Final report of the Expert Panel: Supporting Canadians aging at home: Ensuring quality of life as we age

Contributors

The National Seniors Council (the Council) would like to express its gratitude to all the individuals and organizations who shared their knowledge, experiences, and advice. Their input contributed to the process that shaped this final report. The Council welcomed all contributions. The Council hopes this final report will contribute to paving the way to make Canada a great place to age at home. A list of the entities and sectors represented in the Council's community engagement activities is under Annex A.

Finally, the Council would like to thank government officials who supported this project. Their ongoing support made it possible for the Council to fulfill its mandate within the time frame provided.

Land and labour acknowledgments

The National Seniors Council respectfully recognizes and acknowledges the relationship that the First Nations, Inuit, and Métis across Canada have with the land all Canadians live on and enjoy.

The Council encourages all Canadians and visitors to these lands to learn about and acknowledge the historic and current relationship that exists between the unceded land on which we live and work and the First Nations, Inuit, and Métis. We also encourage all Canadians to consider how they can personally contribute to Canada's reconciliation with Indigenous Peoples.

The in-person meetings and the coordination work took place mainly on the traditional territories of the Anishinaabe Algonquin People. We are grateful to live, work and learn on these lands. We honour the Nations who have always cared for these lands, waters and air and continue to do so today.

We also acknowledge the historical presence and contributions of African Canadians and persons of African descent, whose forced labour played a significant role in forming the foundations of Canada, and whose own relationship with land has been complicated by the impacts of slavery and colonization.

The 4As: Availability, Accessibility, Affordability and Accountability and their collective impact

The Expert Panel identified and analyzed the barriers to aging at home, focusing on 4 key policy pillars:

• availability
• accessibility
• affordability
• accountability

These pillars are key to ensuring people can benefit from the services to age at home.

The 4 perspectives are linked and can have a stronger collective impact when addressed in parallel or together. Also, a comprehensive approach would involve various service sectors and disciplines, foster collaboration across levels of government, and bring together diverse partners. Such an approach would more likely achieve system-level change and maximize impact.

The quality of life framework for aging in Canada

As final recommendations are being presented to Ministers, the Council has aligned its recommendations with the Quality of Life Framework for Canada (Finance Canada, 2021). As a result, the Expert Panel created a framework called the "Quality of Life Framework for Aging in Canada".

The recommendations align with the 5 domains of the Quality of Life Framework for Canada:

• prosperity
• health
• society
• environment
• good governance

Recommended actions for federal consideration

These 20 recommendations for immediate action support the broader, long-term outcomes pursued by the federal government. Implementing these recommendations will help older persons to age at home and achieve and/or maintain their quality of life.

The Expert Panel believes that given national and international demographic trends, the 3 main areas of focus should be:

• financial benefits focusing on low-income older persons (often women). See recommendations #1, #3 and #9
• community-based support and services. See recommendations #10 and #11
• planning for aging, retirement, and life in later years. See recommendations #2 and #7

Strengthening governance and accountability will be important complementary measures to ensure quality of life as we age in Canada. This can be achieved by adopting relevant legislations, regulations, standards, governance, and accountability. See recommendations #16, #17, and #18.

List of the 20 recommendations

Aligned to the 5 domains of the Quality of Life Framework for Aging in Canada and to the 4 priority policy pillars (4As).

Expert Panel mandate

This project gave members a unique opportunity to understand what is needed to successfully age at home. Also, to understand what it takes to impact the well-being and quality of life of older persons and caregivers across the country. The goals of this work were to:

• identify existing measures in Canada (for example, federal, provincial, territorial, and municipal support) as well as international best practices that help older persons age at home (for example, disease prevention, health promotion, home and community care, health care, social and community services, income support and tax policy)
• identify what is needed to further support older persons to age safely at home with dignity and address the areas of greatest need to help identify domains of actions
• identify and assess current and potential new federal measures to address the greatest need to support aging in place, factoring in overall government fiscal constraints

Definitions

There are many terms and perspectives used in Canada and internationally to name key elements and concepts related to aging. The Expert Panel carefully considered the literature and its past deliberations. The Expert Panel has agreed upon the following definitions of key terms to be used in the context of its work.

