Editorial : We ' ve Come a Long Way but Are We

The two-part article on the development and implementation of a resident classification system for long-term care facilities by Cathy Charles and Corinne Schalm in this issue of the Journal merits special attention. The description of the process and work involved in attempting to develop an equitable funding arrangement for these facilities provides a good example of the contribution applied research can make to public policy. It illustrates the potential of a funding formula for influencing standards of care. It also demonstrates the direction and pace of change in provincial governments' policy towards nursing homes during the last two decades. The history of nursing homes in Canada is about as old as the country itself, but it has taken a long time for them to get on our health policy agenda. By the 1970s nursing homes had evolved through two phases. The first was the "alms-house" phase, during which benevolent societies and churches cared for chronically-ill, frail and disabled indigent persons who had no informal sources of help. The second was the "Social Allowance" phase during which provincial governments paid for the care of the indigent (cost-shared with the federal government after the enactment of the Canada Assistance plan), leaving other persons to pay for their own care. The only exceptions to this policy were persons in long-term care facilities called hospitals where they did not pay because their care was covered under the 1959 Hospital Insurance and Diagnostic Service Act. During this phase, the provinces also instituted or strengthened building and public health regulations governing these facilities. By and large, the norm for long-term care facilities was then still to provide custodial care. Workers in these facilities were, therefore, generally expected to act as proxies for family members who were not available or were too poor to keep an old, debilitated relative at home. On the other hand, workers caring for persons in the long-term facilities called hospitals (e.g., Ontario's Chronic Care, British Columbia's Extended Care and Alberta's Auxiliary hospitals) were doctors, nurses and para-professionals. During the 1970s, long-term care facilities entered a third phase during which the care they provided was increasingly medicalized. The impetus for this change was influenced by a number of factors. The respectability, indeed the respect, with which the public regarded hospitals, combined with the generally low regard in which nursing homes were held, suggested to the facilities themselves that professionalization would improve their image and their potential for additional provincial funding. Provincial licensing bodies, and complaints from increasingly powerful organizations of seniors and their families persuaded the provinces of the need to improve care stand-