Understanding Residential Care: Public & Private
This is a comprehensive education article on the continuum of care, assisted living and residential care.
Of all the areas in healthcare that we’re failing at, residential care is at the top of the list. Massive chasms were exposed in the early days of the COVID pandemic and virtually none of that has been addressed. We have a critical crisis of lack of staffing. Now the Baby Boomer wave is just starting to hit this system without any substantial change to infrastructure in decades.
For adults and their loved-one’s face this is one of the most stressful parts of their lives.
If you are reading this education article, it is because you or a loved-one needs, or will need, assisted living or long-term care. Be part of the solution by writing to your MLA – but, more importantly, your Member of Parliament – regarding increasing funding for residential care. Consider joining the Canadian Association for Retired Persons (CARP) and find out what you can do to lend your voice to this cause.
As an empowered Substitute Decision Maker you must be an advocate for your loved-one:
Understand Medical Orders for Scope of Treatment and help choose the most appropriate level based on your loved-one’s values and beliefs.
Be assertive about letting your loved-one’s health team know about any Advance Care Planning wishes and documents. Give the residence a copy of the adult’s Representation Agreement and ask that it be put at the front of the chart. You will likely have to remind them it’s there and what it’s for.
Monitor your loved-one’s health and care. Be assertive when you find care and treatment that is inappropriate or does not meet your loved-one’s need.
Understand the Continuum of Care
Independent Living
There is an assumption that there is a step-by-step process from home living independently at home and then to an Independent Living community or Supportive Housing, then to Assisted Living and, finally to Long Term Care. This is rarely the case as each of these have their own distinct admission criteria.
For those with a serious life-threatening or life-ending disease, assisted living or long-term care are not appropriate for those who are nearing end-of-life. In these cases, in-home and in-facility palliative care and hospice should be considered. See Chapter 11, Understanding Palliative Care and Hospice.[CJ1]
Technically, Independent Living is not considered part of the continuum of care of assisted living and long-term care. Independent living housing communities are privately owned and operated, usually by large national companies, and amenities and services vary within each. Some allow the units to be purchased with additional amenities and services as a separate fee. Most are rental units with amenities and services included in the fee. Monthly fees vary widely.
Although it is not considered part of the continuum of care, it is often where older adults down-size to and it is important to know its limitations. Supportive non-nursing care is not provided. Some have contracts with private care home care companies. Most communities have emergency call buttons 24/7, and some will have a registered practical nurse answering these calls and providing crisis support.
Too often, adults opt to move to independent living when they already have significant cognitive and/or physical decline. In these cases, assisted living or long-term care would be a more appropriate choice. This is often to save their loved one’s independence. The repercussion can be another move within a short period of time after a health crisis.
Questions to ask when looking for Independent Living communities:
Is Independent Living something that can be afforded over the long term?
All of us should plan to live until we’re 100. Could you afford independent living (or private-pay assisted living or long-term care) for that long? If not, what is your back-up plan? It is wise to involve a financial planner before making this move.
If additional care is needed if you or your loved-one experiences physical or cognitive decline is additional public-subsidized or private pay home care allowed and, if so, what are the restrictions? Some communities won’t allow it at all (or for a limited period of time); some will only allow a few hours a day of outside private care, while others allow 24/7 care. How long will they allow home care to come in: i.e., weeks, months or ongoing?
What will happen if you or your loved-one has physical and cognitive decline, and they need to move to long term care? How will the facility facilitate and support the process? Will they help bring in a community case manager or is that the representative/loved-one’s job?
Do they have a ‘Campus of Care’ (continuum of care) allowing the adult to move within the facility or to sister-facilities when there is physical or cognitive decline?
Seniors’ Supportive Housing
Seniors’ Supportive Housing provides specially modified rental homes for low-income seniors and people with disabilities who need some assistance to live on their own. It is not considered as part of the continuum of care. It includes 24-hour response, light housekeeping, meals, and social and recreational activities.
Assisted Living
Assisted Living is only appropriate for those with physical disabilities or when they need assistance with three or more Activities of Daily Living and home care is not an option. It is not appropriate for those who cannot direct their own care due to advanced cognitive decline. If cognitive decline is mild, or develops while in Assisted Living, transfer to a long-term care often becomes necessary.