Policy context

More and more people in Canada and around the world are finding ways to improve and support the independence and quality of life of older persons. As the older population in Canada is expected to grow, it's crucial to factor in healthy aging when designing policies, programs, services, and spaces. This will make it possible for older persons to achieve, maintain or improve their quality of life as they age.

People are living longer and are healthier than in previous generations. By 2052, one quarter (24.9%) of Canadians could be 65 years of age or older (Statistics Canada, 2022a). Those aged 85 and over are among the fastest-growing age groups, with a 12% increase between 2016 and 2021 (Statistics Canada, 2022b).

Most older persons in Canada prefer to age in their homes and communities. In a 2020 survey, as many as 96% of Canadians aged 65 and older reported that they would do everything they could to avoid going into a long-term care facility (National Institute on Ageing, 2022).

With the right support, some older persons can stay in their homes, while others may transition to congregate or institutional living. The Canadian Institute for Health Information (CIHI) notes that about 1 in 10 newly admitted long-term care residents potentially could have been cared for at home (CIHI, 2022). Statistics Canada also reported that in 2021 475,000 people (1.6% of the Canadian population) reported unmet home care needs. Unmet home care needs were the most prevalent among Canadians aged 65 and older (Statistics Canada, 2023).

Improving home care would improve quality of life and result in significant savings through reducing the increasing demand for new long-term care setting units. Scenario-based analysis performed in the Quebec context also found that government costs for long-term care services delivered through home care would be less expensive than services delivered in long-term care settings and intermediate and family-type resources for most levels of needs (Clavet et al., 2021).

Aging at home requires a comprehensive and multi-sectoral approach that ensures older persons, caregivers, community organizations, and governments have the resources and tools to ensure older persons can achieve or maintain quality of life. This includes access to social support and services to live safely, happily, and independently and in their own homes for as long as possible.

Yet healthcare, social and community services are often fragmented, unavailable, inaccessible, and/or unaffordable. Complex processes for accessing services, limited alternative care, and living solutions, and a lack of age-friendly environments, are obstacles to seniors experiencing a smooth continuum of care in a way that meets their physical, mental, social, and psychological health and well-being (Deloitte Canada, 2020).

Also, an aging population affects family and friend caregivers, many of whom (almost one-quarter) are over the age of 65 (Statistics Canada, 2020). Caregivers play a key role in making it possible for people to age at home. However, the continued rise of one-person households could mean that older persons will increasingly not have kin family to rely on (Statistics Canada, 2022c).

As people age, they tend to access the health care system more often, continuing into their final years of life (Salde et al., 2019; Rotermann, 2017). According to a 2018 Conference Board of Canada report, population aging was expected to add $93 billion in health care related costs between 2017 and 2026. This represents 20% of all health care spending growth over that decade (Conference Board, 2018). This comes at the same time as an aging population reduces labour force participation. As a result, employment and tax revenues are decreasing.

The Organization for Economic Co-operation and Development (OECD) data also suggests that Canada is lagging behind leading countries such as the Scandinavian countries and the Netherlands when looking at total long-term care spending (inclusive of care at home and in institutions). Canada also lags behind leading countries such as Denmark, Belgium or Norway when looking at the proportion of spending on home care as a share of total long-term care. Those countries spend about 50% of their total long-term care spending on home care based on the OECD methodology, while Canada spent 18% in 2019 (OECD, 2021).

Connecting with others and keeping personal relationships with family and friends is central to one's sense of purpose, identity, culture, belonging and security. Social cohesion, community vitality and opportunities for cultural expression are essential for personal enrichment, fulfillment, health, and well-being. They also make sure that older persons feel valued, respected, and included.

