seniors and Aging
The percentage of seniors with a regular family physician ranges across
the provinces from 93% in Quebec to 97% in Ontario, Nova Scotia and P.E.I.
Across the country, younger Canadians were consistently less likely than
seniors to report having a family physician.
Figure 13: Percentage of the Population With a Family Physician, by Age Group,
Province and Territory, Canada, 2009–2010
100%
Percentage With a Family Physician
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
B.C.
Alta.
Sask.
Man.
Ont.
Que.
N.B.
Non-Senior Adults (Age 20 to 64)
N.S.
P.E.I.
N.L.
Y.T. N.W.T.* Canada
Senior Adults (Age 65+)
Notes
* Interpret with caution.
Figure does not include data for Nunavut.
Based on Canadian household population age 12 and older.
Excludes individuals living on Indian Reserves and Crown land, institutional residents, full-time members of
the Canadian Forces and residents of certain remote regions.
Source
Canadian Community Health Survey Annual Component, 2009–2010, Statistics Canada.
Although the percentage of Canadian seniors with a family physician is high,
5% (approximately 220,000 seniors in 2010) remain without one.3 In 2009, 61%
of seniors without a family physician accessed care through a clinic and 17%
went to the emergency department. The majority of others visited a community
health centre or used telehealth.3 Of seniors without a family physician, 39%
reported that it was because their regular doctor had moved or retired. Almost
one-fifth (18%) stated that they could not find a family physician in their area
who was taking new patients. Almost one-third (30%) said that they had not
tried to find one.3
52
Chapter 3: Primary Health Care and Prescription Drugs—Key Components to Keeping Seniors Healthy
Access to Geriatricians
Geriatricians specialize in the conditions, treatments and prevention strategies
specific to seniors.4 In 2000, there were 144 geriatricians in all of Canada. In 2003,
The National Advisory Council on Aging raised concerns about the relatively low
numbers of these specialists.5 By 2009, the number of geriatricians had risen to
228,6 but it remains below the more than 500 geriatricians that some experts
believe are needed to meet the needs of all of Canada’s seniors.5
There is wide variability in rates of geriatricians across jurisdictions. In 2009,
Nova Scotia had the highest at 6.8 per 100,000 seniors age 65 and older.
There are currently no geriatricians practising in the territories.
Several methods of fostering interest in geriatrics at Canadian medical schools
have been developed, including requiring medical students to interact with
seniors more often during their training.7 Such efforts may be working, as
the number of medical doctors entering geriatrics training increased by 27%
between 2005 and 2010.8, 9
Having a regular family physician may help to ensure that seniors’ primary
health care needs are met. But having a family physician does not necessarily
ensure timely access to that primary care. Less than half of surveyed
Canadians reported same- or next-day access to a doctor or nurse when
they needed care. One-third reported waiting six days or longer for an
appointment—the longest time reported among the 7 developed countries
included in the study.10
53
Health Care in Canada, 2011: A Focus on Seniors and Aging
A Team-Based Approach to
Accessing Primary Health Care
In 2004, as part of the 10-Year Plan to Strengthen Health Care
Care, the first
ministers committed to ensuring that 50% of Canadians have 24/7 access to
multidisciplinary teams for primary health care by 2011.11 Recognizing the need
to prevent and manage chronic conditions, especially with an aging population,
governments emphasized the development of multidisciplinary teams and the
importance of health promotion, disease and injury prevention and chronic
disease management.12
In 2005, family health teams were implemented in Ontario and serve as one
example of a multidisciplinary, patient-centred model of primary health care
delivery.13 Part of the family health teams’ vision is to help patients navigate
the health care system by providing continuity of care.14 As of August 2010,
approximately 200 family health teams were providing care to almost
3 million Ontarians.15
Family health teams can include family physicians, nurse practitioners,
registered nurses, dietitians and social workers. These, as well as other
professionals, work collaboratively to provide a spectrum of health care
services, especially for those without a regular doctor.15, 16 While specific
services may vary based on community needs and composition of individual
teams, all family health teams must provide a core set of services, including
•
•
•
•
•
Health assessments, diagnosis and treatment;
Primary mental health care;
Patient education and preventive care;
Primary palliative care; and
Support for hospital, home and long-term care homes.17
In addition, all offer 24/7 response, care coordination and referral services.18
54
Chapter 3: Primary Health Care and Prescription Drugs—Key Components to Keeping Seniors Healthy
Other Primary Care Providers
Beyond family physicians, there are many health professionals that regularly
provide primary care to Canada’s seniors—dentists, for example. Experts have
suggested that the role of dentists in maintaining seniors’ health is at times
overlooked. Lack of appropriate oral care can contribute to serious declines
in seniors’ health status.19 In 2008–2009, nearly half (44%) of all seniors had
not visited a dental professional in the previous year, compared with just more
than a quarter (27%) of those age 45 to 64. Fourteen percent of seniors who
responded to the survey had difficulty chewing hard foods—a difficulty that
increased with age, affecting 19% of those age 85 and older.20 Such problems
can in turn affect nutrition, body weight and the progression of many diseases.19
Visits to some other primary health care providers remained relatively low.
Seniors visit psychologists, social workers and alternative providers less often
than younger adults.20
55
Health Care in Canada, 2011: A Focus on Seniors and Aging
Integration in Delivering Care
Many experts are calling for Canada’s health care system to provide a more
integrated approach to care, providing services across the continuum in a
coordinated way. One example of a program that takes an integrated approach
is the Winnipeg Regional Health Authority’s Geriatric Program Assessment
Teams (GPAT).
In Manitoba, six GPATs have been established since 1999, with one assigned
to each main emergency department in the Winnipeg Regional Health Authority
(WRHA). Comprised of clinicians with geriatric-specific training, the teams do
comprehensive in-home assessments with at-risk seniors to gauge their health and
well-being. A range of supports, such as home care or help in taking medications,
are put in place when needed. The goal is to keep seniors safe, healthy and
independent while controlling health care costs through reduced emergency
department visits and delayed moves to residential care.
Previously, referrals for home health care or home support services were made
through primary care providers, so those without a family doctor often fell through
the cracks. GPAT referrals can come from anyone who is concerned about a
senior—a doctor, relative, banker or police officer. The teams receive about 2,200
referrals annually. Each assessment takes approximately 90 minutes and is
reviewed with a geriatrician. Recommendations are wide-ranging and have
included modifying the environment, changing medications and revoking driver’s
licences. After review, recommendations are sent to the client’s family physician.
“The system here could not function without GPATs now. It’s filled the niche so
appropriately,” says Jo-Ann Lapointe McKenzie, WRHA’s program director of
rehabilitation and geriatrics.
An internal audit in March 2008 by the Manitoba Centre for Health Policy
revealed that Winnipeg had the lowest overuse of medication in the province,
while Accreditation Canada recently deemed the GPAT program a leading
practice in the country.
For seniors with complex needs that go beyond GPAT’s ability to meet them,
the region created PRIME in 2009. Designed for the frailest seniors committed
to remaining at home, PRIME aims to meet the full range of care needs. Each
participant has a case manager and weekly health monitoring. Home visits to
follow-up on new medications or other health issues ensure that clients are
managing well. Participants can also call an after-hours phone line with
questions or concerns.
Lapointe McKenzie says that one man in the program used to go to the
emergency department 30 to 40 times a month because of anxiety. “Now
he never goes to the emergency department, he comes to PRIME. He calls
the phone line—or the after-hours nurse calls him first.”
56
Chapter 3: Primary Health Care and Prescription Drugs—Key Components to Keeping Seniors Healthy
Chronic Disease and Prescription Drug Use in Seniors
Seniors with three or more chronic conditions are significantly more likely than
seniors without chronic conditions to have a high number of annual visits to
their primary health care provider.1 Data from the population covered in CIHI’s
Primary Health Care Voluntary Reporting System confirms these findings. Not
surprisingly, higher numbers of chronic conditions treated in primary care mean
higher numbers of prescription drugs needed to manage those conditions.
Treating Chronic Illnesses
Medications have become an increasingly significant component of Canada’s
health care system, accounting for the second-largest share of health spending,
after hospitals. 21 In 2009, more than half (52%) of seniors on public drug
programs i had claims for at least a 180-day supply of drugs (defined as “chronic
use”) to treat two or more select chronic conditions. A quarter (25%) of seniors
in six reporting provinces—representing almost 210,000 seniors—had claims
for drugs to treat three or more chronic conditions.
In 2009, the proportion of seniors who were chronic users of prescription drugs
to treat select chronic conditions ranged from 7% for respiratory disease to 65%
for high blood pressure and heart failure (see Figure 14).
i.
Data is from Alberta, Saskatchewan, Manitoba, New Brunswick, Nova Scotia and P.E.I.
57
Health Care in Canada, 2011: A Focus on Seniors and Aging
The rate of chronic prescription drug use for seven selected conditions
varied across age groups. The treatment of high blood pressure and heart
failure, acid-related gastrointestinal (GI) disorders, depression, respiratory
disease and osteoporosis increased with age. In contrast, the treatment of
high cholesterol and diabetes decreased with age.
Figure 14: Rate of Chronic Drug Use Among Seniors on Public Drug Programs,
by Selected Disease Category, Selected Provinces,* 2009
80%
Rate of Chronic Drug Use
70%
60%
50%
40%
30%
20%
10%
65–74
75–84
pi r
ato
ry
Re
s
is
ros
po
teo
Os
De
p
re
s
si o
n
s
ete
Di
ab
tin
al
tes
Ga
str
oi n
Hi
gh
an Blo
d H od
e a Pr
rt D es
ise sure
as
e
Hi
gh
Ch
ol e
ste
rol
0%
85+
Note
* The six provinces submitting data to the National Prescription Drug Utilization Information System
Database as of March 2011: Alberta, Saskatchewan, Manitoba, New Brunswick, Nova Scotia and P.E.I.
Source
National Prescription Drug Utilization Information System Database, Canadian Institute for
Health Information.
58
Chapter 3: Primary Health Care and Prescription Drugs—Key Components to Keeping Seniors Healthy
In 2009, 5 of the top 10 drug classes used by seniors were for the treatment of
high blood pressure or heart failure. Seven of the top 10 drug classes were also
among the 10 most commonly prescribed in 2002. While there was little change
in the most common drug classes prescribed to seniors between 2002 and
2009, there was significant change in the use of some drug classes.
The most significant increases in use occurred in statins (from 22% to 39%)
and proton pump inhibitors (PPIs) (from 14% to 25%). The increased use
of statins, which treat high cholesterol, is likely due in part to changes in
treatment guidelines as well as to an increased prevalence of cardiac risk
factors, including high blood pressure, diabetes and obesity. 22, 23 Changes in
treatment guidelines were likely also a factor in the increased use of PPIs, used
to treat gastro-esophageal reflux disease and peptic ulcer disease.24, 25 Coxibs,
used to treat inflammation, was the only drug class with a large decrease in
use between 2002 and 2009, declining from 19% to 4%. This drop was likely
due to the emergence of new safety information about some of the products
in this class.26
This data shows that within a relatively short time frame, the pattern of drug
usage among seniors to treat chronic conditions can change significantly
for specific drug classes, even though the overall top drug classes remained
relatively stable over time. Monitoring such trends can help inform planning
for future needs and decision-making.
Use of Multiple Medications
Taking prescription medications to control symptoms is an important part of
managing many chronic conditions. Although it may be appropriate for some
seniors to be taking several drugs, the use of five or more medications—known
as “polypharmacy”—increases the risks of drug interactions and side effects.1, 27–29
The number of seniors taking multiple prescription medications is rising.
In 2009, about two-thirds (63%) of seniors on public drug programs in six
provinces were claiming 5 or more drugs from different drug classes; nearly
one-quarter (23%) had claims for 10 or more. ii In 2002, by comparison, 59%
had claims for 5 or more drug classes and 20% had claims for 10 or more. The
number of drug classes used by seniors also increased with age. In 2009, 18%
of seniors age 65 to 74 had claims for 10 or more drug classes, as did 26% of
those age 75 to 84 and 30% age 85 and older.
ii.
The number of drugs a senior is taking in one year does not necessarily reflect the number of drugs
he or she is taking at one time.
59
Health Care in Canada, 2011: A Focus on Seniors and Aging
A recent survey of Canadian seniors found that, among those with at least one
chronic condition and taking five or more prescription drugs, 13% experienced
a side effect―more than twice the rate experienced by those taking only one
or two prescriptions.1 Seniors are especially at risk for adverse medication
reactions because of the lowered renal and liver function that comes with
advanced age.30 This issue is compounded by the fact that seniors are often
excluded from clinical trials, and therefore there is often a lack of clinical
evidence available on treating seniors with medication.31
In addition to taking prescription drugs, seniors take more over-the-counter
medications than any other age group. 29 Interactions between over-the-counter
and prescription medications can be of particular concern because prescribing
physicians are not always aware of all the non-prescription medications and
supplements that their patients are taking. 29, 32 In a 2008 survey, fewer than
half (48%) of seniors who had at least one chronic condition and who were
taking regular prescription medications reported having had their medications
reviewed by a medical doctor in the previous 12 months.1
Potentially Inappropriate Medications
The higher prevalence of chronic conditions does contribute to the number
of drugs seniors are taking. However, it is important to evaluate the
appropriateness of each of the medications prescribed.33, 34 The Beers list is an
internationally recognized list of drugs that have been identified as potentially
inappropriate to prescribe to seniors because they “are either ineffective or
they pose unnecessarily high risk for older persons and a safer alternative is
available.” This list was first developed by Dr. Mark H. Beers and a panel of
experts in 1991, and it applied specifically to nursing home patients. It was
updated in 1997 to apply to all seniors and was updated again in 2003.35–37
Looking at chronic drug use by seniors on public drug programs, roughly 1 in 10
was taking a drug from the Beers list in 2009. Rates ranged from 11% in Alberta
to 16% in New Brunswick. A previous study found that chronic use of a drug
from the Beers list decreased between 2001–2002 and 2005–2006 (with rates
of use between 13% in Alberta and 19% in New Brunswick in 2005–2006)38
(see Figure 15). The 2009 data suggests that this trend in declining chronic use
has continued.
In 2009, only three drugs on the Beers list were used on a chronic basis by
more than 1% of seniors on public drug programs. The most commonly used
was amitriptyline, an antidepressant, followed by conjugated estrogens, used
in hormone replacement therapy, and oxybutinin, used to treat incontinence.
60
Chapter 3: Primary Health Care and Prescription Drugs—Key Components to Keeping Seniors Healthy
The figure below shows the use of potentially inappropriate prescription
medications among seniors on public drug programs in six provinces. New
Brunswick had the highest age–sex standardized rate of chronic use (16%),
Alberta the lowest (11%). The rate increased only slightly with age.
Figure 15: Age–Sex Standardized Rate of Chronic Beers Drug Use Among Seniors
on Public Drug Programs, Selected Provinces,* 2009
18%
16%
Age–Sex Standardized Rate
14%
12%
10%
8%
6%
4%
2%
0%
Alta.
Sask.
Man.
N.B.
N.S.
P.E.I.
Province
Note
* The six provinces submitting data to the National Prescription Drug Utilization Information System
Database as of March 2011: Alberta, Saskatchewan, Manitoba, New Brunswick, Nova Scotia and P.E.I.
Source
National Prescription Drug Utilization Information System Database, Canadian Institute for
Health Information.
In 2009, public drug program spending on Beers drugs used on a chronic
basis was roughly $15 million, accounting for 1.4% of total program spending
on seniors. Reducing usage of all Beers drugs would likely result in fewer
adverse events and, in turn, reduce the costs associated with these events.
However, it is unclear whether reducing Beers drug use would reduce total drug
spending. For example, although it would be appropriate in some cases to stop
these drugs without prescribing an alternative, in other cases an alternative
therapy would be needed.
61
Health Care in Canada, 2011: A Focus on Seniors and Aging
Strategies to Promote Safe and Appropriate Drug Use
Health care providers and policy-makers continue to work on promoting the
safe and appropriate use of medication for all Canadians, including seniors.
