Crisis in Long Term Care: The Whole Story

by Audrey Miller on April 2, 2018

in Articles & Blogs by Audrey, Elder Care

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Blog # 1: Setting the Stage

THE WHAT:

Recently on most days newspaper articles are highlighting some injustice or abuse regarding seniors living in Ontario’s Long Term Care facilities, commonly known as ‘nursing homes’ or ‘old people’s home’. This is a major problem facing society and one that we must get under control. Last week’s Marketplace Crying Out for Careexposé highlighted abuse amongst residents in many facilities within Ontario. Frankly, it likely caused nightmares for many families as they worry about their family members who reside in some of these facilities.
The yearlong investigation found that in Ontario, “the reported rates of abuse have doubled in 6 years and every day, 9 residents are harmed by another resident and 6 are harmed by staff who are supposed to care for them. The investigation revealed that staff-to-resident abuse increased 148 % from 2011 to 2016.”
I thought I would spend the next few blogs discussing this important issue. This first blog will help set the stage.
I have found that almost all of the seniors I have met would like to remain living in their own homes. I am no different and am sure you feel the same way. The 2011 census data supports this as over 90% of seniors aged 65 plus live in their own private households[1].

In helping families to decide whether ‘to stay or to go’ which means either remain living at home with available care and modifications that might be needed or to explore alternate accommodation, I review the the 3 C’s which include: Care, Cost and Choice. Included in the discussion is explaining the difference between Long Term Care, which is publicly funded by the Ministry of Health and retirement living, which is privately paid.

THE WHY:
However, many seniors don’t have a choice as they cannot afford to either stay at home as their care needs exceed what is possible at home or cannot afford to pay for a private retirement setting. As such, the demand for publicly funded facilities that provide 24/7 nursing care continues to increase. Stats Can tells us that from our current demographics that older seniors, those 85+ are the 2nd fastest growing demographic with centenarians (those aged 100 and older) leading the way as the fastest growing age group[2]. The demand on our health care and home care sectors is ballooning and cannot keep up with the current demand for care.
As well, we know now that there are more seniors over age 65 than children under 15, resulting in less workers contributing tax dollars as well as fewer individuals, whether paid or by size of family, who are interested or able to assume a caretaking role.
The demand on employed carers (35% of working Canadians provide unpaid care to a family member or friend) is high, with the average employee spending 9 hours per week on caregiving. Families are juggling to keep up.
Income for many seniors prohibit them from hiring private care (averaging in the GTA at approximately $28 +) and without family to assist, they often do with the little that is available from the LHIN’s (Local Health Integration Network, formerly the Community Care Access Centres or CCAC). The services provided by the LHIN will be discussed in a subsequent blog.
The Conference Board of Canada in their report, Future Care for Canadian Seniors, A Status quo Forecast” shared: “The status quo forecast indicates that by 2026, over 2.4 million Canadians age 65+ will require paid and unpaid continuing care supports—up 71 per cent from 2011. By 2046, this number will reach nearly 3.3 million.” Older seniors (85+) tend to have greater care needs which greatly impact their ability to live on their own. Functionally they are limited, whether it be from a cognitive or physical impairment. Falls are the number 1 reason that senior have to leave their homes.
In sum, this introductory blog highlights our demographics and sets the stage of the who and the why of those individuals who require Long Term Care. Our Long Term Care options are in a crisis and unless there are some major changes, the future does not look bright.
Subsequent blogs in this series will address eligibility, costs, alternate level of care beds, challenges for younger differently abled adults and the LGBT community, those with dementia and behaviorial challenges and hopefully concluding with some suggestions for improving the system and some options. Stay tuned!
Blog # 2: Who is impacted

THE WHO:

The sad story of our Long Term Care crisis continues and this blog will focus on what’s available and the seniors who apply for them. As we know, Long Term Care homes provide Ontario residents with access to 24 hour nursing and personal care and are available to those 18 years or older whose care needs cannot be safely met in the community. As the Ministry website states: “you can expect much more nursing or personal care here than you would typically receive in a retirement home or supportive housing[1]”. In 2017 there were 627 long term care facilities operating 78,120 beds in Ontario[2]. From these, approximately 550 beds are convalescent care beds are allocated to provide short term care and 400 beds are allocated to provide respite care.

