Sophia Marquez’s* aunt Daisy is a retired social worker in her 70s who immigrated to Canada from the Philippines as a young woman. She lived in Toronto most of her life, never married, and enjoyed her independence, her friends and her family. About a year ago, Daisy started showing signs of dementia and all but stopped eating. She stopped taking her medications. She moved in with Marquez’s parents, and soon began experiencing pain so severe that she couldn’t sleep at night. This was extremely disruptive for Marquez’s mother, who has Alzheimer’s, and the situation escalated to the point that Marquez brought Daisy to the emergency department. Daisy was admitted to hospital, her pain was brought under control, and within a week, she was ready for discharge. But the family no longer felt they could safely care for her at home. Marquez, who is Daisy’s decision maker, was given a list of nursing homes. She toured several homes and gave the care coordinator her top four choices, all of which had wait times of less than three months (some of the homes had wait times of two years). After being in hospital for several weeks, Daisy moved into Marquez’s third choice.
This family’s story features two pressing concerns about Ontario’s long-term care system: the increasing prevalence of dementia among seniors and the housing of people in hospital while they wait for long-term care beds, a phenomenon known as alternate level of care, or ALC (which is thought to contribute to a phenomenon the recently elected Ontario government has called “hallway medicine”). The concerns have led to calls for more LTC beds, and the government has committed to adding 30,000 by 2030.
There is little debate about the need for more beds, but there are many questions about how best to go about adding them. There are also other concerns about long-term care homes, including the funding structure, how they are staffed, and whether some seniors would be better served in other types of settings.
New beds: Where and what type?
Of the roughly 78,000 LTC beds in the province, 30,000 are in homes that need to be redeveloped, says Candace Chartier, CEO of the Ontario Long Term Care Association, which represents nearly 70 percent of LTC homes in Ontario. These homes, many of which opened in the ’70s and ’80s, have licenses that will expire in 2025, and in order to acquire new licenses, one thing the homes need to do is eliminate any four-bed wards. This means these LTC homes must renovate existing facilities or build new ones—either way, they will need new beds. The OLTCA wants these homes to be first in line for the first half of the promised beds which the Ministry has said will be added in the next five years.
Lisa Levin, CEO of AdvantAGE, an association representing non-profit services for seniors in Ontario, including long-term care, housing and community services, says it’s important that beds be allocated to all types of facilities, regardless of funding model: private, as well as community-based not-for-profit, charitable and municipal. The last time the province put out a call for proposals for new LTC beds, in April 2018, people had two weeks to put together their pitches. “Municipal homes weren’t able to respond,” says Levin. “They have unique circumstances and everything goes through council.” Large chains, she says, have an easier time applying for beds, because they have proposal writers on staff and a quick internal approval process.
Walter Wodchis, professor at the University of Toronto’s Institute of Health Policy, Evaluation and Management, thinks perhaps only a third of the 30,000 beds that the system needs ought to actually be built anew. Another third might be freed up through better use of existing beds (through shorter lengths of stay), and the capacity of the last third could be provided through alternatives to institutional care such as supportive housing and assisted living, alternatives which allow people to live in their own (often subsidized) apartments with varying degrees of on-site, as-needed medical, personal and housekeeping support. Ideally, says Wodchis, these three options would be built near each other and work in tandem on “campuses of care,” such as Schlegel Villages, which has locations throughout southern Ontario, and Finlandia in Sudbury. “By doing that, we can delay—not avoid, but definitely delay—admission to LTC,” says Wodchis. He points to research out of Manitoba which showed that people who used assisted living had a shorter length of stay in LTC. “A shorter length of stay rapidly increases flow,” he says. “Let’s say you reduce LOS by a third, that instantly creates 30 percent capacity. That’s like adding 30 percent new beds.”
Samir Sinha, director of geriatrics at Sinai Health System and University Health Network, has challenged the plan to build more beds. For one, he’s concerned about a repeat of what happened in the early 2000s, when the addition of 20,000 new beds deepened gaps between well-bedded and poorly bedded communities. “It’s easier to build beds in places where land is cheaper, and maybe in communities where developers exist,” he says. “Let’s actually look at what the need is, and try and match new bed-building to areas that need the most.”