Several provinces have implemented medication management strategies to
promote activities such as medication reviews.39 Although medication reviews
have shown some success in reducing inappropriate medication use, they are
limited by the information available to the person conducting the review.29, 32, 40
It is important for patients, where possible, to inform their prescribing
physician(s) and pharmacist(s) of all medications they are taking, including
those that are over-the-counter or prescribed by other physicians.
Team-based approaches to delivering primary care may also help. Physicians
and pharmacists working together in the same practice will most likely lead
to increased communication on prescribing. Many provinces fund academic
detailing programs, where the most recent information on particular treatment
guidelines is shared with physicians, often through face-to-face visits by
experts.40 Some provinces/territories have also expanded pharmacists’ roles,
allowing them to adjust prescriptions in some cases. For example, pharmacists
in some provinces are compensated for refusing to dispense a prescription for
reasons such as drug abuse, interactions and therapeutic duplication.39
Integration across various health care providers may also help to coordinate
care for Canada’s seniors by improving communication and knowledge transfer
about patients in this age group, who often have multiple chronic conditions and
need to manage several different medications.
Technology is also facilitating information sharing. Drug information systems
have been at least partially implemented in several provinces, and work on their
full implementation is ongoing across Canada.41 More widespread adoption of
electronic medical record systems may facilitate physician decision-making
in the future, by ensuring access to complete information on patients’ medical
conditions and medications.41, 42
62
Chapter 3: Primary Health Care and Prescription Drugs—Key Components to Keeping Seniors Healthy
Conclusion
Primary health care is the level at which the majority of Canadians make their
first point of contact with the health care system. It encompasses a wide range
of health services and can serve as the gateway to more specialized care.
This discussion focused on two specific aspects of primary health care that
have particular importance to seniors with multiple chronic conditions: family
physicians and prescription medications.
For the most part, Canada’s seniors do have regular family physicians. Seniors
diagnosed with multiple chronic conditions were more likely to seek care from
a family physician than those with fewer diagnosed conditions.
Data on drug claims for seniors underscores survey information showing that, with
advanced age, the likelihood of being diagnosed with chronic conditions increases.
In 2009, the medications most commonly prescribed to seniors were associated
with the treatment of high blood pressure and heart failure. The drug claim data
also shows that as seniors age they are prescribed more drugs. In 2009, about
two-thirds of seniors on public drug programs were claiming 5 or more drug
classes, and nearly one-quarter were claiming 10 or more. Those who take a
higher number of drugs are at greater risk of side effects. Although the majority
of the drugs used by seniors may be required to treat their conditions, more
than 1 in 10 seniors were taking a drug considered “potentially inappropriate”
to prescribe to them. However, the use of these drugs has decreased in the
past decade.
Several strategies have been implemented to promote the safe and appropriate
use of drugs in seniors, including team-based approaches to care, medication
reviews and the implementation of drug information systems and electronic
medical record systems. These strategies all play a role in more effectively
managing chronic conditions and reducing inappropriate medication use.
63
Chapter 3: Primary Health Care and Prescription Drugs—Key Components to Keeping Seniors Healthy
References
1. Canadian Institute for Health Information, Seniors and the Health Care
System: What Is the Impact of Multiple Chronic Conditions? (Ottawa, Ont.:
CIHI, 2011).
2. Institute of Medicine, America’s Health in a New Era (Washington, D.C.:
National Academy Press, 1994).
3. Statistics Canada, Canadian Community Health Survey 2009 Annual
Component (Ottawa, Ont.: Statistics Canada, 2011).
4. Merck and Co. Inc, The Merck Manual of Geriatrics, last modified 2005,
accessed from <http://www.merckmanuals.com/professional/sec22/ch337/
ch337a.html>.
5. National Advisory Council on Aging, Seniors in Canada 2006. Report Card
(Ottawa, Ont.: NACA, 2006).
6. Canadian Institute for Health Information, Supply, Distribution and Migration
of Canadian Physicians, 2009 (Ottawa, Ont.: CIHI, 2010).
7. S. J. Torrible et al., “Improving Recruitment Into Geriatric Medicine in
Canada: Findings and Recommendations From the Geriatric Recruitment
Issues Study,” Journal of the American Geriatrics Society, 9 (2006):
pp. 1453–1462.
8. Canadian Post-M.D. Education Registry, Annual Census of Post-M.D.
Trainees 2005–2006 (Ottawa, Ont.: CAPER, 2006).
9. Canadian Post-M.D. Education Registry, Annual Census of Post-M.D.
Trainees 2010–2011 (Ottawa, Ont.: CAPER, 2011).
10. The Commonwealth Fund, Mirror, Mirror on the Wall: How the Performance
of the U.S. Health Care System Compares Internationally (New York, New
York: CWF, 2010).
11. Health Canada, First Minister’s Meeting on the Future of Health Care
2004, last modified 2006, accessed from <http://www.hc-sc.gc.ca/hcs-sss/
delivery-prestation/fptcollab/2004-fmm-rpm/index-eng.php>.
12. Health Canada, Objectives of the PHCTF, last modified 2004, accessed
from <http://www.hc-sc.gc.ca/hcs-sss/prim/phctf-fassp/object-eng.php>.
13. W. W. Rosser et al., “Progress of Ontario’s Family Health Team Model:
A Patient-Centered Medical Home,” Annals of Family Medicine 9, 2 (2011):
p. 165.
65
Health Care in Canada, 2011: A Focus on Seniors and Aging
14. Government of Ontario, Introduction to Family Health Teams (Toronto, Ont.:
Government of Ontario, 2006).
15. Ministry of Health and Long-Term Care, Family Health Teams, last modified 2011,
accessed from <http://www.health.gov.on.ca/transformation/fht/fht_mn.html>.
16. Government of Ontario, Primary Health Care, last modified 2005, accessed from
<http://www.healthforceontario.ca/HealthcareInOntario/PrimaryCare.aspx>.
17. Government of Ontario, Guide to Interdisciplinary Team Roles and
Responsibilities (Toronto, Ont.: Government of Ontario, 2005).
18. Ministry of Health and Long-Term Care, Guide to Physician Compensation
(Toronto, Ont.: MOHLTC, 2009) .
19. M. McNally et al., The Silent Epidemic of Oral Disease: Evaluating
Continuity of Care and Policies for the Oral Health Care of Seniors
(Dartmouth, N.S.: Atlantic Health Promotion Research Centre and
Dalhousie University, Faculty of Dentistry, 2004).
20. Statistics Canada, Canadian Community Health Survey: Healthy Aging,
Cognition Component 2008/2009 (Ottawa, Ont.: Statistics Canada, 2011).
21. Canadian Institute for Health Information, Drug Expenditure in Canada,
1985 to 2010 (Ottawa, Ont.: CIHI, 2011).
22. J. Genest et al., “2009 Canadian Cardiovascular Society/Canadian
Guidelines for the Diagnosis and Treatment of Dyslipidemia and Prevention
of Cardiovascular Disease in the Adult—2009 Recommendations,”
Canadian Journal of Cardiology 25, 10 (2009): pp. 567–579.
23. C. Jackevicius et al., “Long Term Trends in Use of and Expenditure for
Cardiovascular Medications in Canada,” CMAJ 181, 1–2 (2009): pp. E19–E28.
24. Canadian Institute for Health Information, Proton Pump Inhibitors: An
Analysis Focusing on Drug Claims by Seniors, 2001 to 2008 (Ottawa, Ont.:
CIHI, 2009).
25. B.C. Ministry of Health Services, Gastroesophageal Reflux Disease—
Clinical Approach in Adults, Guidelines & Protocols Advisory Committee,
last modified January 30, 2009, accessed on May 2, 2009, from <http://
www.bcguidelines.ca/guideline_gerd.html>.
66
Chapter 3: Primary Health Care and Prescription Drugs—Key Components to Keeping Seniors Healthy
26. Health Canada, Merck Sharp & Dohme (MSD) Announces Voluntary
Worldwide Withdrawal of VIOXX® (Rofecoxib)—Merck Frosst Canada
Ltd., last modified August 10, 2009, accessed on November 5, 2009, from
<http://www.hc-sc.gc.ca/dhp-mps/medeff/advisories-avis/prof/_2004/
vioxx_2_ltp-lp-eng.php>.
27. D. Juurlink et al., “Drug–Drug Interactions Among Elderly Patients
Hospitalized for Drug Toxicity,” JAMA 13 (2003): pp. 1652–1658.
28. P. Lin, “Drug Interaction and Polypharmacy in the Elderly,” The Canadian
Alzheimer Disease Review (2003): pp. 10–14.
29. D. Qato et al., “Use of Prescription and Over-the-Counter Medications and
Dietary Supplements Among Older Adults in the United States,” JAMA 300,
24 (2008): pp. 2867–2878.
30. R. Bressler et al., “Principles of Drug Therapy for the Elderly Patient,” Mayo
Clinic Proceedings 78 (2003): pp. 1564–1577.
31. D. M. Zulman et al., “Examining the Evidence: A Systematic Review of the
Inclusion and Analysis of Older Adults in Randomized Controlled Trials,”
Journal of General Internal Medicine 26, 7 (2011): pp. 783–790.
32. P. Gardiner et al., “Factors Associated With Dietary Supplement Use Among
Prescription Medication Users,” Archives of Internal Medicine 166, 18
(2006): pp. 1968–1974.
33. L. Clatney et al., Improving the Quality of Drug Management of
Saskatchewan Seniors Living in the Community (Saskatoon, Sask.:
Health Quality Council, 2005).
34. Z. A. Marcum et al., “Medication Misadventures in the Elderly: A Year
in Review,” American Journal of Geriatric Pharmacotherapy 8, 1 (2010):
pp. 77–83.
35. M. H. Beers et al., “Explicit Criteria for Determining Inappropriate
Medication Use in Nursing Home Residents,” Archives of Internal
Medicine 151 (1991): pp. 1825–1832.
36. M. H. Beers, “Explicit Criteria for Determining Potentially Inappropriate
Medication Use by Elderly. An Update,” Archives of Internal Medicine 157
(1997): pp. 1531–1536.
37. D. M. Fick et al., “Updating the Beers Criteria for Potentially Inappropriate
Medication Use in Older Adults,” Archives of Internal Medicine 163, 22
(2003): pp. 2716–2724.
67
Health Care in Canada, 2011: A Focus on Seniors and Aging
38. Canadian Institute for Health Information, Drug Claims by Seniors: An
Analysis Focusing on Potentially Inappropriate Medication Use, 2000 to
2006 (Ottawa, Ont.: CIHI, 2007).
39. Canadian Pharmacists Association, Pharmacists’ Medication Management
Services: Environmental Scan of Canadian and International Services
(Ottawa, Ont.: CPha, 2011).
40. I. Sketris et al., Optimal Prescribing and Medication Use in Canada: Challenges
and Opportunities (Ottawa, Ont.: Health Council of Canada, 2007).
41. Health Council of Canada, Progress Report 2011: Health Care Renewal
in Canada (Toronto, Ont.: HCC, 2011).
42. R. Hillestad et al., “Can Electronic Medical Record Systems Transform
Health Care? Potential Health Benefits, Savings, and Costs,” Health Affairs
24, 5 (2005): pp. 1103–1117.
68
Informal caregiver support is key
to enabling many seniors to remain
in their communities safely and
independently as they age.
Chapter 4
Caring for Seniors in Community Settings
Given that seniors currently represent 14%1 of Canada’s population and that
this proportion is expected to reach close to 25% over the next 25 years, 2
understanding the health and housing needs of older Canadians will become
increasingly important. The next three chapters of this report discuss care
received in different settings: when they live in the community, when they live
in residential care facilities and when they become acutely ill. This chapter
focuses on seniors who live in the community and the variety of formal and
informal care they can receive to help them remain there.
Independent Living
Most Seniors Live in Private Households
The majority (87%) of Canadians age 55 years and older want to live at home
as long as possible.3 According to the 2006 Canadian census, the vast majority
(93%) of seniors age 65 and older do live at home (see Figure 16). Across
provinces, the proportion of seniors living in private households did not vary
substantially: from 91% in Quebec to 94% in British Columbia. There was,
however, greater variation across Canada in the proportion of seniors living alone
in private households, ranging from 13% in Nunavut and 24% in Newfoundland
and Labrador to 34% in Saskatchewan and almost 37% in Yukon.4
Seniors’ first source of health and social support is typically a spouse or coresident.5 Consequently, the proportion of seniors living alone is an important
consideration in the planning and delivery of care. The proportion of seniors living
alone in a household dwelling consistently increased with age: more than a third
(37%) of older seniors (age 75 and older) lived alone, compared with almost half
(49%) of those in the eldest age group of seniors (age 85 and older).
Women’s living arrangements in older age are driving this increase. Women age
85 and older were twice as likely as their male counterparts to be living alone
(59% versus 29%). This is due in large part to women continuing to live alone
after the death of their spouse. Other contributing factors include the longer life
expectancy of women (although the gap is now narrowing), the age differential
at marriage2, 6 and higher rates of widowhood among senior women than among
men—of all ages—although rates of widowhood have declined in Canada.2
Health Care in Canada, 2011: A Focus on Seniors and Aging
Though living alone may provide independence, it can affect seniors’ financial
status, housing affordability7 and degree of isolation. It also has an effect on
overall well-being. 2 Without available community supports, appropriate housing,
an informal caregiver or formal care, living alone may precipitate the likelihood
of institutionalization.
More than 90% of seniors age 65 and older were living in a household
dwelling in 2006. For the eldest seniors (those age 85 and older), the
percentage was lower, at just more than 70%. Women age 65 and older
were twice as likely as their male counterparts to be living alone (34%
versus 16%). This trend is consistent across jurisdictions (data not shown).
Figure 16: Variations in Seniors’ Living Arrangements, by Age, Canada, 2006
100%
Percentage Living in a Household Dwelling
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
65+
75+
85+
65+
Males
Females
Living Alone
Source
Census of Canada, 2006, Statistics Canada.
72
75+
Living With Another
85+
Chapter 4: Caring for Seniors in Community Settings
Supporting Seniors to Maintain Their Independence
More than forty percent (41%) of Canada’s seniors are in very good or excellent
health, based on their perceptions of their general and mental health, functional
abilities and independence in activities of daily living (ADLs).8 At some point,
help may be required with personal care or tasks around the home due to
physical or mental decline.9 As age advances, such supports facilitate seniors’
ability to maintain independence and continue successfully living in their
own homes.
There is a wide range of care and services available to seniors through primary
care, home care (involving a combination of home health and support services
provided by trained personnel), informal care (unpaid care usually provided by
a spouse or family members) and community support programs. The provision
of primary care was discussed in the previous chapter. The information below
focuses on the provision of formal home care, informal community care and
supportive community housing.
Home Care
At any given time across the country, almost 1 million Canadians are receiving
home care.10 The majority (82%)11 are age 65 or older.
Home care encompasses a broad range of services that must be coordinated
across many different providers. Its definition continues to evolve to meet
the changing and individualized needs of home care recipients.12 Home care
typically includes both home health services and home support services.
Home health services include nursing, as well as physical, occupational and
respiratory therapy, all delivered by licensed health personnel. Home support
services include assistance with activities such as homemaking and personal
care (for example, bathing, dressing and eating). Home care may also include
provision of adult day programs, meal services, home maintenance and repair,
transportation and respite services.
A variety of professionals—such as nurses, physiotherapists and social
workers—provide home care (see Figure 17). But the majority of home care
providers are home support workers—home health aides, personal support
workers, personal care workers and home health attendants.12
73
Health Care in Canada, 2011: A Focus on Seniors and Aging
Coordination and Delivery
of Home Care Programs
There is no formal obligation on the part of provincial or territorial governments
to provide a minimum basket of home care services, as there is for physician
or hospital services covered by the Canada Health Act.
Act 12 As such, home care
legislation varies considerably across the country. This variation contributes to
differences in access to and availability of home care services for Canadians.13, 14
Given that home care and long-term care are not covered by the Canada
Health Act
Act,, several policy-relevant research questions regarding access were
identified and articulated in the 2010 Canadian Health Services Research
Foundation roundtable discussions.15 For example,
• What sources of financing are available for home care and long-term care that could be
implemented in Canada to increase funding for and improve access to these services?
