Long-Term Care Homes in Canada – How are They Funded and Regulated?

(Disponible en français : Comment les foyers de soins de longue durée sont-ils financés et réglementés au Canada?)

According to census data, almost 160,000 people lived in Canada’s long-term care (LTC) facilities in 2016. Health Canada defines residential LTC as “living accommodation for people who require onsite delivery of 24 hour, 7 days a week supervised care, including professional health services, personal care and services such as meals, laundry and housekeeping.”

However, there is no common definition of LTC across the country. Long-term care facilities are sometimes confused with assisted living facilities, seniors’ residences or retirement homes. Residents of the latter are generally fairly independent and medical services offered are more limited.

This HillNote reviews jurisdictional issues related to LTC, summarizes the cost of providing care in LTC facilities and provides a list of the legislation that governs LTC across Canada.

For more information, please see: Long-Term Care Homes in Canada –The Impact of COVID-19.

Jurisdiction Over Long-Term Care Facilities

Jurisdiction over health and health care is a shared responsibility between the federal and provincial governments. Sections 91 and 92 of the Constitution Act, 1867 assign exclusive legislative authority to either Parliament or provincial legislatures, respectively.

Although there is no specific reference to health, some health-related subjects are listed in these sections. For example, section 91(11) assigns matters related to quarantine and marine hospitals to Parliament while section 92(7) assigns responsibility for hospitals, other than marine hospitals, to the provinces.

Parliament has used its jurisdiction in criminal law power and spending power to enact several health-related statutes. The federal criminal law power (section 91(27) of the Constitution Act, 1867) can be used to enact legislation in the areas of public health and safety.

Parliament also relies on its spending power – which has been inferred from sections 91(1A), 91(3) and 106 – to provide the Canada Health Transfer to the provinces under the Federal-Provincial Fiscal Arrangements Act and to set national standards and conditions under the Canada Health Act.

While the Canada Health Act defines the health services that must be included by each provincial health insurance program in order to qualify for federal funds, LTC is not included. Rather, LTC is considered an extended health care service (section 2). Various stakeholders are urging the federal government to either specifically include LTC in the Canada Health Act or to implement separate legislation on LTC that would include national standards.

In addition, exclusive provincial responsibility for the direct delivery of most medical services, the education and regulation of health professionals, and related matters is derived from the provincial jurisdiction over property and civil rights – section 92(13), and matters of a local or private nature  – section 92(16).

As such, LTC facilities, which provide both health care and social services to residents who are unable to care for themselves due to physical or cognitive impairments, fall within provincial jurisdiction. Consequently, legislation regulating the delivery of these services has been implemented in all provinces and territories.

Funding and Regulation of Long-Term Care Facilities in Canada

Although the Canada Health Act does not include LTC as an insured health service that must be publicly insured by the provinces and territories to qualify for federal funds, all jurisdictions allocate some public funds to LTC.

According to a 2014 report from the Canadian Institute for Health Information, approximately 73% of LTC home costs are covered in Canada by provincial, territorial and municipal plans and agencies, whereas 23% of costs are covered by residents either out-of-pocket or through supplementary private insurance.

In 2018, total spending on nursing home care was $27 billion, with $20 billion from public funds (74%) and $7 billion (26%) from private funds. Residents of LTC are financially responsible for rent, laundry and housekeeping, accounting for much of the 26% in private funding. All provinces and territories subsidize the costs associated with the provision of health care services in LTC facilities, and most governments offer further subsidies to residents as needed.

The table below provides provincial and territorial legislation and regulation governing LTC facilities and indicates how much cost is assumed by residents. While all provincial and territorial governments provide funding for LTC facilities, the specific allocation by each government could not be determined. However, British Columbia publicly funds $182-$272 per diem per bed and Ontario provides $182 per diem per bed.

A variety of terms are used to refer to LTC facilities. “Old-age home” is a term that is no longer used, while “nursing home” is commonly used. Other terms used are included in the table below.