Sinha is also concerned that more appealing ways of caring for seniors—which can be more cost-effective—are being overlooked. In a provincial review he led in 2012 as expert lead of Ontario’s Seniors Strategy, he found that Ontario’s least-bedded region, Mississauga Halton, also had the lowest demand for LTC. The LHIN in this area had heavily invested in supportive housing, a model that “costs one quarter of what it costs to provide care in an LTC home for people who were just as high-needs as many LTC residents,” says Sinha.
Similarly, models such as the U.S.-based PACE—a program for all-inclusive care for the elderly—allow nursing-home-eligible people to live at home and access all manner of services, from primary care to dental care to lunch, through community-based agencies. “If we change nothing today, we would have to warehouse more people,” says Sinha. “If we allow more creative care models and actually fund them—fund even some existing programs better and allow them to have more flexibility—I think we could care for far more nursing-home-eligible-patients in the community than we [are] able to today, with the current system.”
The OLTCA agrees that more creative models are needed for Ontario’s seniors. “Right now we just have acute care, home care and long-term care,” says Chartier. A 2014 report from an expert panel commissioned by the OLTCA suggests that the system adopt several transitional options, such as short-stay beds in LTC homes for convalescent care, the incorporation of supportive housing in LTC facilities, and expanding the role of LTC in end-of-life care. “What we’re hearing more and more of is moving away from this standardized cookie-cutter approach and looking at the programs for specialized populations that may have a different type of need,” says Chartier.
Everyone seems to agree that the current system is overly homogenous. “Maybe we need 30,000 long-term care spaces, but not to say that that means an institutional bed,” says Wodchis.
Staffing issues, funding and quality of care
There is also agreement among those in the sector that staffing is a major problem in LTC. “We’re in the middle of a human resources crisis,” says Chartier. “There are places in the province where you can’t even get a registered nurse, no matter what the homes have done.”
Eighty percent of homes that belong to the association have trouble filling shifts for RNs and PSWs, says Chartier. The OLTCA is in favour of changing the requirement in the Long-Term Care Homes Act that one RN be on shift at all times. Instead, depending on what individual homes see as their staffing needs, they could hire more registered practical nurses, who would have access to a nurse practitioner or attending physician via telemedicine.
Doris Grinspun, CEO of the Registered Nurses’ Association of Ontario, wants to see more RNs in LTC, not less. “Nine percent of the staffing in LTC are RNs; seventeen percent are RPNS,” says Grinspun. Both of these numbers are very low, she says. “The rest are unregulated care providers, [despite] the complexity that we have in the system.”
Grinspun says the key to sorting out the staffing problem in LTC is changing the funding formula. Currently, LTC homes receive funding from the Ministry for staff and programming based on the complexity of their clients. The needs of all LTC residents in Ontario are assessed with a tool called MDS 2.0, which has a built-in algorithm that produces a case mix index (CMI) for every long-term care home. The government uses the CMI to determine how much each home receives. When a nursing home’s CMI goes down, so does their funding.
Grinspun describes this system as archaic and says it needs to be replaced with a model that combines complexity and quality outcomes. “If you decrease complexity because you’re providing quality outcomes, you [should be able to] keep the funding, not to give to shareholders, but to actually re-invest in programs for these individuals, re-invest in staffing,” says Grinspun. “People say no one wants to work in LTC. Many people want to work in LTC, and people want to provide quality of care. They are absolutely unable to do so because of the conditions of the funding formula and the staffing that we have currently in place.”
The OLTCA agrees that the current funding system needs to change. “The problem is that the pie isn’t big enough,” says Nancy Cooper, director of quality and performance at OLTCA. “Almost everyone has the same CMI—there’s very little wiggle room.” The OLTCA has developed a quality index that looks at how its members are performing on publicly reported indicators—such as pain, falls, use of antipsychotics—collected by CIHI and Health Quality Ontario. “It says that the sector is improving,” says Cooper. “Quality is improving every year.” The OLTCA would also like to see the Ministry incorporate quality into its funding decisions, and reward homes that are performing well in quality indicators. They are still studying how best to do this. “How do we measure quality of life?” says Cooper. “And how do we reward it?”