Definition of Activities of daily living: bathing and personal grooming, dressing, transferring, ambulating, and eating.
The options of type of housing are wide-ranging from apartments to private homes. Units can be individual rooms to self-contained apartments.
Care is ‘non-medical’ to assist with dressing, bathing and transferring. It is provided, largely, by registered care aides. Residents must be able to direct their own care, and in many facilities must be able to do or direct their own personal laundry and get themselves to and from meals and activities.
If the adult has increasing needs (especially due to cognitive decline), additional community or private-pay home care may be put in place to augment care until long-term care is available – but those in assisted living face the same waitlists as the general public.
There is a profound lack of assisted living facilities, especially for those waiting for a publicly-subsidized unit.
Residential Care is the same as Long-Term Care (LTC)… and is also known as Extended Care.
“Special Care,” is a higher level of care within residential care for adults who have complex behavioral issues and risk of wandering.
ng-Term Care is nearly always a last-step and the last place that an adult will live.
While the vast majority of adults who live in long-term care will die in long term care, death nearly always occurs due to complications of the aging process or advanced cognitive decline rather than from serious and complex physical health issues such as cancer, respiratory, and neurological diseases.
When our loved-one has significant physical or cognitive decline, a move to long term care is amongst the most important, difficult, stressful decision our lives. Deciding what facility is best for the person we love is nearly always grueling.
Publicly-subsidized care costs for both assisted living and LTC are outlined below. If publicly-subsidized care is what you are seeking, home care will have to be explored and maximized first (See, Understanding Home Care.)
Qualifications for Public-subsidized Long-Term Care
In order to qualify to be put on the publicly-subsidized LTC the adult must have moderate to advanced dementia or physical needs that cannot be met by home care supports and family caregivers. Wait times for publicly-subsidized care long at 12 to 24 months. That can force loved-one’s to make the difficult decision to place the adult at risk and family caregivers in private-pay long-term care. See below for a detailed list of admission criteria.
All facilities, whether public or private, are to meet the same minimum care requirements, and care is no different for someone who is receiving public-subsidized care and those who are paying privately. In fact, the Seniors Advocate of BC stated in 2020, that the average amount of care provided in private-pay facilities was lower than in public-subsidized facilities.
Author’s opinion: There is a national and provincial call for all facilities to become public-subsidized – but this is a very expensive proposition for governments because they would have to buy-out hundreds of multi-million-dollar businesses. Currently few, if any, government funded residential care facilities are being built, despite the ‘grey tsunami’ that is already hitting the system. Private-pay facilities continue to be built and fill an enormous need.
When Long-Term Care meets Palliative Care and Hospice
While LTC is often the last home for many aging adults, and the adult is likely to die there, it is best-suited for people who are approaching the end of their lives from the aging process and not from serious, life-threatening illness.
LTC is often not appropriate for adults who have a life-ending illness such as late-stage cancer, or neurogenerative diseases as staffing levels and caregiving experience are not high enough. In these cases, palliative and hospice care, at home, and in facilities should be considered.
Unfortunately, those who are already housed in long-term care who are dying of an acute disease (most often, cancer) will not be eligible for transfer to hospice as long-term care is deemed ‘palliative’. They may go to a hospital palliative care unit for severe pain and symptom control but will likely be discharged to their ‘LTC home’ to die.
In cases of serious physical illness, RN and physician staffing levels can be suboptimal for managing pain and symptoms. In these cases, the representative/loved-one’s need to be vigilant and assertive about appropriate care. If you do not feel your loved-one is getting the pain and symptom control they need, assertively ask for transfer to hospital and/or palliative care.
Understanding Publicly-Subsidized Assisted Living and Long-Term Care
You have a choice… sort of.
Note that a Representation Agreement is massively important at this stage – but it must have been put in place while the adult was still capable. Read: Who will Speak for You: Representation Agreements.
If the adult is deemed capable, they will have to give consent to be transferred to assisted living or long-term care. If you do not feel your loved-one has the capacity to make that decision, and you feel they are at risk if they remain at home, assertively ask for a geriatric psychiatry consultation and evaluation. If the healthcare team do not comply, reach out to a patient advocate and/or an experienced estate lawyer.