Scope of work

From October 2022 to June 2023, the Expert Panel examined the topic through various activities, including:

• deep dialogue among Council members to determine the basis for the environmental scan and community engagement. This resulted in the development of 4 primary policy pillars, the 4As: Availability, Accessibility, Affordability and Accountability
• an environmental scan to identify existing provincial, territorial, Indigenous, and international strategies, programs, and services. It also took into account 15 key factors for consideration (see Key factors for consideration section below)
• a literature review to assess the most recent evidence (knowledge acquisition), thinking (knowledge translation) and leading and emerging practice (knowledge application). This included almost 300 documents, studies, articles, reports, etc.
• a robust community engagement strategy, including:
  • a survey (with over 12,000 respondents)
  • roundtables (2 English, 1 French with 22 participants)
  • key informant one-on-one interviews with over 70 individuals with diverse perspectives. These included older persons in Canada, their family members, caregivers, and care providers
• development of a set of 11 guiding principles (Annex D). These were used as anchor to ensure that the recommended approaches are responsive to the human rights of older persons
• development of a Quality of Life Framework for Aging in Canada. It is based on Canada's Quality of Life Framework developed by Finance Canada and supported by Statistics Canada

The Expert Panel's work and recommendations focus on what it takes to age at home with autonomy, dignity, safety, security, and quality of life in the Canadian context. Its advice focuses on measures the federal government can either directly implement with its levers or encourage through collaborative leadership. The Expert Panel considered a broad range of measures, including a potential aging at home benefit.

The Expert Panel recognizes and acknowledges all the work being done to better support aging at home at all levels. Those include regional, national, and international levels. The considerations and lessons drawn from existing measures have helped the Expert Panel understand the context and shaped their recommendations.

Insights gathered from the Expert Panel, confirmed a wide range of support and services are required to achieve and maintain quality of life as people age at home in Canada. Examples include:

• community services such as transportation, meals, social and recreational services, activities, or home renovations/adaptations
• access to basic health care such as access to a primary health care provider, a family physician or family health team
• a broad variety of aging at home services, including:
  • home health care (for example, nursing, palliative care)
  • home support services (for example, activities of daily living such as bathing and eating, and instrumental activities of daily living such as housecleaning and laundry)
  • community support services
  • caregiver supports
• system navigation services (for example, increase accessibility)
• financial support to help cover out-of-pocket expenses

While each of these unique initiatives is helpful, these interdependent initiatives increase in value when considered together to achieve and/or maintain quality of life as people age at home.

Key factors for consideration

Based on its experience as well as on the environmental scan and community engagement, the Expert Panel identified the following social, economic, environmental, and political key factors. The Expert Panel took these factors into consideration as they developed their recommendations and advice:

• respecting federal, provincial, territorial, and Indigenous jurisdictions and facilitating collaboration
• respecting fiscal responsibilities and financial considerations
• recognizing the recovery and learnings from the COVID-19 global pandemic
• adjusting to the impacts of climate change and extreme weather events
• using a healthy aging lens
• achieving and maintaining quality of life as people age in Canada
• applying the Quality of Life Framework for Canada
• integrating equity, diversity, inclusion, belonging, anti-racism, justice and reconciliation
• integrating Sex- and Gender-Based Analysis Plus and the gendered elements of aging
• aligning with Canada's international commitments to the United Nations Decade of Healthy Aging and the United Nations Sustainable Development Goals
• integrating the social determinants of health and moral determinants of health^{Footnote 2}
• recognizing the importance of the integration of health and social support at the community level
• acknowledging the pervasiveness and the need to address ageism in Canada
• acknowledge the pervasiveness and need to counter the mistreatment of older persons in Canada
• understanding the significant challenges faced by the health care and home care sectors (including labour force and human resources)
• applying the continuum of care and recognizing the importance of independence
• recognizing the heterogeneity of the population of older persons and their diverse requirements to age at home
• acknowledging biases and assumptions related to older persons and aging. For example, capability, confidence, technology readiness, retirement readiness and health status solely based on age

The 4As: Availability, Accessibility, Affordability and Accountability and their collective impact

The Expert Panel has identified and analyzed the barriers to aging at home using 4 key angles (policy pillars):

• availability
• accessibility
• affordability
• accountability

These policy pillars are key to ensuring people can benefit from the services to enable aging at home and achieve or maintain quality of life. Yet, it is important to acknowledge factors such as income and how some measures will have a greater impact on older persons with low income versus those with middle and high income.