• What implications would the financing models have for stakeholders, including payers (public
and private), providers and consumers?
• Are there other ways to improve access to home care and long-term care, including financial
incentives for unpaid caregivers or improving transitions across sectors of care?
Variation in the organization and delivery of home care is not unique to
Canada. In some European countries—such as France, Spain and the
United Kingdom—the health component of home care is part of the health
care system while the social component falls under the social system.16 In other
countries—such as Denmark, Finland and Sweden—both the health and social
components of home care are coordinated and delivered solely through
the municipalities.16
Regardless of which part of the government is responsible for home care
delivery, in 2008, the World Health Organization (WHO) identified several
factors for providing effective home care services:16
•
•
•
•
Availability of reliable information on home care usage and expenditure;
Transparency in what is publicly funded and what the user pays;
Sustainability of current funding arrangements; and
Improvement of service efficiency by increasing the integration of services and/or changing the
skills mix of home care providers.
Data from CIHI’s Home Care Reporting System shows that approximately 68%
of assessed i home care clients received home health services in 2009–2010.
Approximately 38% received home support services. Overall, female seniors
were more likely than male seniors to receive formal home care.
i.
74
Using the most recent Resident Assessment Instrument–Home Care (RAI-HC)© assessment in
2009–2010 for home care clients age 65 and older.
Chapter 4: Caring for Seniors in Community Settings
Where To Find It
Chapter 5: Caring for Seniors in Residential Care provides detailed comparative
information on functional and cognitive health status among home care clients
and residents in long-term care. It also reports on quality indicators for both
populations, including measures of signs and symptoms of depression, pain
control, pressure ulcers and falls.
The type of home care services received by seniors living in the community
varies with age. As age increases, seniors are more likely to receive services
such as homemaking and meal support. Younger clients are more likely to
receive care during home visits from nurses and social workers. In some
provinces and territories, these services are paid for publicly; in others,
these may need to be paid out-of-pocket or by private insurance plans.12
Figure 17: Variation in Services Received by Long-Term Home Care Clients,
by Age Group, 2009–2010
Age Group
Type of Home Care Service
20–64 (%)
65–74 (%)
75–84 (%)
85+ (%)
Home Health Aides
42
47
53
59
Visiting Nurses
40
31
21
19
Homemaking Services
23
27
33
42
Meals
5
5
9
15
Volunteer Services
1
1
1
1
Physical Therapy
8
8
7
7
Occupational Therapy
9
8
7
5
†
0†
*
Speech Therapy
1
1
0
Day Care or Day Hospital
3
3
3
2
Social Worker in Home
4
1
1
0†
Notes
* Prepared meals delivered by a (paid) formal caregiving agency to the client’s home.
† Indicates data rounded to zero.
Data for this analysis is based on assessments using the Resident Assessment Instrument–Home Care
(RAI-HC)© of 151,101 long-term home care clients (those expected to be on service for more than 60
days) age 65 and older receiving publicly funded home care services in Ontario, Nova Scotia and Yukon
in 2009–2010. Formal home care and home support service utilization are based on formal care received
within the last seven days of when the assessment was performed or since the last assessment if less than
seven days.
Source
Home Care Reporting System, 2009–2010, Canadian Institute for Health Information.
75
Health Care in Canada, 2011: A Focus on Seniors and Aging
With the number and proportion of seniors in the Canadian population set to
increase, researchers have suggested that the need for home care services
will increase in turn.17 Contributing factors include
•
•
Increases in the number of seniors having some form of disability;18
•
Increases in chronic disease prevalence.17
Changes in the characteristics of the senior population, such as educational
levels, marital status and living arrangements (potentially affecting the
likelihood of receiving family support);2 and
Informal Care in the Community
Informal caregiver support is key to enabling many seniors to remain in their
communities safely and independently as they age.19 Most informal care
(about 80%) comes from unpaid family, friends and neighbours.20 These
caregivers provide vital help with ADLs, such as personal hygiene, toileting,
eating and moving about inside the home.19, 21 In addition to emotional support,
informal caregivers also provide help with instrumental ADLs, including meal
preparation, housework, medication management, shopping and transportation.2
There are more than 2 million informal caregivers age 45 and older in
Canada. 22 Approximately 97% of all home care recipients have an informal
caregiver, nearly one-third of whom are spouses; almost half are children
or children-in-law.11
The responsibilities of informal caregivers often extend around the clock.
This can be extremely stressful for the caregiver. Nearly 17% of all informal
caregivers helping seniors reported distress in their role—representing more
than 24,000 distressed caregivers in Ontario and Yukon alone.11 Further, the
rate of caregiver distress increased with the total hours of care provided (see
Figure 18). In addition to the number of hours of informal care provided, other
factors affect caregiver distress, such as caring for seniors with moderate or
severe cognitive impairment and symptoms of depression, caring for those
who have difficulty with instrumental ADLs and caring for seniors with difficultto-manage behaviours, such as resisting care or verbal or physical abuse.19
76
Chapter 4: Caring for Seniors in Community Settings
Informal caregivers’ distress levels rise with the number of hours of care
provided. Almost one-third (32%) of caregivers providing more than 21 hours
expressed distress, four times more than the percentage of distressed
caregivers who provided less than 10 hours of informal care per week.
Figure 18: Caregiver Distress, by Number of Hours of Informal Care per Week,
2009–2010
35%
32%
Percentage of Clients With
a Distressed Caregiver
30%
25%
20%
17%
15%
10%
8%
5%
0%
0–10
11–20
21+
Number of Hours of Informal Care
Note
Includes data from Ontario, Nova Scotia and Yukon.
Source
Home Care Reporting System, 2009–2010, Canadian Institute for Health Information.
The distress experienced by informal caregivers extended into their paid
working hours. More than half of women (55%) and almost half of men (45%)
providing informal care reported repercussions at their place of employment.23
For example, caregivers reported that they had to change their work patterns
or work hours, or decline promotions or job transfers to accommodate their
informal caregiving responsibilities.24
The differences observed between men and women in the rates of employment
repercussions might be attributed to differences in the type of care provided.25
They may also reflect traditional gender role differences. 25 For example,
women are traditionally more likely than men to provide personal care to family
members. And research suggests that providing personal care is a strong
predictor of making workplace adjustments.25 In addition, caregivers with dual
responsibilities—caring for children and parents at the same time—are also at
increased risk of resigning from employment due to challenges in balancing the
demands of work and family.26
77
Health Care in Canada, 2011: A Focus on Seniors and Aging
Financial Support for
Informal Caregivers
A strong predictor of institutionalization is a lack of social support.27 The health
care system’s sustainability may rely in part on informal support networks to
delay institutionalization for as long as possible.19 From a health policy
perspective, it has been recommended that adequate support be available not only
for care receivers but also for caregivers.6, 28
Respite care forms the basis for one of several policies supporting caregiver wellbeing.29 Respite care may vary by duration (short- versus long-term) or location
(in-home versus institutional). While there is likely not one best approach to the
structure and delivery of respite care, it should offer a range of services
responsive to both caregiver and care recipient characteristics and needs.
Several policies have been developed to support caregivers within the
Canadian health care system:
• Tax credits, such as the Medical Expenses Tax Credit and the Caregiver Tax Credit, reduce a
caregiver’s tax burden. 20
• The Employment Insurance Compassionate Care Leave Benefit allows family members of
palliative patients to take time off to care for them. 20
• There are also several provincial and territorial policies and programs in place. For example,
the Caregiver Benefit Program in Nova Scotia uses the resident assessment instrument
(MDS-HC) as part of its assessment process to inform allocation of $400 monthly to informal
caregivers of qualified recipients.30
Social services are important in facilitating seniors’ continued community
living.31 They can also help support informal caregivers who may be called
upon to provide similar care. Examples include seniors’ centres, outreach
services, respite care, adult day programs, internet-based support groups,
Meals on Wheels, home and yard maintenance, and escorted transportation
to essential appointments. Experts have suggested that the “small things”—
low-level services—truly matter in large health systems.32 Help with housework,
gardening, laundry and home maintenance and repairs can all enhance the
quality of life for seniors and help them maintain their independence.31 Across
Canada, eligibility requirements, processes for arranging care and funding for
such services vary substantially.33
78
Chapter 4: Caring for Seniors in Community Settings
Supportive Housing
Described as neither fully independent living nor residential care,34 supportive
housing—or assisted living—combines permanent housing with access to
supportive services.34 Supportive housing may offer an intermediate level of
care tailored to the needs of many of Canada’s seniors. Ideally, it integrates
accommodations with access to a comprehensive and coordinated package of
services (homemaking and personal care) and community programs necessary
to support health and well-being. Definitions of supportive housing vary broadly
across Canada, with no agreed-upon national standard.35–37 Supportive housing
is a relatively recent designated care setting for providing an appropriate level
of care to seniors, one that facilitates continued living in their communities.38
Supportive living arrangements are varied, ranging from apartments and
congregate housing to multi-level facilities.34 They may be owned and operated
by municipal governments or non-profit groups,39 as well as the private sector.37
Some units are government-subsidized, making them generally more affordable
than residential care options.38, 39
Few studies have assessed the costs, benefits and outcomes of supportive
housing models in Canada.34 However, potential benefits to overall well-being
and quality of life in such settings may be gained via
•
•
•
•
Daily provision of nutritious meals;
Opportunities for socialization;
Participation in physical activities; and
Access to health services in the community.37
Supportive housing may also reduce emergency department visits,
hospitalizations and admission to long-term care.40
79
Health Care in Canada, 2011: A Focus on Seniors and Aging
The Role of Technology in Keeping
Seniors in Their Homes
Adoption of new technologies may facilitate community living in the future. Some
jurisdictions across Canada have begun to assess the use of telehealth41 or telehomecare42 to provide seniors with access to immediate health care information
from their home. For example, a tele-homecare project in New Brunswick called
[email protected] has been piloted and evaluated among clients with congestive
heart failure and chronic obstructive pulmonary disease. It shows potential in
reducing hospital admissions and emergency room visits, as well as better
self-management of chronic disease.42
This technology may expand beyond the telephone to involve videoconferences
and other telecommunication technologies.41 For example, Norway is investigating
the potential role of robots in providing care for seniors living at home.43 The robots
may one day be able to perform daily chores or provide medical surveillance.
These technologies are in the early stages of development, and it may be some
time before they become widely available.43
80
Chapter 4: Caring for Seniors in Community Settings
Conclusion
Most seniors want to age at home and maintain their independence for as long
as possible. Many remain healthy enough to do so well beyond age 65, even
into their 80s and 90s; others require increasing levels of formal and/or informal
support to remain in their communities. At any given moment, it is estimated
that close to 1 million Canadians receive home care.10 The majority (82%)
of home care clients are seniors, and almost all of them (97%) also have an
informal caregiver.11
Home care encompasses a broad range of services that must be coordinated
across many different providers. Several health human resource challenges
are recognized in the home care sector, including home care worker shortages,
recruitment and retention challenges, as well as concerns about training and
safety, and labour conditions, especially among home support workers.12
Along the continuum from independent living to institutionalization, supportive
community housing may offer an intermediate level of care that is appropriate
to the needs of many of Canada’s seniors. As the system adapts to meet
the projected increased needs of seniors in the future, policy-makers should
continue to find new ways of supporting informal caregivers and integrating
care received through both social and health services. Given the critical role
of caregivers in the lives of seniors in the community, interventions to reduce
caregiver distress can potentially reduce premature admission of seniors to a
residential care facility. Integration of social and health services may reduce
fragmentation and improve the continuity and coordination of care provided
to seniors as well as to the informal care provider. Such initiatives have been
successfully implemented in Quebec.44
As described in this chapter, housing and care needs play an increasingly
important role in seniors’ lives as they age. With advanced age, seniors are
more likely to live alone and to require both formal and informal support to
continue doing so. Despite the variety of care options available to facilitate
continued community living, some seniors will eventually transition to an
institution—either by choice or out of necessity.
81
Chapter 4: Caring for Seniors in Community Settings
References
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11. Canadian Institute for Health Information, Quick Stats: Home Care
Reporting System, 2009–2010 (Ottawa, Ont.: CIHI, 2011).
12. Canadian Healthcare Association, Home Care in Canada: From the Margins
to the Mainstream (Ottawa, Ont.: Canadian Healthcare Association, 2009).
13. M. MacAdam, “Home Care: It’s Time for a Canadian Model,” Healthcare
Papers 1, 4 (2000): pp. 9–36.
83
Health Care in Canada, 2011: A Focus on Seniors and Aging
14. K. Seggewiss, “Variations in Home Care Programs Across Canada
Demonstrate Need for National Standards and Pan-Canadian Program,”
CMAJ 180, 12 (2009): pp. E90–E92.
15. Canadian Health Services Research Foundation, Better With Age: Health
Systems Planning for the Aging Population (Synthesis Report) (Ottawa,
Ont.: CHSRF, 2011).
16. World Health Organization, Home Care in Europe: The Solid Facts (Italy:
WHO, 2008).
17. G. Carriere, “Seniors’ Use of Home Care,” Health Reports 17, 4 (2006):
pp. 43–47.
18. Y. Carrière et al., Projecting the Future Availability of the Informal Support
Network of the Elderly Population and Assessing Its Impact on Home Care
Services (Ottawa, Ont.: Minister of Industry, 2008).
19. Canadian Institute for Health Information, Quick Stats: Supporting Informal
Caregivers—The Heart of Home Care (Ottawa, Ont.: CIHI, 2010).
20. Human Resources and Skills Development Canada, Caregivers,
last modified January 25, 2006, accessed on March 21, 2011, from
<http://www.hrsdc.gc.ca/eng/cs/comm/sd/caregivers.shtml>.
21. H. Gilmour and J. Park, “Dependency, Chronic Conditions and Pain
in Seniors,” Health Reports 16 (2005): pp. 21–31.
22. K. Cranswick, 2002 General Social Survey Cycle 16: Aging and Social
Support—Tables (Ottawa, Ont.: Statistics Canada, 2003).
23. S. Brink, Elder Care: The Nexus for Family, Work and Health Policy
(Ottawa, Ont.: The Caledon Institute of Social Policy, 2004).
24. K. Cranswick, 2002 General Social Survey Cycle 16: Caring for an Aging
Society (Ottawa, Ont.: Minister of Industry, 2003).
25. D. Lero and G. Joseph, A Systematic Review of The Literature on
Combining Work and Eldercare in Canada (Guelph, Ont.: University
of Guelph, 2007).
26. L. Duxbury et al., Balancing Paid Work and Caregiving Responsibilities: A
Closer Look at Family Caregivers in Canada (Ottawa, Ont.: Canadian Policy
Research Networks, 2009).
84
Chapter 4: Caring for Seniors in Community Settings
27. Canadian Healthcare Association, New Directions for Facility-Based Long
Term Care (Ottawa, Ont.: Canadian Healthcare Association, 2009).
28. R. J. Romanow, Building on Values: The Future of Health Care in Canada—
Final Report (Saskatoon, Sask.: Commission on the Future of Health Care
in Canada, 2002).
29. F. Colombo et al., Help Wanted? Providing and Paying for Long-Term Care
(Paris, France: Organisation for Economic Co-operation and Development,
2011), accessed from <www.oecd.org/health/longtermcare/helpwanted>.
30. Nova Scotia Department of Health, Continuing Care Branch, Caregiver
Benefit Program Policy, last modified 2010, accessed from <www.gov.ns.ca/
health/ccs/pubs/Caregiver_Benefit_Program_Policy.pdf>.
31. B. J. Simpson & Associates, Seniors in Home Services Review: Systems
Overview (Calgary, Alta.: City of Calgary, 2001).
32. A. P. Williams and J. M. Lum, “Chicken Little? Why the Healthcare Sky Does
Not Have to Fall,” Healthcare Papers 11, 1 (2011): pp. 52–58.
33. Ontario Association of Non-Profit Homes and Services for Seniors, Making
Seniors a National Priority (Woodbridge, Ont.: OANHSS, 2010), pp. 1–4.
