Lean Long-Term Care:
Ownership, Management & Delivery
Dr. Tamara Daly
CIHR Research Chair in Gender, Work and Health
Associate Professor,
York University, School of Health Policy & Management
dalyt@yorku.ca
A Seniors Healthcare Plan for Canada
Monday, December 2nd, 2013
Delta Ottawa City Centre
Panel II: Privatization of Continuing Care
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
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?
Literature on Quality & Ownership
• For-profits perform worse on clinical measures of
quality
– McGregor and colleagues (2006; 2010)
• Systematic reviews: Quality & Ownership
1. Inconclusive findings -- Davis (1991)
2. Process and outcome measures:
• non-profits out-performed and provided better quality of care
than do for-profits -- Hillmer and colleagues (2005)
3. Higher quality staffing & lower incidence of pressure
ulcers
• Non-profits outperformed for profits -- Commodore and
colleagues (2009)
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)
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)
1. Commercialization of
Ownership
Consolidation
“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
SSHRC Study: Re-imagining LTC
CIHR Study: Invisible Women: Gender and the Shifting Division of Labour in Long-term Residential Care
SSHRC Study: Re-imagining LTC
CIHR Study: Invisible Women: Gender and the Shifting Division of Labour in Long-term Residential Care
2. Commercialization of
Management
FPC management firms
SSHRC Study: Re-imagining LTC
CIHR Study: Invisible Women: Gender and the Shifting Division of Labour in Long-term Residential Care
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
“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
“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
• “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
3. Private Delivery of Care in Publicly
Funded Facilities in Ontario
CIHR Study: Invisible Women: Gender and the Shifting Division of Labour in Long-term Residential Care
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
CIHR Study: Invisible Women: Gender and the Shifting Division of Labour in Long-term Residential Care
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
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
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
Photo: Howard MacWilliam
http://www.telegraph.co.uk/finance/personalfinance/insurance/longtermcare/7546776/How-to-pay-for-long-term-care.html
Lean Long-Term Care:
Ownership, Management & Delivery
Dr. Tamara Daly
CIHR Research Chair in Gender, Work and Health
Associate Professor,
York University, School of Health Policy & Management
dalyt@yorku.ca
A Seniors Healthcare Plan for Canada
Monday, December 2nd, 2013
Delta Ottawa City Centre
Panel II: Privatization of Continuing Care