Whatever the answers, the issues with staffing need to be solved. “There are pretty high turnover rates in LTC at the PSW, nursing and even leadership level,” says Walter Wodchis. “It’s hard to improve quality in an individual home when turnover is high.” Equally important is ensuring that the needs of those looking after seniors in LTC are met. In institutions, this means staff. In the community, it usually means family—people like Sophia Marquez and her parents. “Most of LTC support in the community is by informal caregivers. And we don’t have a lot of supports for them right now.”
Names have been changed for privacy
The comments section is closed.
I have been on numerous committees of the LHINS, MHLTC, MH and others fro over the past 50 years and the only thing that I can report is that I feel that the ministry uses committees to slow down progress. The first committee was to take 2 1/2 months and went on for over three years and finally the ministry agreed with me and the committee that Oakville needed more long term beda and we did get them but slowly over about 20 years by which time the need had increased considerably. The latest committee submitted it’s report to the ministry over two years ago and the report has never been acknowledged. It also suggested that many more chronic care/long term beds were needed. Most of the time on these committees, I was the only one not being paid for my help. We do not need more committees but rather action on the multiple reports tha we (I) have produced.
SARS was 17 years ago and we knew of the four bed wards then.
It’s neglect bordering on murder to have these four bed wards.
Worked in Chartwell Aurora
Resthaven for 40 years!!
RN
Management
We need to stop allowing multinationals to profit from our seniors. no more “for profit” LTC homes should be allowed.
While all was written about nursing care-retirement-long term care beds/just want to add about the hours-time requires for another very important dept/and normally forgotten/DIETARY DEPARTMENT.Time and time again/or years and years,time allotted to dietary department has not changed in the last 8 years or so/yet demands-expectations increases and increases.Dietary staff(at least where I am),do come earlier or leave a lot later than their scheduled shifts,to ensure their job are fully done-i.e. thicken fluids-3 kinds of everything from milk/water/juice/nutritional supplement,nectar-honey-pudding like consistency.Lately with budget increase,nectar-honey consistency on milk/water/juice ,we are able to purchase.One staff had develop carpal tunnel syndrome.It is hope that next increase of hours will be on dietary department.
When our new Alberta Government came to power in 2015, we had had 40 years of conservatism here – and we were short 6,000 long term care beds. Read Parkland Institute’s publication “From Bad to Worse” (2013) and it’s sequel “Losing Ground” (2016).
We seem to forget that we are dealing with human life here. There is no algorithm that will fit this. I understand the need to have a budget however how would you personally feel whwn youe mom and dad only receive care based on a rhythm this is truly absurd. Get rid of the people at the top and you will have money to provide care. The focus is wrong it’s on revamping. It should be looking from the bottom up. I left long term care because I felt all I did was push pills and chart on most days it was 1 to 2 hours of my own time, charting, meeting’ s and organizing your day and or the next day. Not enough staff in long term care now for many years!!! This is not new problem it is an old problem resurfacing..You need to talk to the people who are holding the position of direct care. PSW’s RPN’S & RN’S we know the the care and what is needed. And please please decrease all the paper work and monitoring
I would like to start a Long Term / Palliative care place. Something small in size. I’ve worked long term care and hospital. There is a need for beds in Oxford/Perth counties . I’m registered nurse, lay minister. Where do I go to apply ?
What do I need to apply?