34. Canadian Research Network for Care in the Community, Supportive
Housing, last modified 2006, accessed from <www.crncc.ca/knowledge/
factsheets/pdf/InFocus-SupportiveHousingOct4intemplate.pdf>.
35. J. Lum et al., Balancing Care for Supportive Housing: Final Report (Toronto,
Ont.: University of Toronto, 2010).
36. A. Jones, The Role of Supportive Housing for Low-Income Seniors in
Ontario (Ottawa, Ont.: Canadian Policy Research Networks and Social
Housing Services Corporation, 2007), pp. 1–55.
37. Social Data Research, Searchable Database of Supportive Housing for
Seniors in Canada: Final Report Prepared for Health Canada (Ottawa, Ont.:
Health Canada, 2005), accessed from <www.hc-sc.gc.ca/hcs-sss/pubs/
home-domicile/2005-seniors-aines/index-eng.php>.
38. N. Jutan, Integrating Supportive Housing Into the Continuum of Care in
Ontario (Waterloo, Ont.: University of Waterloo, 2010), pp. 1–230.
39. Ontario Ministry of Health and Long-Term Care, Seniors’ Care: Supportive
Housing, last modified 2010, accessed from <www.health.gov.on.ca/english/
public/program/ltc/13_housing.html>.
85
Health Care in Canada, 2011: A Focus on Seniors and Aging
40. Champlain Local Health Integration Network, Aging at Home Project:
Transforming Health Care For Seniors in Cornwall & Rockland, last modified
2010, accessed from <www.champlainlhin.on.ca/WorkArea/showcontent.
aspx?id=4512>.
41. A. Deshpande et al., Real-Time (Synchronus) Telehealth in Primary Care:
Systematic Review of Systematic Reviews [Technology Report no. 100]
(Ottawa, Ont.: Canadian Agency for Drugs and Technologies in Health, 2008).
42. A. Seymour et al., “Evaluation Demonstrates Telehomecare Reduces Need
for Hospital Care,” Canadian Healthcare Technology October (2006).
43. A. C. Stoltz, Short of Staff, Norway Eyes Robot Care for Elderly, last
modified 2011, accessed on July 25, 2011, from <http://uk.reuters.com/
article/2008/02/10/science-norway-robots-dc-idUKL0719538520080210>.
44. I. Vedel et al., “Ten Years of Integrated Care: Backwards and Forwards.
The Case of the Province of Quebec, Canada,” International Journal of
Integrated Care 11 (2011).
86
Comparisons of long-term home
care clients and seniors living in
residential care facilities showed
that the latter tend to have higher
care and support needs.
Chapter 5
Caring for Seniors in Residential Care
As discussed in Chapter 4, a variety of formal and informal care supports
is available to help seniors maintain their independence. Sometimes these
measures are enough to enable people to stay in their homes; sometimes they
are not. Several factors may precipitate a move to residential care, including
•
•
•
•
Cognitive decline or decline in physical health status;1
Challenges with basic or instrumental activities of daily living;2
Lack of informal support;1, 3 and
Increasing caregiver burden and distress.4
This chapter provides information on the segment of Canada’s seniors who live
in residential care settings, known alternatively as nursing homes, long-term
care facilities and personal care homes. It looks at rates of institutionalization,
as well as the demographic and clinical characteristics of residents. Select
quality indicators for residential and home care settings are presented
and compared. The comparison highlights four areas where future quality
improvement and prevention efforts could be focused: depression, pain,
pressure ulcers and falls.
Health Care in Canada, 2011: A Focus on Seniors and Aging
Living in Residential Care
In 2008–2009, Statistics Canada estimated that there were 4,845 residential
care facilities in Canada, comprising nearly 270,000 beds. i, 5 Almost half (46%)
of these facilities were homes for the aged, delivering services specifically to
seniors. Among residents in all facilities (excluding those in Quebec), ii 42%
of those in homes for the aged were older than age 85, of which 78% were
female. Across jurisdictions, there was variation in the services and number
of beds in homes for the aged per senior population. On average in Canada
in 2008–2009, there were 46 beds staffed and in operation per 1,000 seniors
age 65 and older, ranging from 35 in Quebec to 89 in Prince Edward Island.
In recent decades, rates of institutionalization among seniors have declined.6, 7
In 2006, only 1.4% of those between age 65 and 74 and 12% of those 75 and older
lived in a special care facility as defined by the census. iii, 8 In 1981, rates were
3% and 17%, respectively.7 The decline may be partly explained by increased
access to home care and community supports, improvements in overall health
and decreasing rates of admission among clients with less complex health
needs.9 Although the number of long-term care beds per 1,000 seniors has
remained stable since 2004, the level of care has increased, with residents
receiving more intensive care than in the past.10
The decline in institutionalization rates may also be due in part to targeted changes
in health technology. Some types of care traditionally provided in residential
care are now provided through home care, due to technological advances.11
Researchers have suggested that this trend toward de-institutionalization is less
about the stated preferences of seniors and more about the organization of care,
asserting that institutional settings have higher costs associated with them than
do services provided through home care.12
Data from CIHI’s Continuing Care Reporting System shows that the profile
of seniors in residential care varies across the country. Figure 19 compares
residents from seven jurisdictions on measures of functional and cognitive
status in 2009–2010.
i.
Includes all types of care, ranging from room and board with custodial care, with a maximum
of 30 minutes of care per day, to 24-hour monitoring outside of an acute care setting.
ii. Quebec data has no age and sex breakdown.
iii. The 2006 Canadian census defines special care facility as “nursing homes, residences for
senior citizens, chronic and long-term care and related facilities.” 8
90
Chapter 5: Caring for Seniors in Residential Care
Integration of Health and Social
Services in Quebec
In Quebec, health and social services are integrated into a single administration,
based on legislation enacted in the early 1970s.13 Reforms then took place
between 2003 and 2004, resulting in the creation of 95 local health and social
service networks across the province.14 These reforms effectively reorganized
Quebec’s health and social services to better meet the needs of its population,
as well as managing primary and secondary health and social services.15
At the local level, a range of services are brought together, including care
providers such as family physicians, as well as other social service partners,
including community pharmacies and community organizations.13 Each local
network has a health and social services centre (CSSS). Although some
variation exists,15 these centres typically combine local community services
centres (CLSCs), residential and long-term care centres (CHSLDs) and, in most
cases, a hospital centre (CH). Additional services include rehabilitation centres
(CRs) and child and youth protection centres (CPEJs). The CSSS forms the
basis of an integrated provision of services, helping to ensure accessibility,
case management, follow-up and coordination of services for the population
it serves.13
91
Health Care in Canada, 2011: A Focus on Seniors and Aging
The profile of seniors in residential care is fairly consistent across the
country. The majority of residents have cognitive impairment and require
extensive assistance, thus requiring substantial amounts of care.
Figure 19: Jurisdictional Comparisons for Assessed Seniors Living in
Residential Care, 2009–2010
Jurisdiction
B.C.
(%)
Sask.
(%)
Man.
(%)
Ont.
(%)
N.S.
(%)
N.L.
(%)
Y.T.
(%)
Total
(%)
Characteristic
Descriptive
Age
Percentage of
the assessed
senior population age 85+
58
62
61
56
67
41
37
57
Marital Status
Not married
78
74
77
76
76
78
81
76
Functional
Status
(Activities of
Daily Living
Hierarchy)
Extensive
assistance or
dependence
73
70
71
75
69
74
51
74
Cognitive
Performance
Scale (CPS)
Moderate
to severe
impairment
64
65
65
59
61
68
60
60
Notes
Sample sizes are small for Newfoundland and Labrador and Yukon, potentially contributing to some of
the variation observed.
Data included is based on a sample of residential care facilities in Newfoundland and Labrador, Nova
Scotia, Ontario, Manitoba, Saskatchewan, British Columbia and Yukon.
Source
Continuing Care Reporting System, 2009–2010, Canadian Institute for Health Information.
92
Chapter 5: Caring for Seniors in Residential Care
Analysis of data in CIHI’s Home and Continuing Care Reporting Systems
can help to gain a better understanding of the range of care needs across
the sectors. In a comparison of home care clients and seniors who are living
in residential care, on various measures, it was found that seniors in residential
care were more likely to require extensive assistance with activities of daily
living (ADLs), such as bathing and toileting (74% versus 18%). They were also
more likely to have moderate to severe cognitive impairment (60% versus 14%)
(see Figure 20).
Many of these factors, when coupled with a lack of home care and informal
support, are associated with admission to a residential care facility.9 Diseasespecific factors, dementia16 and cerebrovascular disease,17 also play a role
in institutionalization among the elderly.
The characteristics of assessed seniors in residential care facilities
compared with those of seniors living in the community and receiving home
care reveal a number of differences. Seniors in residential care are more
likely to be older (age 85+), unmarried and more functionally dependent.
Figure 20: Comparing Residential Care and Home Care Clients, 2009–2010
Home Care
HCRS*
(%)
Residential Care
CCRS†
(%)
Characteristic
Descriptive
Age
Percentage of the assessed
senior population age 85+
40
57
Marital Status
Not married
64
76
18
74
14
60
Functional Status Extensive assistance/
(Activities of Daily dependence
Living Hierarchy)
Cognitive Performance Scale
(CPS)
Moderate to severe
impairment
Notes
* Includes Ontario, Nova Scotia and Yukon.
† Includes a sample of residential care facilities in Newfoundland and Labrador, Nova Scotia,
Ontario, Manitoba, Saskatchewan, British Columbia and Yukon.
Sources
Home Care Reporting System and Continuing Care Reporting System, 2009–2010, Canadian Institute
for Health Information.
93
Health Care in Canada, 2011: A Focus on Seniors and Aging
Prioritizing Wait Times for
Long-Term Care
There are several tools available to assess patients’ care needs. One such
tool, the Method for Assigning Priority Levels, or MAPLe, is used in allocating
community and facility-based services by prioritizing clients’ needs. MAPLe
scores identify clients at risk for institutionalization and caregiver burnout,
as well as assess need in patients waiting for long-term care placement.
Recent data from Ontario has shown that seniors living in the community with
higher assessed need (as measured by their MAPLe scores) are placed in
nursing homes faster than those with less assessed need. From 2004 to 2008,
almost 50% of seniors with high or very high need were placed within a year
of being on a wait list. In comparison, less than 40% of seniors with lower need
were placed in this time frame.
For hospital inpatients, however, assessed need does not appear to influence wait
time for long-term care placement. More than 60% of hospitalized seniors on longterm care wait lists were placed within one year, regardless of assessed level of
need. Researchers have suggested that the first-come-first-served approach
may place older adults at greater risk of unnecessary institutionalization.18
They recommend that seniors’ assessed need be considered in decisions
about the most appropriate location of care for seniors.
Quality Indicators for Seniors in Home
and Residential Care
Receiving appropriate home care services in combination with informal support
can help ensure continued, relatively independent, community living. However,
clients may experience further health decline or a breakdown in their support
system. This, in turn, may result in an increased dependency on formal or
informal care, or even institutionalization.19
The following section highlights four selected quality indicators for home and
residential care settings, specifically signs and symptoms of depression, pain,
pressure ulcers and falls. They provide information on the relative health needs
of seniors in both settings and highlight variability between these locations of
care. These standardized measures are amenable to preventive efforts and
affect a large number of Canadian seniors receiving long-term care.
94
Chapter 5: Caring for Seniors in Residential Care
They speak to keeping people healthy, suggesting that appropriate home or
residential care services can play a role in slowing decline and maintaining
or even improving health. In the context of other evidence, they can flag
potential quality problems and give care providers and facility administrators an
opportunity to target quality improvement actions and best care practices. 20, 21
The findings in this section are based on assessments of both long-stay clients
receiving publicly funded home care services and seniors in residential care, all
for the period 2009–2010.
Where to Find It
Chapter 4: Caring for Seniors in Community Settings provides detailed information
on the proportion of seniors living at home in the community, as well as information
on the types of care and support (formal and informal) received to help them
remain there.
Signs and Symptoms of Depression
Mood disorders are the most common mental illness among seniors in Canada.
In 2009–2010, 5% of seniors in the community had a mood disorder such as
depression, bipolar disorder, mania or dysthymia, compared with 8% of those
age 45 to 64. 22 Mental illnesses tend to be under-diagnosed among seniors
because symptoms are often dismissed as a natural part of aging or as a
response to a physical illness.23
Mood disorders, such as depression, are more common among seniors living
in institutions. 24 Assessment of seniors in residential care facilities and in longterm home care settings in 2009–2010 revealed that 31% of those in residential
care facilities showed signs of possible depression, more than double the
percentage of those in long-term home care (14%). Further, 23% of seniors
living in residential care facilities who had been identified as having depression
or anxiety had symptoms worsen over a three-month period.
Although some events associated with worsening of condition are unavoidable,
there are strategies that may help. For long-term care residents, providing
meaningful activities, social networks, visitors, medications or pet therapy have
proven useful.25 For seniors in the community, encouraging them to have and
engage with social networks, join in social activities and participate in chronic
disease management may help.25
95
Health Care in Canada, 2011: A Focus on Seniors and Aging
Daily Pain and Pain Management
Like depression, chronic pain is common among seniors. It is often
unrecognized and, as a result, under-treated. Results of an assessment
of seniors in the two care settings in 2009–2010 found that 16% of seniors
living in residential care facilities reported daily pain, in contrast to 34% of
long-term home care clients. Several factors may account for this difference.
For example, there may be better pain control in residential facilities, given the
24-hour availability of nursing staff and the structured environment for medication
management. Home care clients are also less likely to suffer from dementia
and are therefore better able to report their pain.
Among seniors in residential care, 11% reported worsened pain in the past
three months. Although the measures used for quality of pain control in both
settings are not exactly the same, standardized indicators of quality of pain
control are available for home care clients. The prevalence of disruptive or
intense daily pain was 34% among long-term home care clients; the prevalence
of inadequate pain control among clients with pain was 22%.
Strategies to help control pain can be put in place in both home and residential
care settings. To facilitate this, standardized assessment instruments can be
used by clinicians to flag home care clients and residents whose pain should be
further investigated.26 Among residential care clients, research has shown that
the use of appropriate painkillers, physiotherapy, massage therapy and certain
types of exercise can help.27
It is important for home care providers to recognize pain in their clients,
especially among individuals with dementia or those who have communication
difficulties. Environmental factors in clients’ homes that may contribute to their
pain can be monitored and corrected, and visits to family physicians for targeted
care of underlying conditions can be encouraged.27
Pressure Ulcers
Sometimes called bed sores, pressure ulcers are open sores on the skin.
Because they are preventable, pressure ulcers are considered an indicator of
the quality of care received. Among seniors living in residential care, 5% had an
advanced pressure ulcer (stage two to four). Over a three-month assessment
period, the condition of 3% of these residents worsened.
96
Chapter 5: Caring for Seniors in Residential Care
Pressure ulcers are more common among frail individuals or those with a
disability that makes it difficult for them to move around easily. These ulcers
can be prevented by assessing resident risk, providing special mattresses
and/or padding, periodically turning those who cannot move independently,
avoiding incontinence, keeping skin dry and providing good nutrition.28 Special
wound dressings and treatments can be used to help pressure ulcers heal
faster.28 In cases where the pressure ulcer does not show signs of healing, the
person should be evaluated for complicating factors, such as nutritional deficits,
terminal illness, elevated bacterial levels or the presence of other comorbidities.
Clinical assessment protocols for pressure ulcers, similar to those described
for the pain quality indicator, are available. These are designed to work with a
variety of assessment instruments, and the results can inform overall plans of
care to help address the problems associated with pressure ulcers.
Falls
Falls are the leading cause of injury hospitalizations for seniors across the
country, contributing to 9% of all emergency department visits by seniors.29
Falls can lead to serious injuries, reduced mobility, nursing home admission
and death.30 The prevalence of falls is an important quality indicator for home
and residential care clients, as well as individuals in other settings (see Figure 21).
