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