Availability: Ensuring information, resources and supports are available. This can be done by enhancing support to community organizations, the care workforce, other levels of government and individuals to provide a range of health and social support. Improving integration and coordination of health and social services. Increasing the availability of the care workforce. Increasing the availability of alternative housing options and increasing service availability in rural and remote areas.

Accessibility: Ensuring equal access to information, services and supports, by improving navigation services. Streamlining/simplifying program requirements and application processes. Ensuring that equity-deserving groups can access services and that services are culturally and linguistically adapted. Expanding health promotion, disease prevention, and chronic disease management programs to delay and prevent loss of independence and to decrease demand on long-term care facilities.

Affordability: Ensuring older persons can afford services and supports. This can be done by increasing income support to specified target audiences to age at home. For example, enhancing or expanding existing tax measures.

Accountability: Ensuring governments, organizations, service providers and vendors are held accountable. Examples include:

• implementing long term care standards and home care legislation
• collaboration and partnerships across jurisdictions and within communities
• documenting and sharing information on promising/leading practices
• scaling up key promising/leading practices

The 4As framework also suggests that the 4 policy pillars are interconnected. They can have a stronger collective impact when addressed in parallel or simultaneously. For example, affordability measures, without improved availability or accessibility, will leave many older persons behind. Increasing availability without proper standards and accountability mechanisms to provide quality oversight will lead to sub-optimal outcomes. No single, narrow measure will significantly improve the ability of older persons to age at home.

Actions need to be taken on many fronts to support the collective impact of the 4As leading to large improvements.

The approach should bring together various service sectors and fields, foster collaboration across different levels of government, and bring together diverse partners and stakeholders. Such an approach would achieve system-level change and have a bigger impact.

The Quality of Life Framework for Aging in Canada

The Expert Panel created the Quality of Life Framework for Aging in Canada, inspired by the Quality of Life Framework in Canada.

This approach recognizes that:

• aging at home requires a holistic effort and a broad range of services and support
• aging at home should not strictly aim at helping people stay at home. Instead, help people live fulfilling lives at home. This aligns with the goals of the Quality of Life Framework
• a successful aging at home policy will lead to improved quality-of-life indicators for older persons living in the community. Statistics Canada is building a measurement framework through its Quality of Life Hub. Those indicators, broken down by age and intersecting factors, can track the outcomes of aging at home policies

Aligning recommendations with the 5 domains (prosperity, health, society, environment, and good governance) of the Quality of Life Framework for Canada showcases how aging at home recommendations support the ultimate, long-term, whole-of-government outcomes pursued by the federal government. The cross-cutting "Fairness and Inclusion Lens" and the "Sustainability and Resilience Lens" included in the Quality of Life Framework for Canada align with the Expert Panel's principles and recommendations for equity-deserving groups and intergenerational equity.

The Expert Panel's recommendations are tagged to the 4As. This is to showcase how the recommendations are expected to have the most significant impact in supporting older persons in Canada to age at home.

Collective impact

The Expert Panel identified the importance of acting on several key recommendations at the same time to make a difference and make it possible for more older persons to age at home. The Expert Panel reiterates the critical importance of implementing multiple actions in parallel to ensure older persons with all socioeconomic experiences, demographics and health status feel the impact. For example, providing financial support might not go a long way if services are not available.

Areas for further exploration and future considerations

While the Expert Panel's recommendations covered a wide range of measures, some issues need further attention to support aging at home in the Canadian context in the longer term.

The federal government uses different fiscal measures to reduce the amount of taxes paid by people with complex medical or disability challenges. Complementary measures with various income levels and eligibility criteria can be complex to understand and navigate. For example, the Medical Expense Tax Credit has been criticized by commentators and scholars for decades for being too regressive (Philipps, 2001; Tedds, 2012). Changes to tax policies will not solve the issue of availability, accessibility, and affordability of aging at home supports. But refundable measures and simpler and broader eligibility criteria would lead to more fairness.