Often, falls among home care clients are caused by safety hazards in their
homes.30 Underlying issues that can lead to a fall in either setting include muscle
weakness, vision problems and side effects from medications.31, 32 In some
cases, cognitive impairment, including dementia and delirium, can increase
the risk of a fall.30
A number of clinical practice guidelines on fall reduction exist in Canada
and internationally.33–36 Most can be adopted in both home and residential
care settings. Also available across Canada are a number of fall prevention
initiatives aimed specifically at seniors. Some offer educational sessions on
fall prevention.37 Others are more interactive, focusing on building strength
and improving balance.37 It has been suggested that the most effective fall
prevention strategies are collaborative, aim to change more than one risk
factor and are specific to individual risk profiles.31
97
Health Care in Canada, 2011: A Focus on Seniors and Aging
The figure below provides comparative information on falls among seniors
age 65 and older. The 2009–2010 data spans different care settings. Taken
together, it provides a picture of the prevalence of falls among the seniors
population across care settings. In complex continuing care, 7% of seniors
fell within 30 days of assessment, whereas in home care, 28% fell within
90 days of assessment. Differences among sectors may be partly explained
by the profile of individuals in each setting and by characteristics specific
to each. This data is not directly comparable across all settings because it
is based on different methodologies and different settings.
Figure 21: Falls Among Seniors, 2009–2010
Care Sector
Percentage of
Seniors (Age 65+)
Experiencing a Fall
Time Frame
Prior to Admission/Visit
Acute Care
8%
Prior to admission
Emergency Department
9%
Prior to visit
Mental Health (Inpatient)
12%
30 days prior to admission assessment
12%
Within 30 days of assessment
7%
Within 30 days of assessment
28%
Within 90 days of assessment
Within Care Setting
Residential Care
Complex Continuing Care
Home Care
Note
Data across sectors is not necessarily mutually exclusive. For example, a senior admitted to inpatient
acute care who had fallen while receiving home care services would be counted in both sectors.
Sources
National Trauma Registry, National Ambulatory Care Reporting System, Ontario Mental Health Reporting
System, Continuing Care Reporting System and Home Care Reporting System, 2009–2010, Canadian
Institute for Health Information. Please visit www.cihi.ca for the methodology specific to each database.
98
Chapter 5: Caring for Seniors in Residential Care
Conclusion
Most seniors in Canada reside in their own homes and in their own communities.
As their needs increase for assistance with daily activities and personal care,
some will eventually require institutionalization.38 Chapters 3, 4 and 5 have
shown that care for seniors comes from a variety of providers in a variety of
settings. Comparisons of long-term home care clients and seniors living in
residential care facilities showed that the latter tend to have higher care and
support needs. Although seniors typically prefer to stay in their own homes
for as long as possible, residential care facilities can provide them with many
benefits, including around-the-clock care and a socially supportive environment.
Quality indicators such as signs and symptoms of depression were derived from
standardized assessment instruments developed by interRAI, a collaborative
network of international researchers.39 The assessment instruments share a
common language, which permits the same clinical concepts to be referenced
across instruments and care settings, forming an integrated health information
system.26, 40 Reporting such measures serves not only to illustrate variation, but
also to identify opportunities for improvements in care.41
All of the indicators examined in this chapter are amenable to preventive
measures. Measuring and reporting on them facilitates awareness, which
is the first step to managing the associated issues. The analyses reveal
that the quality of care received by seniors can be improved in some areas,
in both home and residential care settings. Researchers have identified some
barriers to change; where possible, strategies to ameliorate these should
be investigated.
99
Chapter 5: Caring for Seniors in Residential Care
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Quality Ontario, 2011).
29. Canadian Institute for Health Information, Quick Stats: Emergency Department
Visits: Volumes and Median Length of Stay by Triage Level, Visit Disposition,
and Main Problem, 2009–2010 [Online Database], last modified 2011,
accessed from <http://www.cihi.ca/CIHI-ext-portal/internet/EN/Quick_Stats/
quick+stats/quick_stats_main?pageNumber=1&resultCount=10>.
30. Public Health Agency of Canada, Report on Seniors’ Falls in Canada (Ottawa,
Ont.: Minister of Public Works and Government Services Canada, 2005).
31. C. Todd and D. Skelton, What Are the Main Risk Factors for Falls Amongst
Older People and What Are the Most Effective Interventions to Prevent
These Falls (Copenhagen, Denmark: World Health Organization Regional
Office for Europe, 2004).
32. Health Quality Ontario, Explaining Our Indicators: Percentage of Clients Who
Say They Have Fallen in a Three-Month Period, last modified March 31, 2011,
accessed from <www.ohqc.ca/en/hc_pl_def.php?indicatorid=109>.
33. M. A. Norris et al., Canadian Task Force on Preventive Health Care—
Recommendations Statement: Prevention of Falls in Long-Term Care
Facilities, last modified 2011, accessed from <www.canadiantaskforce.ca/
docs/CTF_FallsPrevn_RS_Aug05.pdf>.
34. T. Virani et al., Nursing Best Practice Guideline. Prevention of Falls and Fall
Injuries in the Older Adult (Toronto, Ont.: Registered Nurses’ Association of
Ontario, 2002).
103
Health Care in Canada, 2011: A Focus on Seniors and Aging
35. American Geriatrics Society et al., Guidelines for the Prevention of Falls
in Older Persons (New York, New York: AGC, 2001).
36. American Medical Directors Association, Falls and Fall Risk: Clinical
Practice Guidelines (Columbia, Maryland: AMDA, 2003).
37. S. Ndegwa, Initiatives for Healthy Aging in Canada: Environmental Scan
Issue 17 (Ottawa, Ont.: Canadian Agency for Drugs and Technologies
in Health, 2011).
38. P. L. Ramage-Morin, “Successful Aging in Health Care Institutions,”
Health Reports 16 (2005): pp. 47–56.
39. interRAI, interRAI Mission and Vision, last modified 2006, accessed from
<www.interrai.org/section/view/>.
40. J. W. Poss et al., “A Review of Evidence on the Reliability and Validity of
Minimum Data Set Data,” Healthcare Management Forum 21, 1 (2008):
pp. 33–39.
41. V. Mor, “Improving the Quality of Long-Term Care With Better Information,”
The Milbank Quarterly 83, 3 (2005): pp. 333–364.
104
In 2009–2010, one-quarter
(about 25%) of seniors were
admitted to inpatient care via the
emergency department, compared
with only 8% of non-seniors.
Chapter 6
Caring for Seniors With Acute Illness
As with Canadians of all ages, seniors may become ill enough to require
a hospital visit. They may seek care at emergency departments or be admitted
as inpatients. This chapter describes how the system is meeting the needs
of seniors when they become acutely ill. It looks at the appropriateness of care
they receive in emergency departments and acute care hospitals. In particular,
it examines patient flow, through discussions of waiting to be seen in emergency
departments, hospitalizations for ambulatory care sensitive conditions and
alternate level of care stays. Care at the end of life is also discussed. These
are all interactions that seniors commonly have within the hospital sector.
As the proportion of seniors in Canada’s population grows, issues affecting
older Canadians will have bigger impacts on the system. As such, it will become
increasingly important to carefully manage these issues in order to minimize
their impact on the hospital system.
Where to Find It
Chapter 2: The Sustainability of Canada’s Health Care System provides detailed
comparative information on seniors’ use of hospital care. It reports on hospital
discharges and length of stay for inpatient acute care, mental health care,
complex continuing care and rehabilitation services, as well as outpatient and
emergency care.
Health Care in Canada, 2011: A Focus on Seniors and Aging
Wait Times in Emergency Departments
Almost half of the unmet care needs reported by Canadian seniors in a 2005
survey were related to long wait times.1 Waiting to be seen in the emergency
department remains a challenge, driven in part by the flow of patients through
the entire hospital system. 2 Several provincial and territorial governments have
raised the issue of access to emergency care,3, 4 often underscored by media
reports. Limited resources can result in emergency department closures, which
in turn can impact how far patients need to travel or how long they need to wait
to receive care.5, 6
Seniors have significantly higher rates of emergency department use compared
with their younger counterparts: 44,043 per 100,000 population age 65 and
older versus 29,485 per 100,000 population age 20 to 64. Using data from
CIHI’s National Ambulatory Care Reporting System, comparative indicators
of emergency department wait times can be reported for several Canadian
provinces and territories. There are different ways to measure how long people
stay in emergency rooms, depending on where the clock starts and stops—
Emergency Department Length of Stay and Time Waiting for an Inpatient
Bed, for example. Results from these two measures show some consistent
differences in wait times for seniors compared with younger adults.i
The total time that seniors spend in the emergency department before either
being admitted to the hospital or discharged home was calculated for 2009–
2010. Data shows that the median length of stay in emergency departments
was 4 hours for seniors, compared with only 2.5 hours for adults age 20 to
64. The length of stay increased with age: 3.3 hours for those age 65 to 74;
4.2 hours for those age 75 to 84; and 5.3 hours for those age 85 and older.
Factors such as severity of presenting condition, subsequent destination (home
versus admission to hospital, for example), time needed for patient monitoring,
diagnostic or laboratory test results and consultation with specialists can all
affect the length of time spent in the emergency department.
Because they are more likely than younger adults to have multiple chronic
conditions,7 seniors have more complex care needs, which may also contribute
to the longer waits for older seniors. For example, medical staff need to evaluate
the impact of existing multi-morbidities and current prescription drug utilization
in light of presenting conditions at the emergency department. Gathering such
information takes time. Emergency department staff must also coordinate
care with informal caregivers and often must ensure that formal home support
programs are in place before patients can be safely discharged home.
i. Data includes full coverage of Ontario and parts of Nova Scotia, P.E.I., Manitoba, B.C. and Yukon.
108
Chapter 6: Caring for Seniors With Acute Illness
Once in the emergency department, seniors are also more likely than younger
adults to be admitted as inpatients. In 2009–2010, one-quarter (about 25%)
of seniors were admitted to inpatient care via the emergency department,
compared with only 8% of non-seniors. On average, seniors spend more time
waiting to be admitted to inpatient care, compared with non-senior adults (3.7
hours versus 2.7 hours in 2009–2010). This is due in part to the nature of the
conditions for which seniors are most often being treated (see Figure 22). For
example, cardiac and respiratory conditions represent the majority of hospital
visits by seniors. These conditions can lead to serious complications in seniors,
adding to the complexity and length of treatment.
Innovation in Delivering Care
The traditional approach to providing care has focused primarily on different
levels of care delivered separately and in different places. Many experts are
recommending that the system adapt to provide a more integrated approach to
care, providing services across the continuum in a coordinated way.
The first of its kind in an acute care academic health sciences centre in
Canada, the Acute Care for Elders (ACE) Strategy at Mount Sinai Hospital in
Toronto encompasses a comprehensive and integrated continuum of care that
spans home and community, ambulatory, emergency and inpatient services,
while promoting independence and minimizing the risk of functional decline.
The program aims to get those who are hospitalized home as soon as
possible—or keep them out of the hospital entirely.
“Every day an older person is in hospital, they lose 5% of their function,” says
Dr. Samir Sinha, Mount Sinai’s director of geriatrics, noting that an extended
stay could mean that the person never lives independently at home again.
In the emergency department, every senior is screened to identify risk factors
predicting poor outcomes. If hospitalization cannot be avoided, specialty
inpatient geriatric consultation teams and units manage issues to prevent
functional decline, with the frailest patients receiving enhanced therapy to meet
the goal of returning them home. Discharged patients are followed up on, while
the homebound receive ongoing primary care at home through a partnership
with a local agency and the support of geriatricians and geriatric psychiatrists.
In the strategy’s first year, Mount Sinai’s average length of stay and readmission
rates dropped. It returned home the highest percentage of patients in the region
and achieved a patient satisfaction rate of nearly 97%.
“This is the model we need to move forward if we’re going to ensure that our
publicly funded system can meet the needs of an aging population,” Sinha says.
109
Health Care in Canada, 2011: A Focus on Seniors and Aging
In 2009–2010, 4 of the top 10 reasons seniors were hospitalized in acute
care were cardiac-related. These accounted for 11% of all seniors’ acute care
hospitalizations but only 7% of acute care hospitalizations for non-senior adults.
Other top reasons for the hospitalization of seniors included chronic obstructive
pulmonary disease, pneumonia and palliative care (see Figure 22).
The figure below shows the top 10 reasons for inpatient hospitalization in
acute care among seniors. Several of the top reasons for hospitalization
were similar in senior and non-senior populations, including treatment for
chronic obstructive pulmonary disease, percutaneous coronary intervention
and hip and knee replacements.
Figure 22: Top 10 Acute Inpatient Conditions for Seniors, Canada, 2009–2010
Number of
Seniors’
Discharges
Percentage of
Seniors’ Discharges
Chronic Obstructive Pulmonary Disease
49,914
4.9
Top Acute Inpatient Conditions for Seniors
Heart Failure
43,580
4.3
Knee Replacement
30,784
3.0
Viral/Unspecified Pneumonia
30,385
3.0
Myocardial Infarction/Shock/Arrest
27,804
2.7
Hip Replacement
27,369
2.7
Arrhythmia
25,599
2.5
Palliative Care
21,524
2.1
Percutaneous Coronary Intervention
19,377
1.9
General Symptom/Sign*
17,533
1.7
Notes
* Includes multiple conditions (such as nervousness, unspecified pain and cachexia).
Excludes obstetrical cases, cadaveric donors, non-Canadian residents and records with a most
responsible diagnosis for mental health (ICD-10 diagnosis code with a prefix of F or G30).
Source
Hospital Morbidity Database, 2009–2010, Canadian Institute for Health Information.
110
Chapter 6: Caring for Seniors With Acute Illness
Wait Time Benchmarks for Priority
Interventions
In 2004, Canada’s first ministers agreed to reduce wait times in five priority
areas: cancer treatment, cardiac care, diagnostic imaging, joint replacement
and sight restoration.8 They also agreed to work toward meeting evidencebased targets—called benchmarks—for medically acceptable waits. Canadian
benchmarks were established in 2005 for key procedures such as hip and knee
replacements and cataract surgery.
Seniors comprise a significant proportion of the patients waiting for these
procedures. In 2009–2010, about 60% of hip and knee replacements and 80%
of cataract surgical procedures were carried out on seniors. All three types of
procedures were among the top conditions for which seniors received hospital
treatment. For example, one-quarter of all day-surgery visits among seniors
were for cataract surgery, the highest volume day-surgery procedure for seniors
in 2009–2010.
Since the introduction of the 10-Year Plan to Strengthen Health Care
Care,, progress
has been made in reducing wait times. In 2010–2011, about 8 out of every 10
patients across Canada received their priority procedures within the
benchmarks. Specifically, 84% of patients received their hip replacements, 83%
received their cataract surgery and 79% received their knee replacements
within the benchmark time frames in 2010.9
111
Health Care in Canada, 2011: A Focus on Seniors and Aging
Hospitalizations for Ambulatory Care
Sensitive Conditions
As described in Chapter 1, seniors are a diverse group. Many Canadians
maintain good health well into their senior years, while others develop one
or even several chronic conditions as they age.10 Many of the complications
associated with chronic conditions like chronic obstructive pulmonary disease,
congestive heart failure and high blood pressure can be avoided or delayed
through appropriate delivery of primary care in the community and in specialty
clinics. Because of this, they are considered ambulatory care sensitive
conditions (ACSCs). One of the most important and potentially avoidable
complications is hospitalization.
Overall, ACSC hospitalization rates have decreased from 351ii per 100,000
population in 2006–2007 to 302 per 100,000 population in 2009–2010.11, 12
A number of factors—including where people live, their sex, the severity
of their condition and their income—are associated with variation in ACSC
hospitalization rates.11 Age is also a factor.
An estimated 1 in every 11 seniors who visits an emergency department
is there to receive care for an ACSC.13 Seniors who visited emergency
departments seeking treatment for ACSCs were assessed as requiring more
urgent care than those seeking treatment for other conditions, and they
were more likely to be hospitalized as a result.13 Although the likelihood of
hospitalization for treatment of an ACSC has recently decreased, the numbers
remain high: almost half of seniors (47%) who arrived at the emergency
department seeking treatment for ACSCs in 2009–2010 were admitted (down
from 52% in 2004–2005).13
ii.
112
Figures for 2006–2007 do not include data from Quebec.
