SPOR EA - Cost Accounting for Long-term Care Beds - Conclusions - Call to Action

INTRODUCTION

This article is the tenth and final part of ten short pieces reporting the work presented on May 13, 2025. On that day we held a knowledge mobilization event to share out what we had learned from a Strategic Patient Oriented Research (SPOR) Evidence Alliance (EA) funded study to find out what research has been published on cost accounting for operating long-term care beds in institutional and family-based settings.

In the previous article we argued for establishing a research priority to study long-term care cost accounting to be able to provide evidence-based data when comparing the cost of operating long-term care beds in institutional and home-based settings.

In this article we articulate our call to action for cost accounting research in long-term care across Canada.

1. SCOPING REVIEW

At present the cost of operating long-term care beds in either institutional or home-based settings is unknown in health research publications.

We did not find one study in our scoping review that addressed the problem of the lack of evidence-based cost accounting in long-term care. The problem of measuring and reporting cost accounting data in long-term care has not been defined. The problem of measuring and reporting cost accounting data in institutional settings has not been defined. The problem of measuring and reporting cost accounting data in home-based settings has not been defined.

There were no consistent methodologies for research design to collect cost accounting data reported in the literature. Methodologies for research design to collect and report cost accounting data for long-term care operations in institutional settings have not been developed. Methodologies for research design to collect and report cost accounting data for long-term care operations in home-based settings have not been developed. Methodologies for research design to compare operating costs between institutional and home-based long-term care settings have not been developed.

We know that millions of households will be impacted by an aging population that needs support to manage their activities of daily living. We know that this aging population is increasing exponentially on a daily basis and that the proportion of younger Canadians available to assist frail elders is declining in relation to the increasing proportion of elder Canadians that are going to need help.

This is a problem of health system capacity and social responsibility.

2. FAMILY CAREGIVING

Our home-based family caregiving auto-ethnography was able to generate meaningful evidence-based cost accounting data. We were able to provide a reasonable accounting of the cost of operating a long-term care bed for a fragile elder with complex needs over a duration of 33 months.

We articulated the problem to be addressed in terms of the lack of visibility of the work currently being done by family caregiving households. This lack of visibility includes home-based long-term care operations that require material and labour resources, and the material and time contributions that families bring to care recipients residing in long-term care facilities.

We articulated the problem to be addressed in terms of a lack of resources and supports flowing the families who are providing a significant amount of time and real estate to healthcare system infrastructure.

We were able to test a proof of concept methodology for research design using the practice standards and frameworks from professional project management to organize and collect cost accounting data. We were able to test a proof of concept methodology for research design for a cost accounting framework that would allow data from both institutional and home-based settings to be measured and compared to provide meaningful information about the relative costs of operating long-term care beds across diverse settings.

We were able to show, from our case study data, that home-based long-term care operations for frail elders with complex needs entail significant material and time (labour) resources. We were able to show that the provision of these resources is often drawn down on family household resources - operating at a deficit that increases the socio-economic vulnerability of home-based family health and finances.

3. GROUP DISCUSSION

We were surprised at the lack of research publications reporting the cost of operating a long-term care bed in an institutional or a home-based setting.

We were surprised there was no evidence-based data reporting a cost comparison between operating a long-term care bed in an institutional setting and a home-based setting.

We agreed that the cost accounting framework developed from the research literature had potential to provide the basis for a methodology to study evidence-based cost accounting in long-term care.

We were surprised to learn the cost of operating a home-based long-term care bed for a frail elder with complex needs. It was interesting to account for the material costs of providing long-term care infrastructure. It was helpful to understand how much time a family contributes when they operate a long-term care bed in their home. It was useful to understand that the time spent caregiving is time not spent on either producing income for the household, or having leisure time for rest and recovery from work. Caregiving is work, and when it entails overnight care (24/7 schedule) the time requirements have a significant impact on family resources.

In the group discussion we agreed that the healthcare system is relying on families to provide family caregiving without providing commensurate compensation or supports to offset the cost. We agreed that this situation puts the healthcare system in a position of increasing risk and increasing precariousness. We agreed that, if families who are currently providing unaccounted material and time supports to the healthcare system were to withdraw those contributions, the healthcare system would collapse.

CONCLUSIONS

Our calls to action arising from this study include:

Research priority setting - design and implement a community engagement process to discuss cost accounting in long-term care and how we, as a society, will manage for risk, cost, and health and well being for our aging population;
Research design - develop methodological practice standards and frameworks for collecting evidence-based cost accounting data across diverse caregiving settings;
Research proposal - develop and submit a research proposal to pilot a cost accounting research design for collecting evidence-based cost accounting data across 10 institutional and 10 home-based long-term care settings.

Our historic ignorance of the work being carried out in long-term care and home-based caregiving households is putting our current and future healthcare system at risk of imminent collapse. Pressures will continue to build on both institutional and home-based long-term care beds. We need evidence-based cost accounting data so we can make rational, reasoned decisions about how to provide supports for the highest rate of return. We need evidence-based cost accounting data so we can understand where innovation, creativity, and adaptation can ease pressure and improve health outcomes for all Canadians, including the families and households who are suffering due to escalating operational deficits.

We are the change we need to see to improve healthcare and economic efficacy in our long-term care operations.

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Strategic Patient Oriented Research (SPOR) Evidence Alliance

COST ACCOUNTING FOR LONG-TERM CARE

Table of Contents

Introductory - Follow up / Thank You - 0/10

Introduction - Context - 1/10

Introduction - Project Development - 2/10

Problem to be Addressed - 3/10

Methodology - Approach - 4/10

Methodology - Data Sources - 5/10

Findings - Material Cost - 6/10