My email is bonitav @rocketmail.com
Please stop using Halton as a success story. It’s a shambles. What they do here is two things, dump the care on families and elderly spouses and not factor those costs into the equation. So no, it does not cost a lot less to support people at home. You just leave out the cost of daughters leaving jobs to do the care or the cost of an elderly spouse’s health being destroyed. They say now that caregivers’ telomeres are shortened, so they will in all likelihood not live as long. My 80+ tiny neighbour was expected to support a stroke-Alzheimer’s patient twice her size with the “support” of one bath a week. Then you also have a huge proliferation of full-pay “memory care” fancy-shmancy homes springing up all over Halton to take advantage of the years long waiting list for beds. These homes, that are basically making people pay for their own health-care, seem to be the way of the future. You have extremely sick people as the norm in all the “retirement” homes in Oakville paying huge amounts of money for care because the number of beds here is so low.
I am very supportive of the care options that permit healthy seniors to stay out of hospitals and LTC. I am not in favour of leaving care givers to live an unpaid and uneducated psw’s. At this time the respite care options are very limited. The care giver is assigned to be a care giver without the supports needed. Care giver care needs expansion and so does the professional staff that will do that work.
I know that staffing issues have always been a problem every day that I’ve worked. You see I’m the type that has work ethics which means nothing in today’s world. I’m used to working short as it’s an everyday occurrence at one level or another. This means I’ve had to pick up the slack in which means my workload would increase up to double what I was hired for. In one particular scenario: often times I would end up on days being responsible for 100 residents and often this may have included doctor’s days and orders because the other RN was sick and we couldn’t replace and overtime was not authorized but yet I was made responsible for 100 plus two RPN and 12 psw’s. Also, when I was responsible for 100 people and an RN plus RPN would be sick on the same floor with no replacement and not short enough to pull from another floor I’ve also had to do on top of my job function RPN (pass meds plus treatments)- often time you could even add one or two PSW’s that also called in sick. There was no extra pay for wearing so many hats and not even a thank you for holding it together. – Many facilities are in serious need of renovations and don’t even think they would pass inspections but yet the LHIN or the MOH pass them or they inform the facility that they are coming. I do believe that there’s corruption at the LHIN level and at the MOH as they don’t really care or see what’s happening, and or they do and close a blind eye. Many places hire new grads or immigrants that don’t even speak English because it’s cheaper but they don’t stay. Retention is poor with no incentives for anyone.
I know someone else will take credit for what I’ve said for years now to bring a positive change: I’ve always said that if your going to renovate then add a 5 bed pod for acute care beds to decrease the amount of ‘send to hospital’- with this acute care pod would include telemetry and acute care/ emerg nurses- there’s always a Dr on call, x-rays are now portable, blood work can be done stat, there’s physio, now even mental health assessments are outsourced and done as well, plus maids, and conscious sedation… and so utilize what we have because let’s face it that the acuity in LTC is very high. I do know that this can be successful as family and residents don’t want to go to the hospital and this would be a better alternative than going to be sent to a hospital to be on a stretcher for 6 hours to even be seen or assessed only to be sent back with nothing being done and in my experience the hospital(s) don’t even fill the discharge from hospital form and not even v.s. done prior to leaving the hospital. No, follow up…nothing and so, basically it was an ambulance ride to the hospital and return either the same way or ambutrans, or family brings the resident back. The only thing that can’t be done in an LTC facility is surgery or Hemodialysis.
These seniors are now orphans, widowers and we are mandated to give them a comfortable end of life care as possible.
“Quality is improving every year,” according to the industry. Right. This is pure propaganda. In truth, it has never been worse than it is right now, and is about to become really horrendous unless we change everything about long-term care, right now. The government should hold a round table to get other voices around the table, other than continuing to pander to the big corporations.
We are all sick of this narrative. Show some leadership, for God’s sake.
regarding 30,000 beds, great discussion, interesting ideas–many people would like to access assisted living &/or retirement home living, but are unable to afford this–we also need creative thinking for congregate type living with supports that respects privacy, that is affordable (ODSP/or other guaranteed basic incomes like OAS). I love the idea of village as a person transitions through various levels of need for care.