Chapter 6: Caring for Seniors With Acute Illness
Hospitalization rates for selected ambulatory care sensitive conditions
(ACSCs) vary by age group. With the exception of epilepsy, rates are highest
among those age 85 and older for all ASCSs, most notably for congestive
heart failure and chronic obstructive pulmonary disease.
Figure 23: Rates of Hospitalization for Ambulatory Care Sensitive Conditions,
Canada, 2009–2010
2,500
Rate Per 100,000
2,000
1,500
1,000
500
0
Angioplasty
Asthma
Congestive
Heart Failure
COPD
Diabetes
Epilepsy
Hypertension
Ambulatory Care Sensitive Condition
45–64
65–74
75–84
85+
Note
Excludes cases where death occurred before discharge.
Source
Hospital Morbidity Database, 2009–2010, Canadian Institute for Health Information.
113
Health Care in Canada, 2011: A Focus on Seniors and Aging
Analyses of hospitalization rates for seniors with ACSCs in 2009–2010 show
variation by age group. Rates of hospitalization for congestive heart failure
were significantly higher as age increased, at 387 per 100,000 population for
the youngest group of seniors (those age 65 to 74), compared with 2,240 per
100,000 population for the eldest group of seniors (those age 85 and older).
Similar results were found for chronic obstructive pulmonary disease: 758 versus
1,711 per 100,000, respectively. Smaller differences were seen in hospitalizations
for angioplasty, asthma, diabetes and hypertension (see Figure 23).
Strategies for reducing ACSC admissions, including early detection, regular
monitoring, drug therapy and healthy lifestyle promotion, are all available
through primary care providers. Often, such strategies help seniors manage
chronic conditions successfully in their communities. However, even with
effective chronic disease management, hospitalization is sometimes required.
Preventing Influenza
Influenza is a major cause of hospitalization and mortality among seniors in
Canada. In 2009–2010, approximately 2,300 patients age 65 and older were
admitted for influenza.iii Approximately 10% of them died. In 2008–2009, the
estimated average cost for a flu hospitalization was about $2,900.14 For the same
dollar amount, the government could pay for approximately 384 flu vaccinations
(based on the 2006 Ontario flu shot program).15
Influenza can be prevented. Vaccination has been recommended worldwide,
particularly for high-risk groups, including seniors and people who live and work
with seniors.16–19 To ensure access, public health programs across Canada
provide publicly funded vaccinations to people age 65 and older, who are at
high risk for complications. 20 Vaccination priority is also given to health care and
social service workers who work with high-risk groups. Despite significant
health promotion efforts, vaccination rates in Canada frequently remain below
set targets. 21
Compared with 28 other OECD countries, Canada ranked 10th for influenza
vaccination among seniors, with an estimated 67% of the seniors population
having been vaccinated in 2008. When surveyed, community-dwelling Canadian
seniors offered several reasons for avoiding immunization, including fear of
adverse reactions, belief that influenza vaccination was unnecessary and having
experienced a bad reaction previously.21
(cont’d on next page)
iii Approc
iii. Includes hospitalizations for lab-confirmed and suspect H1N1 virus, as well as for seasonal influenza.
Caution must be used when interpreting these statistics, as rates of hospitalization for H1N1/influenza
were higher for all age groups between April and December 2009 than for seasonal influenza in a
typical year. 22
114
Chapter 6: Caring for Seniors With Acute Illness
Canada ranked 10th among 29 OECD countries for total number
of seniors immunized against influenza in 2008, with only twothirds (67%) of all Canadian seniors having received an influenza
vaccination. Chile had the highest rate, at 78%.
Figure 24: Percentage of All Seniors Immunized Against Influenza,
29 Selected OECD Countries, 2008
90%
Percentage of Seniors Immunized
80%
70%
60%
50%
40%
30%
20%
0%
Chil
Aust e
r
Neth alia*
erlan
ds
Unite Mexic
d Kin
o
gdom
Kore
a
Irela
nd
Unite France
d Sta
tes
Can
ada
Italy
Spain
Belg
ium
Swe
den
New
Zeala
n
Den d
mark
Isr
Germ ael
Swit any †
ze
Luxe rland †
mbo
urg †
Japa
n†
Finla
nd
Port
ug
Hun al*
gary
Slov Austr
ia
ak R
epub *
lic
S
Czec lovenia
h Re
publi
c
Esto
nia
10%
OECD Country
Notes
* 2006.
† 2007.
Source
Organisation for Economic Co-operation and Development, OECD Health Data, 2010 (Paris,
France: OECD, 2010).
Seniors in Alternate Level of Care
The term “alternate level of care” (ALC) describes patients in acute care beds
who are waiting to be moved to another care setting, such as residential care or
rehabilitation.23 Some of the time spent in emergency departments is the result
of beds not being available for those already assessed and requiring inpatient
acute care.24 This may be driven in part by challenges in discharging acute care
inpatients experiencing ALC waits. On any given day, more than 5,200 acute
care beds across Canada are occupied by ALC patients.23 Nearly 85% of ALC
patients are age 65 or older; many (35%) are older than 85.
115
Health Care in Canada, 2011: A Focus on Seniors and Aging
ALC and Dementia
Dementia is a loss of cognitive function resulting from a variety of diseases. 25 It
is most prevalent among seniors, affecting approximately 1 in 11 Canadians
older than age 65. 26 This is expected to double by 2038, along with the increase
in the seniors population. 25
The presence of dementia is an important factor influencing a patient’s
likelihood of discharge from an acute care setting to a long-term care facility. In
2009–2010, almost one-quarter (23%) of all seniors designated as ALC had a
diagnosis of dementia. Their median length of stay in hospital was more than
twice that of seniors without a diagnosis of dementia (20 versus just 9 days).
The increased length of stay was likely due to waiting for an available spot in
long-term care. In 2008, the estimated direct cost of dementia cases in longterm and community care was $4.5 billion. 26
Several jurisdictions are developing strategies to address the expected increase
in dementia-related cases. For example, in Quebec, a committee of experts on
dementia has produced an action plan with several recommendations and a
strategy for their implementation. The recommendations include
• Providing personalized and coordinated assessment and treatment services;
• Developing training programs for professional staff and policy-makers; and
• Improving access to home support services and appropriate end-of-life-care. 27
In Saskatchewan, work is being done on addressing the barriers to using formal
services for dementia in rural communities. Issues such as the stigma of dementia,
lack of awareness and accessibility of services are among the barriers identified
and currently being targeted to improve dementia care.28 Recent research has
identified several factors associated with the onset of dementia, including mid-life
obesity and diabetes.29 It is possible that the prevalence of dementia among future
seniors may be reduced through targeted prevention strategies in these areas.
While about 15% of all ALC stays last only a few days, one in five (20%) lasts
more than a month.23 Research has shown that prolonged hospitalizations are
associated with serious adverse outcomes of particular concern to seniors.
These include accelerated functional decline,30, 31 pressure ulcers32 and infections.33
116
Chapter 6: Caring for Seniors With Acute Illness
Almost half of seniors designated as alternate level of care (ALC) were
ultimately discharged to long-term care facilities (47%), compared with
only one-quarter (26%) of non-senior adults. Compared with younger
adults, seniors were less likely to be discharged to rehabilitation
services (11% versus 20%) or discharged home without support
services (12% versus 23%).
Figure 25: Discharge Destination for Seniors Versus Non-Seniors Designated as
Alternate Level of Care, Canada, 2009–2010
Non-Seniors (Age 20–64)
Seniors (Age 65+)
8%
12%
12%
23%
20%
14%
11%
4%
17%
26%
7%
47%
Home (w/ Support Services)
Rehabilitation
Home (w/o Support Services)
Long-Term Care
Died
Other
Note
Excludes obstetrical cases, stillbirths, cadaveric donors and records with an invalid health care number.
Source
Hospital Morbidity Database, 2009–2010, Canadian Institute for Health Information.
117
Health Care in Canada, 2011: A Focus on Seniors and Aging
Although the overall rate of institutionalization among seniors has declined in
recent decades,34 seniors designated as ALC are most commonly waiting for
placement in long-term care (see Figure 25). On any given day, an estimated
4,400 are waiting for such placements. The number of long-term care beds
per 1,000 seniors has remained virtually unchanged since 2004.35 However,
there has been considerable change in the use of those beds. Specifically,
there has been a rise in the proportion of residents receiving more intensive
care.35 This, coupled with the substantial rise expected in the number of seniors
over the next decade (many of whom will have multiple chronic conditions),
may increase the need for long-term care beds in the near future. The creation
of policies that allow seniors to transition out of hospital to a more appropriate
location of care may help to ensure that patient flow is not compromised as a
result of these trends. One such example is British Columbia’s Residential Care
Access Policy, which was created to ensure that patients with the highest need
are prioritized to receive residential care beds first.36
Care at the End of Life
Discussion in the earlier sections of this chapter focused on caring for seniors
who become acutely ill. The majority of that care is curative. However, as age
advances, the inevitability of the end of life becomes more salient, and the
focus of care may therefore shift from treatment to palliation. As Canada’s
population ages, taking a patient-centred approach to planning end-of-life
care will be increasingly important. The literature suggests that seniors prefer
to die in their own homes.37 Despite this, palliative care was among the top
10 conditions for which seniors were hospitalized in Canada in 2009–2010.
Eight out of every 10 adults who died in hospital, and who had been receiving
palliative care, were seniors.
Most deaths in Canada occur in one of four settings: at home, in long-term
care, in hospice or in an acute care hospital. In the decade between 1996 and
2006, the proportion of Canadians dying in a hospital declined steadily, from
73% to 60%.38 This downward trend of in-hospital death corresponds with
growth in community-based end-of-life care.
An important component in determining the most appropriate care for terminally
ill patients is being responsive to their expressed needs. A 2005 survey of
inpatients with end-stage disease at five tertiary hospitals in Canada found that
it was not the location of care that was most important to them. Rather, having
trust and confidence in their care providers—regardless of setting—was their
primary concern.39 This was also a priority to the majority of family caregivers
for these patients.
118
Chapter 6: Caring for Seniors With Acute Illness
The issue of end-of-life care has figured prominently in discussions of health
care renewal. Since 1995, it has been the focus of two senate committee
reports, as well as related initiatives, such as the appointment of a minister
with Special Responsibility for Palliative Care, the establishment of the
Secretariat on Palliative and End-of-Life Care, the development of a national
strategy on palliative and end-of-life care and a Parliamentary Committee on
Palliative and Compassionate Care.40–44 Many provinces and territories have
programs in place to ensure drug coverage for palliative patients.41 In addition,
recommendations related to end-of-life care appeared in both the Kirby and
Romanow reports of 2002.42, 45
The exact number of seniors whose end-of-life care would most appropriately
be provided in acute care hospitals is unknown. But the hospital system is
under pressure to accommodate admissions for both curative and end-of-life
care. This pressure will likely intensify as Canada’s population ages and the
need for end-of-life care grows.
Conclusion
Patient flow and integration of care across the continuum are critical
aspects of health system design. Length of stay in emergency departments,
hospitalizations for ACSCs and ALC stays all present challenges to patient
flow. These may also be compounded by the unique challenges already faced
by seniors who visit hospitals for treatment, particularly at the transition points
between different care settings. Examining seniors’ experiences with these
areas of hospital care is helpful in understanding how patient flow might be
affected by an increased number of seniors in Canada’s future population.
Compared with non-senior adults, seniors have longer lengths of stay in
emergency departments. Once hospitalized, they remain in acute care settings
longer than their non-senior counterparts—even after their acute conditions
have been addressed. Many are waiting to be transferred to a more appropriate
care setting, most often long-term care. Existing patient flow pressures,
combined with an increasing seniors population, will likely figure prominently
in determining the most appropriate role for acute care hospitals as provision
of end-of-life care evolves in the future.
Policy-makers may benefit from considering seniors’ unique challenges in these
areas. Such understanding may help identify areas where the system could be
adapted to better meet the needs of this growing population.
119
Chapter 6: Caring for Seniors With Acute Illness
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2005” Health Reports 18, 4 (2007): pp. 1–11.
22. Canadian Institute for Health Information, The Impact of the H1N1 Pandemic
on Canadian Hospitals (Ottawa, Ont.: CIHI, 2010).
23. Canadian Institute for Health Information, Alternate Level of Care in Canada
(Ottawa, Ont.: CIHI, 2009).
24. Physician Hospital Care Committee, Improving Access to Emergency Care:
Addressing System Issues (Toronto, Ont.: Ontario Hospital Association, 2006).
25. Chief Public Health Officer, Report on the State of Public Health Care
in Canada, 2010 (Ottawa, Ont.: Chief Public Health Officer, 2010).
122
Chapter 6: Caring for Seniors With Acute Illness
26. Alzheimer Society of Canada, Rising Tide: The Impact of Dementia on
Canadian Society (Toronto, Ont.: Alzheimer Society of Canada, 2010).
27. H. Bergman, Meeting the Challenge of Alzheimer’s Disease and Related
Disorders, accessed from <http://www.medicine.mcgill.ca/geriatrics/
QuebecAlzheimerPlanEnglish.pdf>.
28. D. Morgan et al., “Rural Families Caring for a Relative With Dementia:
Barriers to Use of Formal Services,” Social Science & Medicine 55 (2002):
pp. 1129–1142.
29. D. Barnes and K. Yaffe, “The Projected Effect of Risk Factor Reduction
on Alzheimer’s Disease Prevalence,” The Lancet Neurology 10, 9 (2011):
pp. 819–828.
30. K. E. Covinsky et al., “Loss of Independence in Activities of Daily Living in
Older Adults Hospitalized With Medical Illnesses: Increased Vulnerability
With Age,” Journal of the American Geriatrics Society 51, 4 (2003):
pp. 451–458.
31. C. Graf, “Functional Decline in Hospitalized Older Adults,” American Journal
of Nursing 106, 1 (2004): pp. 58–67.
32. M. Lindgren et al., “Immobility a Major Risk Factor for Development of
Pressure Ulcers Among Adult Hospitalized Patients: A Prospective Study,”
Scandinavian Journal of Caring Sciences 18, 1 (2004): pp. 57–64.
33. S. Ackroyd-Stolarz et al., “Impact of Adverse Events on Hospital Disposition
in Community-Dwelling Seniors,” Healthcare Quarterly 12 (2009): pp. 34–39.
34. M. Turcotte and G. Schellenberg, A Portrait of Seniors in Canada
(Ottawa, Ont.: Statistics Canada, 2006).
35. Canadian Institute for Health Information, Health Care Cost Drivers: The Facts.
(Ottawa, Ont.: CIHI, 2011).
36. Government of British Columbia, B.C.’s New Residential Care Access
Policy, last modified 2011, accessed from <http://www.health.gov.bc.ca/
hcc/pdf/residentialpolicy.pdf>.
37. Canadian Institute for Health Information, Health Care Use at the End of Life
in Western Canada (Ottawa, Ont.: CIHI, 2007), pp. 45–60, accessed from
<http://secure.cihi.ca/cihiweb/products/end_of_life_report_aug07_e.pdf>.
123
Health Care in Canada, 2011: A Focus on Seniors and Aging
38. Statistics Canada, Deaths in Hospital and Elsewhere, Canada, Provinces
and Territories, Annual (CANSIM Table 102-0509), last modified 2009,
accessed on August 10, 2009, from <http://cansim2.statgan.gc.ca/cgi-win/
cnsmcgi.exe?Lang=E&CNSM-Fi=CII/CII_1-eng.htm>.
39. D. K. Heyland et al., “End-of-Life Care in Acute Care Hospitals in Canada:
A Quality Finish?,” Journal of Palliative Care 21, 3 (2005): pp. 142–150.
40. Special Senate Committee on Euthanasia and Assisted Suicide, Of Life
and Death: Final Report, last modified 1995, accessed on September 23,
2011, from <http://www.parl.gc.ca/Content/SEN/Committee/362/upda/rep/
repfinjun00-e.htm#A.Palliative Care>.
41. Special Senate Committee on Euthanasia and Assisted Suicide,
Subcommittee to Update “Of Life and Death” of the Standing Senate
Committee on Social Affairs, Science, and Technology, Quality End-ofLife Care: The Right of Every Canadian. Final Report, last modified 2000,
accessed on September 23, 2011, from <http://www.parl.gc.ca/Content/
SEN/Committee/362/upda/rep/repfinjun00-e.htm>.
