The Ontario Health Quality council reported in 2010 that wait times for a long-term care bed in Ontario have tripled since 2005.
A substantial number of people who are waiting for long-term care – and some who are currently in long-term care – could be cared for at home or in “assisted living” facilities if they were provided with the right kind of support.
Whether or not more long-term care beds are required to meet the needs of the aging population depends on the quality and availability of home care services.
What kinds of programs are needed by frail seniors or ill people living at home?
The needs of people who become ill vary enormously. Some have a sudden illness from which they recover completely – for example an episode of food poisoning. Others have a sudden illness that leaves them severely disabled and unable to live at home no matter what supports are provided – for example a severe stroke. Still others have one or more chronic, progressive illnesses and can still live at home, but only if they receive sophisticated support – for example a senior with osteoporosis and dementia who has suffered a hip fracture.
In Ontario, Community Care Access Centres (CCAC) coordinate and pay for a variety of health care and support services – nursing, bathing, house cleaning and transportation, for example – for people living in their own homes. CCACs provide a range of services, such as palliative care for those who wish to die at home, home care for people trying to manage many complex conditions and assistance with the long-term care admission and placement process.
Many Ontarians waiting for long-term care
Right now there are about 4700 patients in Ontario hospitals waiting for an “alternate level of care” to hospital, such as long-term care. These patients are sometimes pejoratively referred to as “bed blockers.” The percent of hospital beds occupied by such individuals (16%) has not changed very much over the last four years. More than half of these people are waiting for a long-term care bed.
The percentage of hospital beds occupied by people who no longer require acute care varies widely across the province, from 30% in the northeast, to 9% in Mississauga-Halton. The differences across Ontario have been attributed to geography and differences in the services available. People living in rural and remote areas have a difficult time finding long-term care beds that are close to home.
To learn more about alternate level of care patients in Ontario, please read our story on ‘Gridlock in Ontario’s Hospitals’.
There are over 20,000 people at any given time waiting for a long-term care bed in Ontario, most of whom are waiting in the community. For direct transfer from hospital to long-term care, the average wait time is 50 days. People waiting in hospital tend to have higher needs and are encouraged to take the first available long-term care bed. For people waiting in the community, the wait time is almost 6 months.
A study conducted in Toronto in 2007-2008 found that about 1 in 5 people on the waiting list for long-term care actually had low medical or support needs, while just under half had high to very high needs. This suggests that between one third and half of people waiting for long-term care probably don’t need it, if they could receive appropriate support in the home and community. Stacey Daub, one of the authors of this study and chief executive officer of the Toronto Central CCAC, says that “what happens to a system under pressure is that people are looking for a place, and long-term care is the default destination.”
Some argue that Ontario’s health care system is not providing its citizens with the quality and quantity of home care that is needed for people to remain in their own homes.
Why does Ontario still not have optimal home care, assisted living and nursing home care?
When Medicare was established in the 1960s, and even when the Canada Health Act was passed in 1984, physician and hospital services were the most important and costly aspects of health care. But over the last 30 years, it has become clear that home care and long-term care are also crucially important. Because these sectors are not covered by the Canada Health Act, there is a patchwork of funding and delivery approaches to these services. Furthermore, home care and long-term care are not well integrated with physician care and hospital care.
Much of the recent media focus on inadequate access to long-term care has occurred because of concern about the number of hospital beds that are occupied by “alternate level of care” patients, and the impact this has upon overcrowding in emergency departments. However, it is important to remember that even more seniors are waiting for long-term care beds in the community, and their families may be struggling to care for them in their own homes. Jeff Lozon, CEO of Revera, a private company that provides accommodation, care and services for seniors, suggested that the system would be better off if home care and long-term care are thought of as an important part of an overall strategy for meeting the needs of seniors, rather than as a method of solving hospitals’ problems.
The management of the health care needs of the elderly and the chronically ill is fragmented. The hospital sector, home care, long-term care and physicians in primary care are not well integrated, and have trouble managing patients as they move across settings and as their needs intensify. Paul Williams, a health care policy researcher at the University of Toronto, suggests that “everyone in the system is so overwhelmed that they don’t have time to think through what the possibilities are for providing care in the community, how to make connections out there.” Williams explains that the lack of integration amongst various providers leads to “long-term care being the default place.”
There are some highly successful models of care that Ontario can learn from. On Lok Lifeways, which means “peaceful, happy abode” in Cantonese, is a program of comprehensive care for seniors at home that was started in San Francisco’s Chinese community in the late 1970s. This program delivers a range of integrated services, such as primary and specialty medical care, rehabilitation services, meals and day programs for social activity, and helps people stay in their own homes for as long as is possible. Learning from On Lok might make for smart policy too – one study found that costs for seniors enrolled in the program were $1000 less per month than for those who were not.
There are some promising programs in Ontario that also focus on improving quality of care for seniors and ensuring appropriate, effective care. Home First, an approach started by the Mississauga Halton CCAC, and adopted by the Toronto Central CCAC, aims to give seniors who want to try to return home the increased level of service that they need. Another program in South East Ontario, known as SMILE for ‘Seniors Managing Independent Living Easily’ provides seniors who are increasingly frail with assistance through services such as meals, housekeeping, shopping, laundry, transportation for medical appointments, and access to a care coordinator to manage various health-related appointments and providers. However, none of these programs integrate home care, primary care (including physician home visits when needed) and hospital care.
We need to do more to strengthen home care, assisted living and primary care, so that people can be cared for in their homes for as long as possible. Ontario needs creative solutions – and possibly more funding in some areas – to integrate care and better meet the needs of our aging population.