Care of older Canadians: Policy challenges

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Care of older Canadians Policy challenges
emerging issues affecting caregivers byJanice
M. Keefe, PhDProfessor, Canada Research Chair
and Director, Nova Scotia Centre on Aging

• Presented at IRPP
• Montreal, PQ
• April 3, 2009

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Family/friend Caregivers Often invisible and
unrecognized but critical ingredients in the
maintenance and growth of the aging population
Dilemma Caregivers need to be recognize as
individuals with rights to their own services
and supports. At the same time public policy will
need to be targeted to caregivers who provide a
certain amount of care (not help).
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Who will care Reality checks

• 1st Reality Check
• The majority of care provided to older people in
  the community is by family and friends
  assumptions of their continued availability is
  problematic.
• 2nd Reality Check
• System of supports for family/friend caregivers
  is limited and inconsistent their role as
  caregiver, ambiguous.
• 3rd Reality Check
• An increasing proportion of the Canadian labour
  force are caregivers to older persons resulting
  in short and long term consequences.
• 4th Reality Check
• Reduced availability of family and changing
  values in purchasing care will increase demand
  for publically and privately-funded home care
  programs and services Can this demand be met?

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Policy Implications in 4 domains

• Income Security Many caregivers incurred extra
  expenses, other countries have financial support
  policies (beyond tax credits).
• Health/Home care services Caregiver needs are
  rarely assessed their needs are diverse.
  Respite, education and support are needed.
• Labour policy Employed caregivers face short
  and long term consequences on income, career
  advancement, and productivity.
• Human Resource Policy Increased demand for paid
  workers to provide support and personal care

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Reality 1

• Availability of Family/Friend Caregivers

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1 Availability of caregivers

• Issue
• Family/friends caregivers are the reason why home
  care is cost-effective yet supply and demand
  changing.
• Issue
• Limited access to supports for these caregivers
• Income security limited eg financial support,
  CPP, taxation policies (Reality 1)
• Issue Diversity of family caregivers there is
  no one solution but a range of responses that are
  needed
• Solutions
• Review international policies on financial
  support for caregivers

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Supply Availability of surviving children
Proportion of females 65 with no surviving
children, among those living in the community, by
age group, 2001-2051.
65
85
Source Carrière, Y. Keefe, J. Légaré, J. Lin,
X. Rowe, G. (2007).
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Factors affecting Caregiver Availability

• In long term - decreased number of children.
• Narrowing mortality gap means older spouses
  caring.
• In short term more adult children affected by
• Womens participation in the paid labour force
• Mobility Patterns
• In rural areas Out-migration of youth
• In urban areas - Increased cultural diversity
• In rural areas access to supportive services
• Length of care and Sustainability

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Elderly population 65 receiving assistance, by
sex and source of assistance, Canada, 2006-2031
Variation 2006-2031 ()
Women continue to be greatest number of receivers
of informal and formal support but their rate of
increase is less than men
79
111
104
101
142
90
Source Keefe, J. Légaré, J. (unpublished data)
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Reality 2

• Limited Supports for Family/Friend Caregivers

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Issues Affecting Family/Friend Caregivers

• Diversity in support
• Public home care programs vary in supportive
  services for family/friend caregivers
• Most can only be accessed through the client
• Shift to Community Care
• Reduced hospital stays
• Increased complexity of care and expectations/
  burden on family/friend caregivers.
• Caregiver needs not assessed
• System Challenges/opportunities
• Continuing care policies are under P/T
  jurisdiction
• Public continuing care programs becoming
  increasing used for acute care substitution
• Formal support for chronic care privatized and
  not regulated

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Where can I go for support?

• Provincial
• Home care, respite
• Tax relief
• Education, information, support

• Federal
• Compassionate Care Benefit
• Tax relief

• Federal - Issues
• CCB limited scope
• Tax Credits are non-refundable

• Provincial - Issues
• Varies by province and region
• Eligibility, entitlement
• ? Acute HC

• Private
• Home support services
• Respite

• Community
• Voluntary organizations
• Advocacy and support groups

• Private - Issues
• Limited to those who can afford these services
• Location

• Community - Issues
• Do not exist in all regions
• Rural/urban

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Policy for Caregivers in Canada

• Federal Taxation and EI
• Reviewed financial support policies in 10
  countries (direct, indirect labour)
• Review policies for compensating caregivers and
  assess their applicability to Canada
• Understand strengths and limitations of other
  countries approaches
• Assess how they might be implemented in Canada

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Ways of Supporting Caregivers
Assess caregiver needs

• Direct Services
• Enhanced Respite/Home Care
• Education/Information/Support
• Direct Financial Support
• Allowances paid to caregiver (less extent wages)
• Allowances paid to care receiver to pay caregiver
• Reimbursement of expenses
• In Direct Financial Support
• Taxation (benefits, exemptions )
• Pension (Credits, exemptions)
• Social security (workers comp, vacation, sick
  days)

Keefe, Glendinning Fancey (2008). In A. Martin
Matthews J. Philips (Eds) Blurring the
Boundaries
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What can we learn from other countries?

• Caregiving is a global issue
• Countries have carer strategies or
  comprehensive programs
• New Zealand Strategy for Careers (Jan. 2008)
• United Kingdom - National Strategy for Carers
  (Renewed June 2008)
• Australia - Home and Community Care Program HCAA
  (1992) - National Respite for Carers Program
  (1996)
• US Amendment to Older Americans Act (2000)
  established the National Family Caregiver Support
  Program
• Some recognize caregivers as clients
• Australias HCAA recognized caregivers as
  clients in their own right
• United Kingdoms Carers (Recognition and
  Services) Act (1995) gave caregivers the right to
  an assessment of their needs.
• England Wales 2004 The Caring Equal
  Opportunities Act gave caregivers more choice and
  opportunity.
• See http//www.msvu.ca/mdcaging/policyprofiles.a
  sp for more information on international
  caregiver financial compensation policies.