Long-Term Care Legislation and Single Resident Cost Across Canada

Province/Territory Long-term Care Terms Used Legislation/Regulation Accommodation Costs to the Resident
British Columbia Residential care facilities, long-term care homes Community Care and Assisted Living Act (2002) and Residential Care Regulation

Hospital Act (1996), and its regulations

Income-based up to 80% after tax, $1,189 to $3,444/month (2020)
Alberta Long-term care homes, nursing homes, auxiliary hospitals Nursing Homes Act (2000), Nursing Homes General Regulation and Nursing Homes Operation Regulation

Continuing Care Health Service Standards govern publicly-funded facilities, and the Long-Term Care Accommodation Standards

$1,743-2,120/month (2020)
Saskatchewan Special care homes, nursing homes Provincial Health Authority Act

Program Guidelines for Special Care Homes

$1,152 + 57.5% of income over $1,579/month up to a maximum of $2,859/month (2020)
Manitoba Personal care homes The Health Services Insurance Act (1987) and Personal Care Homes Standards Regulations  and other regulations $39-95/day based on income. Minimum retained monthly income of $370 (2020-21)
Ontario Long-term care homes Long Term Care Homes Act  (2007) and its regulation $1,891 -2,700/month (2019)
Quebec [in French] CHSLD (« centre d’hébergement et de soins de longue durée ») Act respecting Health and Social Services and its regulations related to long-term care.

Private CHSLDs that are not under contract with the provincial government are not subject to the same regulations as CHSLDs that receive public funding but are expected to follow provincial standards.

$1,211-1,946/month (2020)
Nova Scotia Residential care facilities, nursing homes Homes for Special Care Act (1989) and its regulation

Required operating standards are issued ministerial guidance.

Income-based up to 85% of after tax up to $110/day. Minimum left to resident $260/month.
New Brunswick Nursing homes Nursing Homes Act and its regulation Average $3437/month depends on services required. (2014)
Prince Edward Island Nursing homes, manors Community Care Facilities and Nursing Homes Act (1988) and its regulations. $92/day (2019)
Newfoundland and Labrador Long-term care facilities Health and Community Services Act (1995) and the Personal Care Homes Regulations. Income-based to a maximum of $2,990/month. Minimum left to resident $150/month
Yukon Long-term care homes, continuing care facilities Health Act (2002)

Yukon Continuing Care: Bill of Rights for Residents Living in Yukon Continuing Care Facilities

$35/day (2019)
Northwest Territories Long-term care homes, supported living Not addressed in legislation or regulation but standards have been published. $844/month (2020)
Nunavut Continuing Care centres, nursing homes, elder homes Not addressed in legislation or regulation No charge to the resident

Source: Table prepared by the author from provincial and territorial and stakeholder websites and Royal Society of Canada, Restoring Trust: COVID19 and The Future of Long-Term Care – A Policy Briefing by the Working Group on Long-Term Care, Table 1, p.53-54, June 2020.

Long-Term Care Facility Ownership in Canada

Long-term care facilities across Canada are a mix of publicly and privately owned facilities governed by provincial/territorial legislation. Publicly owned LTC facilities are all not-for-profit, and privately owned ones can be either for-profit or not-for-profit. However, most receive public funds for the provision of LTC services.

As examples, in the Territories, LTC facilities are 100% publicly owned, while in New Brunswick, they are 100% privately owned. In Quebec, privately owned and operated LTC homes (called centres d’hébergement et de soins de longue durée, or CHSLDs) that are not contracted by the provincial government do not receive any public funds. In British Columbia, publicly subsidized and private pay beds are permitted within the same facility.

Accommodation costs, which are the responsibility of residents, also vary. Consequently, the level of care and access to LTC also varies across Canada.

The figure below illustrates LTC home ownership across Canada.

Long-Term Care Facility Ownership in Canada

Provinces have a range of privately owned and publicly owned long-term care facilities ranging from 100% privately owned in New Brunswick to 97% publicly owned in Newfoundland and Labrador. Privately owned Long-term care facilities are a mixture of for-profit and not-for-profit operations. Ontario has the highest proportion of private for-profit facilities at 57%. All long-term care facilities in the Yukon, Northwest Territories and Nunavut are publicly owned.

Source: Canadian Institute for Health Information, Long-term care homes in Canada: How many and who owns them?, 24 September 2020.

Author: Sonya Norris, Library of Parliament