In recent years, the advantages and disadvantages of for-profit (FP) health care delivery have been robustly debated. In particular, questions have been raised regarding government-funded long-term care (LTC) in Canada, which is provided by a mix of not-for-profit (NFP) and FP facilities. Do FP LTC facilities use tax dollars to provide superior, inferior or equivalent quality of care when compared to NFP nursing homes? American studies indicate that quality of care in NFP nursing homes is superior due to higher staffing levels. To begin to address this question from a Canadian experience, this study examined the effect of type of ownership of LTC facilities on staffing levels in British Columbia. For-profit facilities were found to provide fewer direct-care and support staff. These findings encourage future studies on the effect of staffing levels on health outcomes among residents of LTC.

Background: In Canada, long-term care (LTC) facilities are operated by for-profit (FP) and not-forprofit (NFP) providers. This ownership mix is individual to each province. In the USA, studies have found that FP LTC facilities supply fewer direct-care staff per patient than comparable NFP LTC facilities. Moreover, previous American studies have shown that a positive relationship exists between higher staffing levels of direct care personnel and better quality care. To investigate Canadian experience, the effect of ownership on staffing levels in nursing homes in British Columbia was examined.

The BC government provides LTC funding globally using a funding formula that considers the level of functional dependence of residents and the percentage of fees borne by residents according to their income levels. In 2001, the time of the study, there were no regulations regarding how individual facilities should allocate funding between staffing, administration or property. In addition, both FP and NFP nursing and support staff were members of a single union, where wages were set by a master collective agreement.

Methods: By evaluating existing data, nursing homes were grouped by levels of care according to case mix and facility size. Facilities that provided only extended care and facilities attached to a hospital were excluded from the analysis. Staffing data were obtained from the BC Labour Relations Board. Average hours per day for all staff, including registered nurses (RNs), licensed practical nurses (LPNs), resident care aides (RCAs), activity aides, and support staff (dietary, housekeeping and laundry) were calculated, and analyses performed.

Findings: The nursing homes examined in this study represented 76% (167/221) of the facilities in BC, 65% (109/167) of which were NFP. Comparisons of facilities by ownership and matched for levels of care indicate that for direct care staff (e.g., RN, LPN, RCA), activity aides, and support staff (e.g., dietary, housekeeping), the average number of hours worked per day were higher in NFP compared to FP facilities. FP facilities provided higher average number of hours per day for laundry staff. It was estimated that 20 additional minutes per day of direct-care and 14 additional minutes per day of indirect care was provided in NFP facilities. No meaningful difference was observed between the average number of beds for each type of facility, and no association was found between facility size and directcare or support staff hours. Moreover, no meaningful difference was found between the average number of direct-care hours per day provided by for-profit facilities and corporate chain facilities.

Conclusions: A significantly higher number of hours per day by both direct-care staff and support staff are provided in British Columbia's NFP LTC facilities compared to FP facilities. Although this study did not examine whether higher staffing levels translated into improved clinical outcomes, previous research has found positive relationships between higher direct care staffing levels and better LTC outcomes. Because provinces decide independently the type of ownership mix they provide, further research is needed to evaluate whether the link between type of ownership, nurse staffing and quality of care exists across Canada.

Reference: McGregor MJ, Cohen M, McGrail K, Broemeling AM, Adler RN, Schulzer M, Ronald L, Cvitkovich Y, Beck M. "Staffing levels in not-for-profit and for-profit long-term care facilities: Does type of ownership matter?" Canadian Medical Association Journal, 2005; 172(5): 645-649.

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