42. Standing Senate Subcommittee on Social Affairs, Science and Technology,
The Health of Canadians—The Federal Role. Volume Six: Recommendations
for Reform, last modified 2002, accessed on September 23, 2011, from
<http://www.parl.gc.ca/Content/SEN/Committee/372/soci/rep/
repoct02vol6-e.htm>.
43. Health Canada, Canadian Strategy on Palliative and End-of-Life Care
(Ottawa, Ont.: Minister of Health, 2005), accessed on July 3, 2011,
from <http://www.hc-sc.gc.ca/hcs-sss/pubs/palliat/2005-strateg-palliat/
index-eng.php>.
44. Parliamentary Committee on Palliative and Compassionate Care, website,
last modified 2010, accessed from <http://www.pcpcc-cpspsc.ca/index_
files/Page300.htm>.
45. R. Romanow, Commission on the Future of Health Care in Canada, Building
on Values: The Future of Health Care in Canada, last modified 2002,
accessed on February 1, 2010, from <http://dsp-psd.pwgsc.gc.ca/Collection/
CP32-85-2002E.pdf>.
124
The aging of Canada’s population
will likely put pressure on the health
care system to adapt to meet
Canadians’ needs, both current
and future. This presents health care
decision-makers with the opportunity
to examine aspects of the health care
system that could be improved.
Looking Forward:
Upcoming Challenges
When the first Canadian baby boomer turned 65 in 2011, it marked the
beginning of an acceleration in the aging of the Canadian population. Over the
next few decades, the proportion of seniors will grow to make up approximately
one-quarter of the Canadian population.1 Much evidence has shown that, on
its own, the increasing number of seniors will not threaten the sustainability
of Canada’s health care system.2, 3 However, the aging of the population has
brought several issues to the forefront, including the following: to what extent
the Canadian health care system has met seniors’ needs up until now, how it
will likely need to adapt to continue to meet these needs into the future and how
Canadians’ health care needs may change as the population shifts over the
next 20 to 30 years.
Summary of Report Findings
This report opened with a description of the seniors population. Life expectancy
among this cohort continues to rise, and there is some evidence that the gap
between women’s and men’s life expectancy is narrowing. With this in mind, a
discussion of the health system’s ongoing sustainability followed. It confirmed
that, despite seniors’ more frequent use of the health care system, aging itself
has not been the main driver of increases in public-sector health expenditures to
date. Across three main sectors (hospitals, physicians and drugs), several other
factors had bigger impacts than aging on rising costs over the last decade. Price
inflation, rising fees for service and population growth affected mainly the hospital
and physician sectors, while increased utilization affected mainly the drug sector.
The discussion moved next to exploring seniors’ use of a wide range of health
care services and added context by making comparisons where possible between
seniors and non-senior adults. Today’s seniors live largely in the community (93%)
with a variety of formal and informal supports, including primary care, prescription
medications, home care and informal care. A variety of services are available to
seniors when they become acutely ill or when their health deteriorates to the point
that they require institutionalization.
Health Care in Canada, 2011: A Focus on Seniors and Aging
Several challenges for the current system were identified. By addressing some
of these issues, care for Canada’s seniors could be improved now and in the
future. For example, polypharmacy remains an issue, with close to one in
every four (23%) seniors taking 10 or more prescription drugs. However, there
is some evidence that recommended strategies, such as regularly reviewing
medications with family physicians, are not followed by all seniors.4 In addition,
some of the drugs seniors are taking may not be appropriate for people their
age, though the use of these drugs among seniors appears to be declining.
Challenges were also identified in other parts of the system—home care, for
example. Among the almost 1 million seniors receiving formal home care, more
than a third (34%) reported daily pain and 14% reported signs or symptoms of
depression. And while 97% of home care clients also have informal support to
help maintain their independence, these informal caregivers—typically seniors’
spouses and children—are feeling the stress. Almost one in five informal
caregivers (17%) reported distress in their role. Often, the care they provided is
required around the clock; social services may be needed to help support these
caregivers in their roles. In contrast to home care clients, almost a third (31%) of
seniors in long-term care showed signs of depression, almost one in six (16%)
reported daily pain and 5% had an advanced pressure ulcer.
When seniors become acutely ill, their waits to receive care are due at least in
part to underlying challenges with patient flow across different care settings.
Data on wait times in emergency departments and acute care settings shows
that seniors wait longer for care than their younger counterparts. For example,
85% of alternate level of care patients (those who have completed the acute
care phase of their treatment but remain in an acute care bed) were older than
age 65; 47% of these patients were waiting for placement in long-term care.
While today’s seniors are living longer and healthier lives than ever before,
future challenges are still anticipated. In addition to growth due to the increased
number of seniors, requirements for social support, prescription medications
and primary care to help manage multiple chronic conditions are also likely
to increase, primarily as a result of growth in multi-morbidity. As Canada’s
population ages, there will likely also be a growing need for formal home care
and long-term care services.
This report confirms what experts have previously noted—that the aging of
Canada’s population will likely put pressure on the health care system to adapt
to meet Canadians’ needs, both current and future. This presents health care
decision-makers with the opportunity to examine aspects of the health care
system that could be improved.
128
Looking Forward: Upcoming Challenges
Issues on the Horizon
Many issues play a role in seniors’ use of the health care system. Canada’s
aging population will likely compound existing issues with geographic and
socio-demographic differences. For example, higher concentrations of seniors
in largely rural provinces/territories will likely influence the differences between
urban and rural residents, while the increased immigration to Canada of older
family members will likely make ethno-cultural diversity and the provision of
culturally appropriate services more important.
From a health system perspective, having a system that is responsive to the
unique health care needs of seniors will become increasingly important as
Canada’s population ages. Researchers and decision-makers have identified
a number of strategies that may help the Canadian health care system adapt
to seniors’ needs. Four areas where policy-makers could focus are discussed
below. Many of the ideas within these areas have at least, in part, already been
built into existing provincial/territorial strategies.
1. Improved Integration of Care Across the Continuum
Existing health care delivery systems and organizations were developed to
meet acute care needs. Adept at handling these one-time, episodic conditions,
these same systems are now facing issues such as fragmentation, inefficiency
and poor outcomes (particularly for those with chronic conditions).5, 6 Some
have suggested that delivering appropriate care into the future will require
a paradigm shift from episodic, short-term interventions to long-term,
comprehensive or integrated care for those with continuing care needs.7
Integrated care is especially important in the seniors population, because they
receive care from many different providers in various settings. Integrated care
systems help keep seniors living at home, without reducing quality of or access to
care. Integrated approaches have been shown to reduce stress on the health care
system, through fewer hospital visits and reduced hospital stays. In Australia, a
trial of integrated care tested the use of a care facilitator who directed patients to
their required health care services and education for self-care. This resulted in 21%
fewer emergency room visits and 28% fewer hospital admissions.8
Currently in Canada there is no shared definition for the concept of integrated
health care. The World Health Organization’s European Office for Integrated
Health Care Services defines integrated care as “a concept bringing together
inputs, delivery, management and organization of services related to diagnosis,
treatment, care, rehabilitation and health promotion.” 9 Consequently, integration
can take many forms, and since the mid-1990s, policy-makers have considered
various ways to promote integrated care in Canada.10
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Health Care in Canada, 2011: A Focus on Seniors and Aging
Integrated care can refer to the seamless movement between care settings,
encompassing patient responsibilities, coordination between health and social
services (including communication between health care providers) and informal
caregivers. Research has shown that integration plays a key role in a highperforming health care system for seniors,11 who are more likely than younger
adults to see multiple care providers.
Moving seamlessly between care settings can be accomplished in different
ways. Case managers, for example, coordinate care between providers,
thereby ensuring that patients receive all necessary care for their unique set
of conditions. Case managers can save time for physicians, nurses and other
professionals and help seniors navigate through the many sectors of the
health care system.12 The Program of Research to Integrate the Services for
the Maintenance of Autonomy (PRISMA) is an example of an integrated care
program developed especially for older and disabled populations. Through
the implementation of many elements, including a case management process,
the PRISMA model has achieved preliminary success in coordinating care in
several areas of Quebec.13
Seamless movement between care settings could also be accomplished within
a coordinated overall system that combines different health services. Such a
system for older adults could include chronic disease management and primary
health care, home care, long-term care, end-of-life care and acute care and
rehabilitation.11 Several OECD countries have adopted this approach in their
long-term care policies, in response to the complexity of interactions between
services. The policies were designed to make services work together more
effectively and to manage transitions between services more efficiently.11
Given the potential improvements to health care delivery and health outcomes
as a result of integration, several areas of research along this theme have
been recommended. Some areas to consider include how health and social
services have been integrated within Canada and internationally, how service
integration initiatives that have demonstrated improved service delivery and
health outcomes can be implemented within Canadian jurisdictions, and what
structural changes and financing resources would be required.11
However, despite many successes and substantial evidence of the benefits of
integrated care (including those mentioned above), several obstacles remain,
both in Canada and abroad.14 Care may be provided by separate providers/
organizations whose funding, incentives or eligibility criteria are not necessarily
aligned. Collaboration among providers requires additional time commitments
and ongoing communication. Health care professionals across the various
health care sectors lack the agreed-upon guidelines and protocols required
to effectively guide their behaviour. Differing payment mechanisms for health
professionals (for example, fee-for-service versus salary) between disciplines
and jurisdictions can impede efforts to integrate as appropriate to a particular
patient’s care.9
130
Looking Forward: Upcoming Challenges
Various approaches to integrated care have been suggested; some offer policy
direction, while others propose frameworks to achieve it.10, 14, 15 Regardless
of the specific approach, the overall goals of integrated care are to improve
accessibility, quality of care and fiscal sustainability, through optimizing system
performance and attaining quality patient outcomes.15, 16 Participants in a recent
roundtable discussion suggested that integrated care could result in better
value for money, if successfully implemented.11 As successful implementation
of integrated care will take time, early discussion and planning will ensure that
the system is ready to meet the population’s health care needs.
2. Increased Focus on Primary, Secondary and
Tertiary Prevention
Researchers have also asserted that initiatives that encourage and support
all aspects of healthy living may reduce the demand for health care and other
support services,17 through cost avoidance or shifts to lower-cost sectors.11
While not limited to seniors, such initiatives can lead to greater health, security
and independence in seniors by focusing on the health of the entire population.
One way to promote overall public health is through disease prevention, which
can take many forms. Primary prevention serves to protect healthy people
from developing disease in the first place.18 For example, flu vaccinations or fall
prevention programs may be particularly helpful in preserving good health in
the elderly. Secondary prevention aims to slow or even reduce the burden of
illness once a disease is already present.18 For example, regular blood pressure
checks for people with hypertension may help them manage the condition and
avoid or delay complications such as strokes.
Tertiary prevention focuses on helping people manage complicated, longterm health problems.18 Aspects of chronic disease management, traditionally
considered part of tertiary prevention, can be considered secondary prevention
if introduced early enough in the disease cycle. For example, options now exist
for diabetes patients to self-monitor their blood glucose and blood pressure
using telephone and mobile technology.19, 20 These inexpensive, fully automated
telemonitoring systems provide immediate feedback and action messages
to patients, summary reports of home blood pressure readings and critical
alerts to physicians.19 Initial findings suggest that such measures are effective
in helping to manage these conditions, which in turn can help prevent more
serious complications from manifesting.
131
Health Care in Canada, 2011: A Focus on Seniors and Aging
Current generations are benefiting from successful prevention initiatives
of the recent past. For example, a recent study following Toronto’s ban on
smoking in public places found a 17% decrease in acute myocardial infarction
(AMI) hospitalization rates and a 39% decrease in hospital admissions due to
cardiovascular conditions.21 Alcohol consumption and alcohol-related mortality
are positively associated, with reductions in the former mirrored in the latter.22 While
obesity has become more prevalent in recent years, the effects on the population’s
health from efforts to promote healthy body weights have yet to be determined.
In the health care system, collaboratives have been developed to make
recommendations on preventive measures based on best practices.
For example, the Canadian Task Force on Preventive Health Care was
established with the support of the Public Health Agency of Canada.23 Past
recommendations from this group have focused on preventing weight gain and
obesity in adults (2006), preventing falls in long-term care facilities (2005) and
preventing influenza in the general population (2004). Currently, the task force
is developing new or updated guidelines for prevention and screening of several
chronic conditions, including hypertension, diabetes, obesity, depression, and
breast and cervical cancers.23
There are many examples of specific prevention programs and initiatives across
the country. Two of special significance to seniors—flu vaccinations and falls
prevention—were highlighted earlier in this report. Attention should be paid to
a more consolidated strategy for prevention efforts and policies that focus on
promoting the health of the population as a whole.17 Improving the health of
the population now will result in significant cost savings for the system in the
future17—for example, fewer patients in acute care beds improves access for
those waiting for these services—and will ultimately ensure that Canadians
continue to live long and relatively healthy lives.
3. Adoption and Efficient Use of New Technologies
Many new technologies are emerging, with expected benefits to the health care
system and its users. Some technological advances are in the early stages of
development; with time, such technologies may be of particular service to older
Canadians. Other advances, such as telehealth—the delivery of services by
health care organizations using information and communications technology
solutions, when the clinician and patient are not in the same location24 —are
more widely applicable.
The applications of technology to health care are extremely varied. Some
initiatives are targeted for use by the providers of health care. For example,
implementation of a nationwide electronic health record (EHR) has been
promised for every Canadian by 2016.25 The potential benefits of a national
EHR include enhanced coordination of care among providers; improved
transitions between primary, acute, home and residential care settings; and
better access to complete and detailed health information on each patient. 25
132
Looking Forward: Upcoming Challenges
Other applications are targeted to the patients themselves. While some
evidence suggests that seniors are less likely than younger adults to adopt new
technologies, there are innovative pilot programs that encourage increased
uptake of these technologies by seniors. For example, Alberta provided funding
in 2011 for new technologies aimed at augmenting at-home senior services.
Technologies such as wander management systems, personal emergency
response programs and medication management systems will be tested by
clients in Grande Prairie and Medicine Hat during a two-year pilot project, with
an evaluation phase following. 26 These technologies aim to make more efficient
use of home care services and reduce emergency hospital visits. This program
was devised in response to the growing number of Albertans using home care
services (currently estimated at 107,000 seniors)27 and the shortage of home
care workers.
Still other applications are aimed at informal caregivers and family members, to
help seniors maintain their health in their communities. Among the technologies
being tested is a medication monitoring system equipped with both a sensor-trigger
system and a camera that sends a video clip to family members anywhere in the
world, allowing them to watch and ensure that their relative has taken the proper
dose at the right time.27 A few devices have also been created to help caregivers
of people with dementia. Flexible bed mats with pressure sensors let them know
when their family member has woken up and is moving. This flags the need to
check whether the person is disoriented and likely to fall. As well, magnetic door
sensors send an email, text message or cell phone message to caregivers if a
person with dementia goes outside unattended.27
The evidence on whether new and emerging technologies necessarily equate
to better care and outcomes remains unclear. For example, technological
advances in end-of-life treatment can prolong life but not necessarily in good
health. Research suggests that some of the recent increases in MRI, PET
and CT scans may be unnecessary, as older, less expensive and more readily
available diagnostic technologies—such as X-rays—may be equally effective
in diagnosing some conditions. 28, 29 Similar arguments can be presented for
certain prescription medications—for example, angiotensin receptor blockers
(ARBs), which are used to treat high blood pressure. Although shown to be
effective only in patients who cannot tolerate the side effects of other, older
drug classes, ARBs are being used increasingly by the broader population.30, 31
Quantifying the impact of technology as a driver of health care costs remains
difficult.32 Despite the fact that technology generally increases cost in the short
term, technology can also be a major factor in reducing costs in the medium
to long term.32 While technological change has been a major underlying cost
driver in the drug sector over the last decade, it is likely to also significantly
impact both the hospital and physician sectors in the future, emphasizing the
importance of continuing health technology assessments.32 As the system
133
Health Care in Canada, 2011: A Focus on Seniors and Aging
monitors the costs and benefits of both new and existing technologies, impacts
on system resources and patient outcomes will be better understood. Results
of such evaluations can help policy-makers understand where best to focus
limited resources. Needs assessments can help identify where emerging
technologies should be pursued and where older standards of care may be
more appropriate. In Canada, such evaluations are conducted by agencies in
many provinces as well as by the Canadian Agency for Drugs and Technologies
in Health (CADTH), a not-for-profit agency that delivers evidenced-based
information about the effectiveness and efficiency of health technologies.32
4. Better Information for Policy-Making
Having the information to understand whether high-quality care is available
across the system and where resources are being used most effectively allows
policy-makers to make better decisions. With growing pressure to tighten health
care budgets, performance measurement offers policy-makers an opportunity
for continuing health system improvement and accountability.33 Many have
recognized that before performance can be managed, it must be measured.