Admission Criteria
Long-term care services are for people who can no longer be cared for in their own homes or in an assisted living residence and:
Have severe behavioural problems on a continuous basis
Are cognitively impaired, ranging from moderate to severe
Are physically dependent, with medical needs that require professional nursing care, and a planned program to retain or improve functional ability, or
Are clinically complex, with multiple disabilities and/or complex medical conditions that require professional nursing care, monitoring and/or specialized skilled care.
In addition to the general eligibility criteria for home and community care services, to be eligible for long-term care services you:
Have been assessed as having 24-hour professional nursing supervision and care needs that cannot be adequately met in your home or by housing and health services
Are at significant risk by remaining in your current living environment, and the degree of risk is not manageable using available community resources and services
Have an urgent need for long-term care services
Have been investigated and treated for medical causes of disability and dependency that may have been [treated]
Have a caregiver living with unacceptable risk to their well-being, have a caregiver who is no longer able to provide care and support, or do not have a caregiver and
Have agreed to pay your assessed rate
Long-term care services
See the Ministry of Health website.
Assessments
All adults who are seeking publicly-subsidized residential care services are to receive an assessment using the RAI MDS 2.0 assessment tool (RAI is pronounced ‘rye’) and have a current care plan for care and services in the community. Therefore, it is important to open a file with your community home care branch as soon as the adult is needing support to live at home. Assessments are done once a year, but if the adult’s physical or cognitive decline progress and they are at risk to themselves due to wandering or falls, reach out to their case manager and ask for another assessment.
When the adult needs LTC, families are asked to make pick their top-three facilities within the healthcare authority. The top-three are all equally ranked and whichever comes up first is the one that needs to be accepted.
Interim Beds
When the adult is unable to go home due to significant physical or cognitive decline and the need to move to LTC is urgent or emergent – especially when the adult is being placed from hospital – the adult will be put on the Interim Bed list.
There is little or no choice in accepting an Interim Bed and they will be transferred to the first facility to have a bed within a reasonable distance of their home. The adult will remain on the top-three wait list and when one of those beds becomes available, family has the choice of taking that bed, or not (often the adult has adjusted to the interim bed). They will only have 48 hours to decide.
Higher Priority for:
Reconciliation of couples.
Veterans.
Client Transfers between Health Authorities
While a transfer to another health authority to be closer to family might involve extra paperwork for the adult’s case manager, an adult may, at any time, request this transfer.
Care Costs: Publicly-Subsidized versus Private-Pay
In all circumstances, there is a cost for assisted living and long-term care.
Fees for Publicly-Subsidized Assisted Living or Long-Term Care are based on net income, not assets.
Seek the advice of a financial planner, accountant or estate lawyer to determine how to minimize net income and the impact on spouses’ future finances.
Publicly-Subsidized Assisted Living a calculation is made of 70% of the individual’s income. The minimum client rate for a client receiving assisted living services is $1,070.90 per month and the maximum rate is based on a combination of the market rent for the housing and hospitality services for the geographic area where the client is receiving assisted living services and the actual cost of the personal care services for the client.
Publicly-Subsidized Long Term Care a calculation is made from calculating 80% of the adult’s income (but not the combined household income, as is the case for community home care) to a maximum of approximately $3,575.50 per month.
These costs can be a heavy-toll for households where one person goes into care and the other does not, especially when the remaining spouse is reliant on the income of the spouse entering care.
Families and individuals are fully expected to go into savings and to draw-down from the value of their home. This can be difficult for those who are financially living on the edge. Too often it means that the family home and assets must be liquidated.
Private-Pay Care
Costs are usually based on the amount of care required – and the location of the facility: the higher the land values and taxes, the more care will cost.
• Currently, Assisted Living can range between $6,000 to $12,000 per month depending on location.
• Currently, private LTC can range between $8,000 and $16,000 or more per month depending on care requirements and location and whether it is a ‘Not-for-Profit’ or ‘for-profit’.
Understanding Private-Pay Assisted Living and Long-Term Care: Not-for-Profit & For-Profit
If funds for private care are limited, plan ahead!
You may need to consider a move to a private-pay assisted living or long-term care facility if the waitlist for publicly-subsidized care is longer than can be managed at home due to:
Safety risks to the adult (wandering, falls, safety in the home, etc.)
