Research Funding

1. Lean Long-Term Care: Ownership, Management & DeliveryDr. Tamara DalyCIHR Research Chair in Gender, Work and HealthAssociate Professor, York University, School of Health Policy & Managementdalyt@yorku.caA Seniors Healthcare Plan for CanadaMonday, December 2nd, 2013Delta Ottawa City CentrePanel II: Privatization of Continuing Care

2. Research Funding Reimagining LTC: Promising Practices in Residential Care Institute of Gender & Health Invisible Women: Gender and the Shifting Division of Labour in Long-term Residential Care

3. Outline • Literature • Quality care and ownership • Working Conditions • Organizational Forms • Commercialization: • Is Ontario’s LTC sector fragmented or consolidated? • Ownership of home / beds • Management of beds • Privatization: (informal care in formal care settings) • To what extent is private care occurring within Ontario’s publicly funded LTC? • Why is it important to understand ownership, management & delivery patterns?

4. Literature on Quality & Ownership • For-profits perform worse on clinical measures of quality • McGregor and colleagues (2006; 2010) • Systematic reviews: Quality & Ownership • Inconclusive findings -- Davis (1991) • Process and outcome measures: • non-profits out-performed and provided better quality of care than do for-profits -- Hillmer and colleagues (2005) • Higher quality staffing & lower incidence of pressure ulcers • Non-profits outperformed for profits -- Commodore and colleagues (2009)

5. Literature on Working Conditions • Higher staff to resident ratio in NP & municipal homes • Berta and colleagues (2005; 2006) • Lean techniques in care service creates more routinized and intensified work • Baines and Cunningham (2011) • Higher rates of violence and lower levels of staff in Canada than in Scandinavia • Armstrong and colleagues (2012) • More hierarchical, task based division of labour compared with the relational model in Scandinavia • Daly and Szebehely (2012)

6. Literature on Organizational Forms • New strategies have reduced providers’ liabilities and taxes, and increased bankruptcies • (Harrington and colleagues 2011;Scourfield, 2007; 2012) • “…knowing the proprietary status of a nursing home provider is insufficient to discern how organizational assets are structured and the operational approach of the company managing the delivery of nursing home services.” • (Stevenson and colleagues, 2013)

7. 1. Commercialization of Ownership Consolidation

8. “Leisureworld has significant opportunities for acquisitions in the fragmented LTC industry. With the regulatory burden becoming more onerous for smaller industry participants, larger companies with scale are positioned for continued growth.” Leisureworld Annual Report 2012, p. 7

9. SSHRC Study: Re-imagining LTC CIHR Study: Invisible Women: Gender and the Shifting Division of Labour in Long-term Residential Care

10. SSHRC Study: Re-imagining LTC CIHR Study: Invisible Women: Gender and the Shifting Division of Labour in Long-term Residential Care

11. 2. Commercialization of Management FPC management firms

12. SSHRC Study: Re-imagining LTC CIHR Study: Invisible Women: Gender and the Shifting Division of Labour in Long-term Residential Care

13. For-profit Independents Non-profit & Charitable Non-profit Hospital Municipal SSHRC Study: Re-imagining LTC CIHR Study: Invisible Women: Gender and the Shifting Division of Labour in Long-term Residential Care

14. “Due to the complexity of care provided by LTC operators in Ontario, LTC is highly regulated by the MOHLTC. Operators must meet stringent licensing requirements and adhere to a common set of Ministry rules, as well as public health, safety and privacy laws. No new LTC licenses have been granted in Ontario in the past eight years. The complexity of care combined with government regulations and licensing requirements creates high barriers to entry for potential new participants.” Leisureworld Annual Report, 2012

15. “We have developed a level of administrative and managerial expertise few can match. We have the tools, systems, best practices and proven solutions that enable us to deliver on our commitments in the most efficient and cost effective manner possible.” Extendicare Assist website, 2013

16. “Now, through Extendicare Assist, we can help you do it too. We can help by taking the administrative and management load off your mind and do it in a way that respects your vision, your reputation, your staff and, perhaps most importantly, your residents. Regardless of the size of your long-term care home or the nature of your ownership, we can help you meet every regulation and procedural requirement governing its operation.” Extendicare Assist website, 2013

17. 3. Private Delivery of Care in Publicly Funded Facilities in Ontario

18. CIHR Study: Invisible Women: Gender and the Shifting Division of Labour in Long-term Residential Care

19. Private Delivery of Care in Publicly Funded Facilities in Ontario • Private companions provide care work in more than two-thirds of Ontario’s LTC homes (68.1%) • Companions are: • Independent workers (in 49.5% of homes) • Agency workers (in 41.2% of homes) • More than one third (32.3%) of homes have no rules governing what care private companions can provide CIHR Study: Invisible Women: Gender and the Shifting Division of Labour in Long-term Residential Care

20. CIHR Study: Invisible Women: Gender and the Shifting Division of Labour in Long-term Residential Care

21. Concluding Points • Concentration of Commercial Ownership within for-profit chains • Significant FPC management of homes that are stand-alone non-profit, for-profit independent and public homes • Too few staff mean that families are paying out of pocket for private care for services that are supposed to be publicly funded

22. Ontario LTC Trends Commercialization of ownership and management Public providers Private non-profit providers Private For-profit Chains Privatization: More Informal care in formal care settings Public Funding & Delivery Individuals pay out of Pocket for privately paid care workers

23. Building Boom Carol Martin, “Thursday, May 05, 2011” Ground broken on $40 million local construction project http://www.sootoday.com/content/news/full_story.asp?StoryNumber=52017

24. Photo: Howard MacWilliam http://www.telegraph.co.uk/finance/personalfinance/insurance/longtermcare/7546776/How-to-pay-for-long-term-care.html

25. Lean Long-Term Care: Ownership, Management & DeliveryDr. Tamara DalyCIHR Research Chair in Gender, Work and HealthAssociate Professor, York University, School of Health Policy & Managementdalyt@yorku.caA Seniors Healthcare Plan for CanadaMonday, December 2nd, 2013Delta Ottawa City CentrePanel II: Privatization of Continuing Care