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AustraliaCarer Allowance
GermanyLTC insurance Home Care/ Domiciliary Care
Benefit

• 90 CAD every two weeks to caregiver (600
  annual bonus)
• Available to all caregivers who meet care
  requirements for child or adult (including
  elderly)
• Not taxable
• Recognition rather than income replacement
• CG may be eligible for Carer Payment and direct
  services

• Eligible clients choose money or services or
  combination
• 3 payment levels based on CR needs
• 318 to 1033 per month
• Paid to CR to pay CG but no evidence of how it
  is used
• Additional payment available for 1 month
  Stand-In Care
• Pension and accident insurances premiums covered

All 10 Policy Profiles are available at
www.msvu.ca/mdcaging/policyprofiles.asp
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Key issues and debates

• Introducing Money into the care relationship
• Supportive or negatively affecting women
• Consumer Choice and empowerment
• Woodwork effect costs

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Reality 3

• Employed caregivers

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2 Employed caregivers

• In 2002, more than 1.4 million Canadians age 45
  and older combined paid employment and care to
  older adults, and most caregivers worked
  full-time (Walker Fast, 2005)
• Issues Economic Costs - Short and long term
  consequences, lost productivity
• Non economic Costs Health
• Policy Review International review of public
  policies in labour similar to Canadas EI
  Compassionate Care
• Solutions
• Proposed labour policies to support employed
  caregivers

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Issues Affecting Caregivers

• Consequences to employed caregivers

Percentage of caregivers 45 years and over who
experienced employment consequences, 2002
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Initiatives by Country
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How to best support employed caregivers
National Policy
Workplace Policy
Employees
Caregivers
Caregivers
Employees
Recognize that any policy occurs in a particular
context Home and continuing care
services Other income security and labour
standards important
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Moving to Labour policy
National policies all caregivers
Percentage of Caregivers Who are eligible
National policies employed caregivers
Workplace policies
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Ways of Supporting Caregivers
Assess caregiver needs

• Direct Services
• Enhanced Respite/Home Care
• Education/Information/Support
• Direct Financial Support
• Allowances paid to caregiver (less extent wages)
• Allowances paid to care receiver to pay caregiver
• Reimbursement of expenses
• In Direct Financial Support
• Taxation (benefits, exemptions )
• Pension (Credits, exemptions)
• Social security (workers comp, vacation, sick
  days)

Labour Unpaid Leaves Paid Leaves for
family Paid Leaves for compassionate/chronic
care
Keefe, Glendinning Fancey (2008).
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Reality 4

• Challenges in accessing formal services

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4 Increase formal services

• Reality Check Reduced availability of family and
  changing values in purchasing care will increase
  demand
• Issue Recruitment and retention of human
  resources result in competition for resources
  within continuing care.
• Issue Working conditions, compensation education
  and training diverse across Canada
• Human resources to meet growing demands
• Less attention given to continuing care/care
  workers

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Retrieved from Women on Home Care Published by
the Canadian Womens Health Network
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Number of hours of help received per week, by
source, 2006-2031
87
100
124
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Issues affect Paid Caregivers Home Support
Workers

• Compensation
• Low wages, wage parity, limited benefits, travel
• Education and training
• Standardized training, entry requirements, skills
  upgrading, meeting current demands/needs
• Quality assurance
• Standards for home care programs, employees and
  continuity of care
• Working conditions
• Work loads, stress, safety, job insecurity,
  value

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POLICY DOMAINS

• Income Security
• Direct Financial Support
• Caregiver Payment/Allowance
• Pension Schemes
• reduced penalty for dropout
• State pays pension credits
• Taxation System
• Inclusion of care expenses
• Expansion of Tax Credits
• Social Security
• State pays employment/sickness insurance

• Health/Continuing care
• Respite care/Home Care
• Recognize caregivers as a client
• Assess caergiver needs
• Employment/Labour
• Leave policy employment insurance
• Labour Standards policy
• Health Human Resources
• Improve working conditions
• Training and Standards
• Focus on Recruitment and retention

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In summary Directions to consider

• Workplace policy directed to employees
• National insurance for all employees
• Direct support policy to all caregivers
  (including employees)
• Increase direct service policy to support care in
  the community
• Intersect of policy domains
• both financial support in multiple domains as
  well as services need to be considered.

BUT WE CANT AFFORD IT IT
COSTS TOO MUCH.
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Services vs. compensation Cost of supporting
persons 65 disability
Option 1 Provision of allowance (2400 per
yr/person) Option 2 Provision of respite (4
hours/week additional respite - 5200/yr) Option
3 Cost of average additional 3 months of an
institution for CR 12000/yr)
10.9 billion
3. Institutional Cost 3 months
Cost (millions)
2. Services
5.7 billion
1. Compensation
Keefe, J. Légaré, J. Carrière, Y. 2007.
Developing new strategies to support future
caregivers ... Projections of need and their
policy implications. Canadian Public Policy, 33,
65-80
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Final Statement

• BUT WE CANT AFFORD IT
• IT COSTS TOO MUCH.

Need to consider the ECONOMIC, SOCIAL, and HEALTH
CARE Costs of NOT supporting caregivers.