Caregiver exhaustion.
Options for publicly-subsidized care that don’t meet the adult and family’s needs.
Pressure is being applied by acute care hospitals for rapid transfer.
How long can you afford private-pay? Let everyone at every stage know your financial limitations so that appropriate planning and a note for urgent or emergent transfer so a publicly-subsidized bed can be started immediately.
Private-pay care is divided into ‘Not-for-Profit’ and ‘For-Profit’
Not-for-Profit Private-Pay
These are often run by religious organizations and foundations (examples: Anglican and Catholic, Masonic, Rotary, Kiwanis and some ethnic communities). The difference in cost between a Not-for-Profit and for-profit can be substantial.
Not-for-Profits often have a limited number of private-pay beds as the majority are ‘leased’ to the health authorities as publicly-subsidized beds (see more, below.)
They are generally less ‘grand’ than for-profit, but the care should be exactly the same as laid out by provincial regulations and guidelines. It’s important to keep in mind that often the esthetics of a facility are more important to the family than they are to the adult.
Often (not always) a Not-for-Profit LTC will allow an administrative transfer to a publicly-subsidized bed when the adult meets the provincial guidelines for necessity of care due to physical and/or cognitive decline, without the need for the adult to physically move.
If you want your loved-one to be placed on the publicly-subsidized wait list, ask the facility director of care to help you facilitate the process when the adult arrives at the facility. Note, this process cannot be started prior to the admission.
Be aware that the waitlist to transfer to a publicly-subsidized bed can be long as the adult is already considered ‘safely housed’.
If funds for private-pay are limited, let the director of care and the assigned community case manager know when funds will run out.
If funds are running out for private-pay, ask that your loved-one be put on the emergency transfer list. The adult will then be put on the ‘interim bed’ list and there will be no choice of where they are transferred to. You can choose your top-three facilities but there is no guarantee that is where the interim bed will be – rarely, this will be outside your city (but always within the health authority).
Your loved-one will ‘lives’ in the community health catchment area for the address of the LTC facility (rather than their home address). You will need to be the one to open the file with the community health branch for your neighbourhood.
Be proactive and keep checking in with the community case manager.
To find your community health branch, ask the director of care for the facility, the adult’s primary care practitioner, or Google Search: your Health Authority + Locations and Services and a map and alphabetized services will come up.
“Contracted” Not-for-Profit Private-Pay and Publicly-Subsidized Care
Families get very confused about whether their loved-one is in a private assisted living or long-term care facility or whether it is a publicly-subsidized one. The answer is often both. What determines the difference is the amount the adult is paying, which will be outlined, below. The care is exactly the same, no matter how much you are paying.
There are very few government-owned assisted living and long-term care facilities, so they ‘contract’ or lease beds from private-pay facilities – usually Not-for-Profits. The number of beds that a health authority leases at any given time fluctuates but it can be up to 90 to 100% of the beds. (This can be a limiting issue when you are looking for a private-pay assisted living or long-term care facility.)
If your loved-one is eligible for long-term care, you will be given a list of facilities by the community case manager or the hospital community liaison (or whomever the hospital unit has designated being in charge of discharge planning). This list includes government owned and operated facilities as well as contracted facilities.
The contracted facilities have their own boards and financing. But they must abide by the Ministry of Health Facilities rules and guidelines. If your loved-one is receiving publicly-subsidized care and you have a complaint regarding care, it must go through the health authority’s Patient Care Quality Office.
For-Profit Private-Pay
Generally, these facilities are owned and operated by large national companies. Some have better services than others so do your homework. Some have campuses of care from independent living, assisted living, long term care, meaning the adult can stay in the same community as their care needs change. Generally, for-profit facilities do not have any publicly-subsidized beds and if the adult’s care needs advance and the facility does not have a campus of care, they will need to be transferred – and when this is a case of advancing cognitive decline, this can be a jarring and stressful change for the adult and loved-one’s.
Private-pay ‘All-in-one’ and ‘A-la-Carte’
Some private-pay facilities have everything included in the same price: care, no matter the level of need; food; rehabilitation and activities.
