Improving quality and safety in Ontario’s nursing homes
Recent media reports have highlighted the problem of neglect in nursing homes.
Reports from the long-term care sector, in response, have focused on how the quality of care in nursing homes could be improved.
However, measuring the quality of nursing home care can be a challenge.
Rob Sargeant is a general internist at St. Michael’s Hospital in Toronto and cares for patients who are transferred from nursing homes when their medical needs exceed what long-term care staff can provide. Sargeant notes that it is common to see nursing home patients admitted who are clearly suffering from neglect. He teaches medical students and resident physicians to recognize neglect, as well as high quality care, when assessing patients. “I will say to my team, someone out there is doing a great job of taking care of this patient – there are no bedsores, they aren’t emaciated, they aren’t dehydrated, their skin hasn’t broken down from being left too long in a dirty diaper,” says Sargeant.
Earlier this year, the Long-Term Care Task Force on Resident Care and Safety, which was established in response to several high-profile incidents of abuse and neglect, released its action plan. The Task Force, which was chaired by Gail Donner, past Dean of Nursing at the University of Toronto, noted that laws and regulations “are not enough to eliminate abuse and neglect in all long-term care homes.”
But if laws and regulations aren’t enough, what more should be done to ensure that the more than 75,000 people who call long-term care ‘home’ receive high quality care?
Long-term care in Ontario
Ontario has 634 nursing homes, or long-term care facilities as they are technically called. Some are privately owned and managed on a for-profit basis, while others are public and operated by municipalities. Some, mostly private non-profits, specialize in providing care tailored to the needs of specific cultural or religious communities.
The Long Term Care Homes Act sets out more than 400 criteria to ensure that all nursing homes provide good quality care. However, there is increasing concern that nursing homes need to do more than meet regulations in order to meet the increasingly complex needs of long-term care residents.
Donner suggests that neglect “is happening across our society – and its not because of bad people, bad homes and bad regulation – rather, some of this is happening because we aren’t paying attention to the increasingly complex and changing picture of the elderly in our communities.”
Most nursing home residents have some form of cognitive impairment, such as Alzheimer’s disease, and some are occasionally aggressive. Older, medically complex patients with cognitive impairments can be very difficult to care for, and require specialized care to manage their medical, social and behavioral needs.
Andrea Gruneir, a researcher at Women’s College Hospital Research Institute, argues that long-term care in Ontario was not designed to meet the needs of this complex population. She says that “the way long-term care is staffed and resourced needs to change.” This is echoed in the Task Force findings, which asked long-term care residents, staff, family members and volunteers “What kind of things lead to abuse and neglect?” The first response was the quality of work life for staff, including workload, recognition and support and staffing numbers.
While the Long-Term Care Homes Act mandates that nursing homes have a nurse on-site 24 hours a day, 7 days a week, there is no provincial requirement regarding what the minimum staff-to-resident ratio should be. A 2006 research report commissioned by the government of British Columbia found that residents who live in nursing homes with higher staff-to-resident ratios are less likely to develop pressure ulcers. Presumably, more staff means that residents who are immobile can be repositioned more frequently.
Measuring nursing home quality
Health Quality Ontario, an arms-length government agency, was tasked in 2008 with measuring and reporting to the public on the quality of nursing home care. Click on the image below to see the current measures of quality for Ontario’s nursing homes.
While Donner suggests that these indicators are “a good start” , but there is a need to “raise the floor” when measuring the quality of care in this sector. Rob Sargeant suggests that further measures could be put in place to ensure that frail elderly residents are receiving appropriate medical care, including measuring processes of care like having regular discussions about end of life treatment plans as well as regular medication reviews, especially after a resident has had a hospital admission or emergency department visit
Donner suggests that outcome measures that focus on adverse events do not provide a full picture of quality of care in the sector. “People will fall in long-term care,” she says. “Sometimes its due to erratic behavior, other times its because they were taken to the bathroom, no one checked in on them and they were left sitting for too long and they fell struggling to get up.”
Samir Sinha, the Director of Geriatrics at Mount Sinai Hospital and the University Health Network, as well as the Provincial Lead for Ontario’s Senior Care Strategy, says that while it is important to ensure that environments are safe and minimize the risk of falls, the way we measure falls should not lead to unintended consequences. If homes try to reduce falls by keeping residents more confined to their beds, there will be negative health consequences, and it is important to balance risk with quality of life for residents.
Sinha argues that “there is a danger in only looking at outcomes such as falls and pressure ulcers, because with very complex patients there is a higher risk of these complications – and we do not want to select indicators that would make homes shy away from meeting the challenge of providing care to patients with higher needs.”
Sinha also notes that an important way to measure quality, which is not yet formally captured in Ontario, is by assessing resident and family satisfaction. Andrea Gruneir agrees. She says, “I think that there is a lot of emphasis on technical measures, rather than the residents’ experience.” Surveys of residents and their families would also allow nursing homes to focus on improving quality of life rather than simply reducing the rate of adverse events.
Others have noted that measuring staff satisfaction is another good way to assess nursing home quality. A large staff survey was recently piloted in 400 nursing homes in Ontario as part of the ‘Determinants of Quality in Long-Term Care’ study led by Walter Wodchis at the University of Toronto. The assumption behind this study is that “quality of care is largely dependent on the quality and effectiveness of staff delivering care” in nursing homes. Suzanne Dugard, a spokesperson for Health Quality Ontario, notes that their organization is a partner on the study, and is working on options for publicly reporting staff satisfaction data in 2013.
Improving nursing home quality
One Ministry of Health and Long-Term Care official who spoke with Healthy Debate noted that “long-term care is a huge, expensive piece of social infrastructure” and that increasing staffing ratios across the board in the sector would be very expensive.
The official noted that “we have 77,000 almost identical beds in nursing homes” but that patient needs vary. Many experts, including the Long-Term Care Expert Panel struck by the Ontario Long-Term Care Association, believe that specialization of beds would improve overall quality. For example, some nursing home beds could be dedicated to people recently discharged from hospital with more medical needs, while others could be dedicated to those with aggressive behaviours.
Catherine Richards, whose mother spent the final months of her life in a Toronto-area nursing home agrees that “neglect is prevalent across long-term care and what it really comes down to is how much time people have [to provide direct care].” Without meaningful data regarding staff, resident and family satisfaction, it is very difficult to know whether nursing homes in Ontario are providing good quality care or not.