Without a doubt, Long term care facilities need an RN on all shifts. The residents have mulltiple diagnosis, behaviors, palliative care, intravenous medications , dressings, feeding tube, colostomies, etc etc. The MDS does not capture the time spent with families, to offer support,to explain the behaviors,the progess of theirs illnesses , the medications, their effects,and yet we have to do it:it is their loved one , for who we care. The time spent is approximately , on a daily basis easily 2 hours, but it is not calculated. The CMI does not reflect this , therefore it is my opinion that the use of the CMI is a “political game“and the MOHLTC does not want to know , they can not afford it.
While client or patient centered care is crucial, the delivery must be flexible enough to properly accommodate couples. The system should not ignore such fundamental relationships. Imagine you’re well into your 90s and still spry and sharp while your slightly younger wife needs nursing care for severe health issues… how can you keep a relationship vital if significantly different levels of support aren’t available contiguously?
Can we PLEASE, PLEASE, PLEASE, PLEASE, & PLEASE +++++++ STOP talking in circles about options and make informed, quality decisions. We need to implement solutions for caring for seniors and supporting caregivers. We’ve known for ages this crisis in senior care was coming and yet today leaders, planners, organizers, policy makers of health care continue to talk and REPEAT the refrain – “we take this very seriously”.
My journey, caring for my dad began in 1999 when I moved him from Quebec to Toronto – cared for him in my home, cared for him while he was in a Retirement Home and quit my extremely well paid career to care for him in LTC from 2008 – 2014, until he died. My husband, developed a chronic condition along the way, and I continue to care for him, in 2018. I was/am involved in advocating for quality care for both my loved ones across silo-ed health care elements from primary care, to specialists, mental health care, to hospital admissions, ER & CCAC, Retirement and LTC Home experiences. Additionally, I joined, met with and contributed ideas to family councils, MOH representatives, speak as a Patient Advisor at conferences, looked into and joined carer organizations and completed numerous surveys too many times to count – all asking the “same” questions. I also became a Patient Advisor and am recruited to work on health research and health quality improvement initiatives.
While I have seen some improvements across some health care elements, I cannot say the same for LTC.
We “all” know the problems, gaps, barriers, especially carers who bear the physical, financial, social, emotional aspects of caring for loved ones. Organizations dedicated to over-seeing, improving, providing senior care – LTC, government, researchers, policy makers, quality improvement stakeholders are true masters of surveys, studies, commissions and issuing reports filled with data.They are the BEST. However, these stakeholders are just as “silo-ed”, constricted by their thinking and limited in their approach to implementating improvements as the health system has been in providing care to patients. We cannot continue to study, talk; we have all the data needed to make significant improvements.
No matter the quantity & quality, nor the seriousness, frequency, power of words, language employed and how deeply, profound the talks are and how much they impact those who hear the talks, the lives of our seniors, & carers’ physical, emotional, mental, social & financial health our society’s productivity, economy can never be sustained, let alone improved by TALK. I certainly am interested in knowing, being involved in making these changes, not just talking about them.
Absolutely! Well said! And why do parents get paid to take care of infants, but caregivers are not paid to take care of their loved ones that are unable to take care of themselves? Sure, there is a tax break if they live with you (doesn’t begin to make a difference), but not all caregivers live under the same roof. My mother lived on her own until the day she was admitted into LTC with mixed dementia. I was there every day for years doing her finances, groceries, cleaning, laundry, driving to appointments and later cooking, feeding, monitoring with a security camera, etc, etc. How was I able to earn an income while doing all of that? If an elderly person is unable to take care of themselves and requires ongoing assistance – they should receive some compensation to help pay for their homecare – whether that care is provided by a “professional” or a family member.
I agree. I have land to develop in the city of Toronto for this very purpose. It is already zoned appropriately. Anyone reading this note would like to respond, I’d be happy to discuss.
Hi Daniel,
We from the Golden Age Village for The Elderly have been looking for land for quite a few years to build a first ever long term care and an affordable senior home for our Vietnamese seniors. We would be very interested to meet with you to explore the opportunity.
please connect with me
I love your straight talk! So sick of talking about social issues or better yet, researching about them some more! Let’s get some action and FIX the problems!
I love your straight talk! So sick of talking about social issues or better yet, researching about them some more! Let’s get some action and FIX the problems!