Some have the A-la-Carte model which is usually only offered in facilities that are exclusively private (i.e., no publicly-subsidized beds) where costs go up as care needs go up. This might seem like the more affordable option at first, but fees can sky-rocket with a sudden health issue.
If finances are an issue, ask what the policy is if care needs suddenly increase and the cost goes up with it. If these massive bills aren’t paid on time, facilities have been known to evict their residents. This becomes an emergency, and a community case manager needs to be notified immediately to put in an interim bed request at a publicly-subsidized facility. In these cases, hiring an independent patient advocate is highly recommended.
Resources
Seniors Advocate of BC
Information and Referral Call Line: Information and Referral Call Line: https://www.seniorsadvocatebc.ca/ 1-877-952-3181 (toll free) or 250-952-3181
The Office monitors and analyzes seniors services and makes recommendations to government and service providers to address systemic issues in five areas: health care, housing, income support, community support and transportation.
Home Support Review (2019): British Columbia’s home support program is unaffordable for most seniors, offers too little service for high-need clients and has created a workforce where 75 per cent of staff are casual or part-time… https://www.seniorsadvocatebc.ca/osa-reports/report-home-support-review/.
BC Long-Term Care Directory (2021): The 2021 Long-Term Care Directory is the seventh edition of information about long-term care homes available to the public. The Directory provides an objective, standardized statement for a variety of measures related to quality in B.C. long-term care homes. https://www.seniorsadvocatebc.ca/app/uploads/sites/4/2021/12/LTCD2021-Summary.pdf
Government of BC
BC Seniors Supportive Housing: https://www2.gov.bc.ca/gov/content/housing-tenancy/seniors-housing
Community Care and Assisted Living Act: https://www.bclaws.gov.bc.ca/civix/document/id/complete/statreg/02075_01
Home and Community Care Policy Manual:
o Residential Care Services: https://www2.gov.bc.ca/assets/gov/health-safety/home-community-care/accountability/hcc-policy-manual/6_hcc_policy_manual_chapter-6.pdf
o Calculation of Publicly-Subsidized Care Rates: https://www2.gov.bc.ca/assets/gov/health-safety/home-community-care/accountability/hcc-policy-manual/7_hcc_policy_manual_chapter_7.pdf
Assisted Living:
o https://www2.gov.bc.ca/gov/content/health/accessing-health-care/home-community-care/care-options-and-cost/assisted-living
o https://www2.gov.bc.ca/gov/content/health/accessing-health-care/home-community-care/care-options-and-cost/assisted-living
Assisted Living Regulation: https://www.bclaws.gov.bc.ca/civix/document/id/complete/statreg/189_2019
End-of-Life Care: https://www2.gov.bc.ca/gov/content/health/accessing-health-care/home-community-care/care-options-and-cost/end-of-life-care
Health Care (Consent) and Facilities Act: Regarding Admission to a Care Facility: https://www.bclaws.gov.bc.ca/civix/document/id/complete/statreg/96181_01#part3
Representation Agreement Act: Regarding Capability and deciding where the adult is to live: https://www.bclaws.gov.bc.ca/civix/document/id/complete/statreg/96405_01#section8
Long Term Care: General Information
BC Ministry of Health: https://www2.gov.bc.ca/gov/content/health/accessing-health-care/home-community-care/care-options-and-cost/long-term-care-services
BC Residents Bill of Rights: https://www.islandhealth.ca/sites/default/files/2018-11/bc-residents-bill-of-rights.pdf
Long-term Care RAI MDS 2.0 assessment tool: https://www2.gov.bc.ca/assets/gov/health/forms/5513datadictionary.pdf
Health Authorities: Access, Contact Information and LTC Facility Listings
Fraser Health: https://www.fraserhealth.ca/longtermcare
Island Health (VIHA):
Locations: https://www.islandhealth.ca/our-locations/long-term-care-locations
Interior Health:
o About: https://www.interiorhealth.ca/health-and-wellness/child-community-and-home-care/long-term-care
o Locations: https://www.interiorhealth.ca/services/long-term-care/locations
Providence Health Care: https://www.providencehealthcare.org/long-term-care
Vancouver Coastal Health:
o Facilities Matrix - at-a-glance guide: http://www.vch.ca/Documents/VCH-Long-Term-Care-Matrix.pdf