Measurement includes collecting high-quality information, calculating comparable
measures and using the results to work toward improvements. It also includes
improving data collection and data quality. For example, researchers have
suggested that too little information exists on the safety and effectiveness
of drugs used in real-world settings (meaning outside of clinical trials). More
information would benefit regulators, policy-makers, health care providers
and patients, and would allow for higher-quality research in Canada.34
Better information can also help policy-makers identify and understand key issues
across sectors of care. Impeding progress in this area, however, is the fragmented
nature of health care data, which some have argued has not kept pace with the
evolution of health care delivery models.35 Continuing and expanding upon the
existing data collection efforts in such centralized data holdings as the Home and
Continuing Care Reporting Systems, National Ambulatory Care Reporting System,
National Prescription Drug Utilization Information System, National Rehabilitation
Reporting System and the Primary Health Care Voluntary Reporting System
would allow for more detailed research across the continuum of care. The quality
indicators derived from the standardized assessment instruments developed by
interRAI (discussed in Chapter 5) underscore how such information can measure
variation and identify opportunities for improvements in care.
134
Looking Forward: Upcoming Challenges
Decision-making would further be supported by information shared seamlessly
between systems. However, existing data-sharing protocols often do not allow
for this.35 This issue becomes particularly salient when near-instant access to
information is often available in other realms, through tools such as the internet
and social media channels. In addition, to fully understand what happens as an
individual moves between various providers and types of service, health care
data must be recipient-centred. Experts have argued that the data systems
used to populate many national-level data sources are not as integrable as
required to provide the foundation needed for population-level analyses.35
Informed comparisons can provide policy-makers, health system managers
and health care professionals with valuable information that can be used to
improve the safety, quality, timeliness and effectiveness of the health care
system, as well as improve the patient experience. Collecting comparable and
high-quality data can allow performance measures to be calculated, which in
turn inform policy-makers’ and program planners’ decisions about where quality
improvement efforts are best focused.
Putting the Pieces Together
This report has provided information on a wide range of topics specific to
seniors’ health care needs and their use of the health care system. Seniors are
a diverse group; on several measures, younger seniors (those age 65 to 74) are
more similar to non-senior adults. With advancing age, the likelihood of multiple
chronic conditions increases, as does the need to access support services, and
a more complex mix of prescription medications is required to maintain health
and independence.
In the near future, policy-makers will likely have to make difficult decisions to
ensure that Canada’s health care system is able to accommodate the needs of
the increasing number and proportion of seniors in the population. This report
has suggested areas for concentrating future research and evaluation efforts and
areas where Canada’s policy and decision-makers may wish to focus attention in
order to maintain a strong health care system for current and future generations.
135
Looking Forward: Upcoming Challenges
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11, 2011), accessed on June 29, 2011, from <http://www2.canada.com/
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140
Index
Index
Note: The lowercase letter “f” preceding a page number indicates
that the information is in a figure, table or sidebar.
A
access to care for seniors
as government priority area, f2
in low-SES neighbourhoods, 16
activities of daily living, seniors
in residential care, 93
variability of, 17–18, f18
Acute Care for Elders (ACE) Strategy, Mount Sinai Hospital, Toronto, f109
adolescents, population proportion of, f10
age
and hospitalization for ACSC, f113, 114
and mental illnesses, 95
of population in general, 1, f8
of seniors, 13
and their health status, 17–19
in residential care, 90, f92
Alberta
population aging, f12
seniors
drug use for chronic conditions, 60, f61
having family physicians, f52
technologies for at-home seniors services, 133
alternate level of care (ALC)
and dementia, f116
for seniors, 115–16, f117, 118
alternative care providers, f55
ambulatory care sensitive conditions (ACSC), 113, f114, 115, f116
angiotensin receptor blockers, 133
assisted living for seniors, 79
Atlantic provinces, population aging, 11
141
Health Care in Canada, 2011: A Focus on Seniors and Aging
B
Beers list of drugs for seniors, 60–62
British Columbia
population aging, f12
Residential Care Access Policy, 118
seniors
having family physicians, f52
in residential care, f92
living in private households, 71–72
C
Canadian Agency for Drugs and Technologies in Health (CADTH), 134
Canadian Task Force on Preventive Health Care, 132
cancer services, wait times, f111
cardiac services, wait times, f111
care providers
family and friends as, 76–78
family and friends as, and caregiver distress, 76–77, f77, 128
chronic conditions, multiple, among seniors
and drug use, 57–62
compared with other adults, 19
primary care for, 51–56, 128
cognitive capacity, of seniors in residential care, f92
complex continuing care, use by seniors compared with other adults, 30, f31
connectedness among seniors, as government priority area, f2
continuum of care see integrated care
coxibs, 59
D
deaths, settings, 118–19
dementia
and alternate level of care, f116
program example, 133
dentists, role in seniors’ health, f55
depression
among seniors, 95
drug treatment for, f58
diabetes mellitus, drug treatment for, f58, 59
diagnostic imaging
142
Index
new versus old technologies, 133
wait times for seniors, f111
drugs
Beers list, 60
health care spending on
drivers, 40, f41
seniors compared with other adults, f36
medication management systems, 133
new versus old, 133
use by seniors
compared with other adults, 34
for multiple chronic conditions, f50, 57–60, 128
potential for inappropriate use, 60–62, 128
strategies for safety and appropriateness, 62
E
electronic health records, 132
emergency department use by seniors
and subsequent admission, 109
compared with other adults, 30, f31, f106, 108
wait times, 108, 128
emergency response systems, personal, 133
end-of-life care, 118–19, 128, 133
F
falls
in various care settings, 97, f98
preventing, as government priority area, f2
family caregivers for seniors, f70, 76–78, 128
family health teams, f54
First Ministers’ 10-Year Plan to Strengthen Health Care, 27
First Ministers’ Accord on Health Care Renewal, 27
First Nations, socio-economic status, f15
friends, as informal caregivers, f70, 76–78
functional capacity
as measure of health status, 17
of seniors, 17–18, f18
in residential care, f92
143
Health Care in Canada, 2011: A Focus on Seniors and Aging
G
gastrointestinal diseases, drug treatment for, f58, 59
gender factors
informal caregivers of seniors, 77
life expectancy, 13–15, 127
seniors and obesity, 19
seniors’ income, 16
seniors living alone, 71
seniors population proportions, 13
Geriatric Assessment Programs, Manitoba, f56
geriatricians
access to, f53
numbers and population ratios, f53
Guaranteed Income Supplement (GIS), 16
H
health behaviours among seniors, 19
health care reform
and population aging, f126
integration of care, f109
public debate on, 27
health care spending
international comparisons, age-related increases, 42–44, f43
on drugs, 57
on seniors, 1–2, f26, 34
compared with other adults, 35–36
for drugs, 57, f58
related to population aging, compared with other factors, 37–40, f41
health care teams, f54
health services, integration of care, f109
health service utilization see utilization of care
health status
and socio-economic status, 15–16
of seniors, 17–19
healthy eating among seniors, as government priority area, f2
heart disease, drug treatment for, f58, 59
high blood pressure
drug treatment for, f58, 59
in seniors population, 19
144
Index
high cholesterol, drug treatment for, f58, 59
home care
coordination and delivery of, f74
for seniors
and level of care needs, f93
quality of care, 94–98, 128
providers of, 73
services included, 73, f75
technological supports, 133
use by seniors, compared with other adults, 34
home support workers, availability, 73
hospitalizations of seniors, reasons for, 110
hospitals
and wait times for long-term care, f94, 128
health care spending on
drivers, 39, f41
seniors compared with other adults, f36
use by seniors, compared with other adults, 28, f29, 30, f31, 32, f33
housing for seniors (assisted living), 79
hypertension
drug treatment for, f58, 59
in seniors population, 19
I
immunizations, against influenza, f114–15
income, of seniors, 16
influenza, preventing, f114–15
informal caregivers
for seniors in the community, f70, 76–78, 128
technological supports, 133
instrumental activities of daily living, seniors, 17–18, f18
integrated care
and patient flow, 119
as priority area for change, f2, 129–31
defined, 129
for seniors with multiple chronic conditions, 51
program examples, f56, f109, 130
international comparisons
age-related increases in health care spending, 42–44, f43
influenza immunization for seniors, f114–15
145
Health Care in Canada, 2011: A Focus on Seniors and Aging
population aging, 13
Inuit
life expectancy, f15
socio-economic status, f15
J
joint replacements, wait times, f111
L
length of stay, seniors compared with other adults, 30, f31
life expectancy
Aboriginal peoples, f15
gender factors, 13–15, 127
increasing, 14, 127
M
Manitoba
Geriatric Assessment Programs, f56
population aging, f12
seniors
drug use for chronic conditions, 60, f61
having family physicians, f52
in residential care, f92
marital status, seniors in residential care, f92
men
income disparities for seniors, 16
in seniors population, 13
life expectancy, 13-15, f14, 127
seniors living alone, 71
mental health care, use by seniors compared with other adults, 30, f31
mental illness, among seniors, 95
Métis, socio-economic status, f15
mood disorders, among seniors, 95
N
neighbourhoods, socio-economic influences, 16
New Brunswick
population aging, f12
seniors
146
Index
drug use for chronic conditions, 60, f61
having family physicians, f52
Newfoundland and Labrador
population aging, f12
seniors
having family physicians, f52
in residential care, f92
living in private households, 71–72
Northwest Territories
population aging, f12
seniors, having family physicians, f52
Nova Scotia
geriatricians, f53
population aging, f12
seniors
drug use for chronic conditions, 60, f61
having family physicians, f52
in residential care, f92
Nunavut
population aging, f12
seniors, living in private households, 71–72
O
obesity among seniors, 19, 59
Old Age Security (OAS), seniors’ use of, 16
Ontario
informal caregiver distress, 76
population aging, f12
seniors
and wait times for long-term care, f94
having family physicians, f52
in residential care, f92
osteoarthritis, 19
osteoporosis, drug treatment for, f58
P
pain, in home care versus residential care, 96, 128
palliative care, 118–19
personal emergency response systems, 133
physical activity, as government priority area, f2
147
Health Care in Canada, 2011: A Focus on Seniors and Aging
physicians
health care spending on
drivers, 39, f41
seniors compared with other adults, f36
visits by seniors, compared with other adults, 34, 51, f52
policies and programs
information needs, 134–35
priority areas for seniors, f2, 129–34
population aging
and health care sustainability strategies, 129–35
causes, 9
cross-Canada variations, 11–12
defined, 9
forecast effects on health care spending, 42–44, 127
forecast proportions, 9, f10, 127
international comparisons, 13
modest effects on health care spending, 1–2, 37–40, f41
pressure ulcers, 96–97, 128
prevention, as priority area for change, 131–32
primary health care
for seniors with multiple chronic conditions, 51–56, 128
providers, f55
team approach, f54
primary prevention, as priority area for change, 131–32
Prince Edward Island
population aging, f12
seniors
drug use for chronic conditions, 60, f61
having family physicians, f52
Program of Research to Integrate the Services for the Maintenance of
Autonomy (PRISMA), Quebec, 130
proton pump inhibitors, use by seniors, 59
provinces
geriatricians, f53
health care spending, on seniors, 1, 35–36
informal caregiver distress, 76
population aging, f12
seniors
drug use for chronic conditions, 60
having family physicians, f52
148
Index
in residential care, f92
living in private households, 71–72
priority service areas, f2
psychologists, visits to, by seniors, f55
Q
quality of care, in home and residential care, 94–98
Quebec
health and social service integration, f91, 130
population aging, f12
seniors
having family physicians, f52
living in private households, 71–72
R
regional comparisons, population aging, 12
rehabilitation, use by seniors compared with other adults, 30, f31
residential care
for seniors
and level of care needs, f88, 93
numbers, 90
quality of care, 94–98
wait times, f94
Resource Intensity Weight (RIW), 32, f33
respiratory conditions, drug treatment for, f58
rural and remote areas
Aboriginal populations, f15
dementia services (Saskatchewan), f116
population aging, 12
S
Saskatchewan
dementia services in rural areas, f116
population aging, f12
seniors
drug use for chronic conditions, 60, f61
having family physicians, f52
in residential care, f92
living in private households, 71–72
149
Health Care in Canada, 2011: A Focus on Seniors and Aging
secondary prevention, as priority area for change, 131–32
self-reported health status, and multiple chronic conditions, 19
seniors
ACSC hospitalizations, 113, f114, 115, f116
defined, f11
demographics, 13
end-of-life care, 118–19, 128, 133
health behaviours, 16, 19
health care spending on, 1–2, f26, 34–36
health service utilization, 20
health status, 17–19
home care, 34, 73–74, f75, 128
in alternate level of care, 115–16, f117, 118
income, 16
independent living
informal care, 76–78
numbers and proportions, 71–72
strategies, f70, 73, f80
in residential care
level of support need, f88, 93
numbers, 90
life expectancy, 13–15, 127
population proportion of, 1, f8, 9, f10
priority areas in services for, f2, 129-35
socio-economic status, 15–16
supportive housing for, 79
utilization of care, 28–34
wait times
for emergency care, 108, 128
for priority interventions, f111, 128
for residential care, f94, 128
where they live, 71–72
with multiple chronic conditions
drug use by, f50, 57–62, 128
primary care for, 51–56, 128
sight restoration services, wait times, f111
smoking
among seniors, 19
and socio-economic status, 16
social connectedness, f2
150
Index
social support
for informal caregivers, f78, 128
for seniors
financial, 16, 34
housing, 79
through informal caregivers, 71
through social services, 78
social workers, visits to, by seniors, f55
socio-economic status
and life expectancy, 15
of Aboriginal peoples, f15
of seniors, 15-16
statins, 59
sustainability of health care system
defined, 27
forecasts related to population aging, 42–44, 127
public debates about, 27
strategies related to population aging
better information, 134–35
focus on prevention, 131–32
improved continuum of care, 129–31
use of new technologies, 132–34
T
technologies
and home care for seniors, f80, 90, 133
efficient use of, as priority area for change, 132–34
telehealth
applicablity, 132
seniors’ programs, f80
telehomecare, f80
territories
health care spending, on seniors, 1, 35–36
informal caregiver distress, 76
population aging, 11, f12
seniors
having family physicians, f52
in residential care, f92
living in private households, 71–72
priority service areas, f2
151
Health Care in Canada, 2011: A Focus on Seniors and Aging
tertiary prevention, as priority area for change, 131–32
tobacco control, as government priority area, f2
U
urban areas, population age, 12
utilization of care, by seniors
continuing care, 34
factors affecting, 20
family physicians, 34
home care, 34
hospitals, 28, f29, 30, f31, 32, f33
prescription drugs, 34
W
wait times
benchmarks for priority interventions, f111
for access to family physicians, f53
for cancer services, f111
for cardiac services, f111
for diagnostic imaging, f111
for emergency care, 108
for joint replacements, f111
for long-term care, f94
for sight restoration services, f111
wander management systems, 133
women
income disparities for seniors, 16
in senior population, 13
life expectancy, 13–15, f14, 127
obesity, 19
seniors, living alone, 71
Y
Yukon
informal caregiver distress, 76
population aging, f12
seniors
having family physicians, f52
in residential care, f92
living in private households, 71–72
152
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How to cite this document:
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