While Ontario’s directive limiting the number of beds in ward rooms in long-term care homes (LTCH) addresses important ethical questions, it also may have unintended consequences.
The COVID-19 pandemic has significantly impacted the safety, functioning and management of LTCHs across the province and has accounted for more than 1,800 deaths. On Aug. 28, Ontario issued Directive #3 for Long-term Care Homes under the Long-term Care Homes Act. Under this directive, both new admissions and re-admissions “from the community or from a hospital (including ALC patients) to a long-term care home or retirement home can occur if: … The resident is placed in a room with no more than one (1) other resident. That is, there shall be no further placement of residents in three or four bed ward rooms.”
Eliminating three- and four-bed ward rooms provides several potential benefits that improve safety and care. First and foremost, it reduces the risk of cross infection between residents and staff. Fewer residents per room will decrease the spread of the virus, resulting in decreased morbidity and mortality. Furthermore, some residents may be pleased to have more privacy and a larger room. With fewer residents housed on site, all residents may benefit from more direct care (provided staffing is maintained).
However, from a system perspective, this change represents a significant net loss in LTCH beds. Will these beds be replaced? If so, where will they go? Prior to COVID-19, wait times for LTCH beds among patients in acute care and Complex Continuing Care/Complex Rehab were long; they will now be substantially longer. This exerts significant pressure on discharge planners from a patient flow perspective.
From a home’s perspective, fewer residents will result in a significant revenue loss. Some homes will hire fewer staff, adversely impacting care. Others may cease to operate and thus create a void. With fewer staff required, workers who seek a living wage will be forced to take on additional work in other homes. The pandemic has proven that employment in multi-institutions increases the chance of cross contamination and thus puts lives at risk.
A psychosocial burden likely to impact some residents is the loss of the community and social support established through years of friendship with fellow residents in ward rooms. This loss could intensify feelings of isolation and loneliness, impacting quality of life and ability to thrive.
A further concern is how new admissions and re-admissions are to be treated equitably. The directive does not provide guidance on handling current residents in three- and four-bed ward rooms. The options are problematic with no optimal solutions.
We propose that when a bed becomes available in a single or double room, a resident is moved from a ward room into that bed. Keep other residents in three- or four-bed ward rooms until they transfer to hospital or die, then remove the bed from the system. This, however, will mean that hospital patient flow will continue to be a major concern. But if we give hospital patients priority over residents awaiting transfer from the three- or four-bed room, the latter group would never be transferred.
Then there is the issue of cost for patients. Normally, residents of single and double rooms are charged a premium. Now that the choice of room is significantly reduced, will residents still be charged a premium? This would disproportionately affect economically disadvantaged residents, the usual occupants of ward rooms.
A consideration likely to ease the transition would be modifying LTCH regulations that currently state a resident’s bed will be held for a maximum of 30 or 60 days for medical or psychiatric absences, respectively. During this transition, could the bed be held for a longer period? Furthermore, during a medical or psychiatric absence should LTCH charge the co-payment to residents waiting to return?
Additionally, there is no indication of how disputes between new admissions or returning residents will be handled. Disputes between hospitals and LTCH about returning residents should be referred to the local placement coordinator/ office. Unresolved issues should be escalated within the relevant Local Health Integration Network (LHiN) or Health Team.
Many LTCH residents prefer to live out their last days in a setting consistent with their faith, culture or language. With fewer beds in the system and pressure for hospitals to discharge patients, will there be fewer opportunities to provide ethno-culturally appropriate settings of care? Given the diversity of Ontario, pressure to address cultural, faith and linguistic needs in LTCH can only mount.
The authors have no conflicts of interest to declare.
There is an alternative: Both residential and in home hospice-palliative care. Hospice-palliative care does not mean just end-of-life, but a period that can last many years where the concern is care not cure. It can mean a very full life, particularly when compared to four-bed warehousing. Compare the costs and the quality of life that can be achieved and the hospice-palliative care approach wins.
An issue discussed far too little is the availability of caregivers. We assume that there is an unlimited supply but we currently have hospitals, seniors’ residences of all kind and in-home care agencies, government and private, all competing for a limited number of PSWs and RPNs. This will drive the cost of care up and the winners will have the deepest pockets.
Thank you for your comments. I would like to find ways to keep people in the community for as long as possible and to use alternatives to long term care if possible. The example of hospices is a terrific idea. They offer quality care and are cost effective.
I also reached out to my federal and provincial politicians to encourage them to think about how we could use income supports similar to maternity leave to provide an opportunity to those who want to be caregivers for someone who needs full time care. This would be especially helpful during a pandemic and could potentially shorten waiting lists for fewer LTC beds. Also if a person is able to remain in the community their linguistic, cultural and faith needs could have a greater opportunity to be practiced as part of their daily lives.
I am also mindful that there are residents in LTCs who are living with disabilities both physical and intellectual. We need to also consider how best to respect their dignity and worth. Thanks for reading my thoughts.
It will cost more but I think a better overall long-term solution is to bring LTC facilities under the Canada Health Act. I would also say we should eliminate for-profit ownership of these facilities as well as mandate living wages. For years there has been a need for more LTC beds and this will only grow with an aging population. Provinces need to build more beds, in not-for-profit, publicly run facilities. In addition provincial standards need to improve eg. safety, infection control, only working in one facility. Ageism is alive and well in Canada and despite research on the LTC industry dating back decades, no significant improvement has taken place.
Excellent piece.
What percentage of those waiting for LTC could be supported with increased home care services? Greater percentage of public funding directed to home-based care is a viable option for the future of long-term care services in Ontario and across the country.