Ensuring quality of life as we age would benefit from leadership at the federal level, even for factors mainly within provincial, territorial or Indigenous jurisdictions. For example, the availability and delivery of in-home rehabilitation services, supports and devices should be improved. Access to medication and nutritional substitutes for older persons who can not afford them is also important. Through federal, provincial, territorial and Indigenous engagement, the federal government could highlight these issues. It could also engage in dialogue and innovative solutions for easier access to rehabilitation services, medication and nutritional substitutes.

Collaborative efforts among stakeholders also benefit from advancing effective and innovating aging at home programs and services. The federal government could consider ways to further connect organizations serving older persons across Canada. This would ensure effective, regular and extensive knowledge sharing on emerging and leading practices related to aging at home.

Dedicated research funding is also important to document the results of various initiatives and approaches and to identify successful strategies that could be scaled up. Expanding and improving national data on long-term care and home care through further working with provinces, territories and Indigenous communities would also strengthen researchers in the field. This would help governments and stakeholders assess the efficacy of aging at home initiatives from a regional and national perspective.

Lastly, past initiatives from the National Seniors Council could be leveraged to get better outcomes for older persons. The age-friendly/healthy aging lens could be promoted and published. The lens could help a variety of stakeholders make their policies, programs, and initiatives more inclusive and age-friendly. The lens could also be applied to federal measures, regardless of age, and to examine existing policies and programs. This could include application of the lens to health bilateral agreements with provinces and territories to identify areas where age discrimination might be at play. Then, integrate safeguards as part of the agreements to prevent this discrimination from occurring.

Representatives of sectors and occupations engaged included, but was not limited to:

Aging at home and aging in place

Older persons can be empowered to age in the most appropriate and preferred place when effective aging-in-place support and services exist, including but not limited to health promotion (for example, fall prevention programs, vaccination campaigns) and disease prevention programs. As a result, supporting:

• aging at home can be understood as enabling healthy aging in one's home and community
• aging in place, according to the World Health Organization (WHO), refers to the ability to live safely, independently, and comfortably in one's own home and community, regardless of age, income, or capacity level
• aging in the right place extends this concept to the ability to live in the place with the closest fit with the person's culture, identity, needs and preferences which may or may not be one's home (National Institute on Ageing, 2022)

Partners in care

Older persons: Although there is no universal definition of older persons, the age of 65 is widely considered in Canada as the age of retirement by provisions in the retirement income system and society at large. As such, the primary target population for potential measures would be people 65 years and older, with family/friend caregivers who provide care to older persons as a secondary target. When developing measures, it is important to consider the diversity of older persons and different life experiences and life transitions. For this report, a functional ability^{Footnote 14} lens rather than an age-based focus has been used.

Care recipient: A person who receives care from an unpaid family/friend caregiver, a paid care provider or a volunteer, either at home or in a long-term care setting. A care recipient may receive care for:

• a shorter time (for example, 6 to 8 weeks post surgery or recovery from a heart attack)
• an extended period of time (for example, 6 to 8 months during cancer treatment)
• episodically (for example, period of depression)
• with increased intensity over time (for example, following a stroke, a neurocognitive disorder, Parkinson's, Amyotrophic lateral sclerosis (ALS), etc.)

Care provider: A person who provides care and usually receives a salary or wage for their time or provides care as a volunteer through an organization. They may be recruited as volunteers or be employed, self-employed, or contracted to work in facilities, clinics, offices, or at the care recipient's home. The relationship between a care provider and a care recipient starts when care providing begins and usually ends when care ends.

Family/friend caregiver ("caregiver"): A person who typically gives unpaid care to someone with a physical or mental health condition or who is chronically ill or frail, either at home or in a long-term care setting. Caregivers can sometimes receive money for their care from the care recipient, for example, in jurisdictions where governmental financial benefits are available to help offset costs incurred by caregivers. Caregivers may be spouses, adult children or in-laws, parents, siblings, youth, extended family members, or someone outside the family. The relationship between a caregiver and a care recipient pre-dates caregiving and may continue until end-of-life.

Types of support

Aging at home support and services refer to all types of care and support that enable individuals who stay in their home or community as they age. The support and service may include home care, access to social or recreational programs, and/or caregiver support. Home care can be grouped into 2 broad categories^{Footnote 15} of support.