In terms of who lives there, in their report, Building Better Long-Term Care: Priorities to keep Ontario from failing seniors. the Ontario Long Term Care Association provides the following resident profile:

 Average age is 85 year old female
 9/10 residents exhibit some form of cognitive impairment with one in 3 being severely impaired.
 Over 40% exhibit aggressive behaviours stemming from their cognitive condition
 1 in 3 are completely dependent on staff and all others require frequent support with their activities of daily living
 2/3 of residents use a wheelchair
 Almost every resident exhibits multiple chronic conditions.

The bolded points above are, in my opinion, a major contributing factor to the worst of the problems- assaults between residents and between staff and residents. “In many cases, the lack of privacy afforded in older homes, particularly those with three- and four-bed wards, results in more seniors displaying responsive behaviours[3].”
These homes are funded, licensed and regulated by the Ministry of Health and Long Term Care under the Long Term Care Homes Act, 2007 and Ontario Regulation 709/10. This spells out residents’ rights, care and services available however most amazingly does not spell out a required staffing patient ratio.

Eligible applicants can apply for either a private room (private room and private bathroom) or a semi private room (2 beds per room with shared bathroom in an older building or a private bedroom with a shared bathroom in a newer building) or a ward or basic bed, which can be up to four beds in a room. The applicant can select up to 5 different facilities. Then the wait begins…. The average placement wait time as of June 2017 was 137 days, with a wait list of 32,046 people. Not every one is equal on the wait list. There is a priority wait list which is determined by the placement coordinator from the LHIN and is based on the Inter RAI assessment[4]. The waitlist priority breakdown[5] is determined in a number of different ways based on:

1) Crisis: People who need immediate admission or in crisis
2) Spouse/partner Reunification: People who need to be reunified with their spouses/partners, who are currently residing in LTCH.
3A) Religious, Ethnic or Linguistic Origin: People waiting for LTCH serving those of a religion, ethnic origin, or culture. People with high care needs but can be supported a home.
3B) Religious, Ethnic or Linguistic Origin: People waiting for LTCH serving those of a religion, ethnic origin, or culture. People with care needs currently managed at home with supports.
4A) People who have high care needs, but can still be supported at home until be become available.
4B) People with care needs who are currently managing at home with support
Once your name gets to the top of the list and a bed is offered, you have 24 hours to either accept or reject the offer. If it is your 5th choice and you are not interested and decline the bed, your name is taken off all of the lists and you must wait 3 months before reapplying, unless there is a significant change in your condition or circumstances. If you accept, you then have 5 days to move in.

Each resident must pay a monthly co payment; regardless of where one lives in the Province the rates are the same. As of July 1, 2017 they were:
Type of Accommodation Daily Co-Payment Monthly Rate
Basic Long Stay $59.82 $1,819.53
Semi-Private Long Stay* $68.02-$72.12 $2,193.65
Private Long Stay* $78.27-$85.45 $2,599.11
Short Stay (Respite) $38.72
*Varies depending a home’s structural class and date of move-in.
Source: Ministry of Health and Long-Term Care, Senior’s Care: Long-Term Care Homes.
Government subsidies or a rate reduction is available for those who can’t afford to pay the full amount, however it is only available for Basic room accommodation.
Lessons Learnt:
Apply early, ask questions of the placement person, research your options, visit and tour each facility, check the Ministry wait lists and the licensing and annual inspection reports of the selected residences.
Most importantly choose wisely so whichever facility has a vacancy and when a spot is offered, you are ready to make the move. My next blog will discuss some of the challenges I have experienced first hand with my clients.
[1] https://www.ontario.ca/page/find-long-term-care-home
[2] City of Toronto 2017 Long Term Care Homes & Services https://www1.toronto.ca/wps/portal/contentonly?vgnextoid=63fedefa5c528510VgnVCM10000071d60f89RCRD&vgnextchannel=8a87116288528510VgnVCM10000071d60f89RCRD
[3] https://s3-us-west-2.amazonaws.com/oltca/bsc2017/OLTCA_Budget_Submission_Request.pdf
[4] http://www.interrai.org/long-term-care-facilities.html
[5] https://www.oltca.com/OLTCA/Documents/SectorDashboards/TC.pdf

Blog # 3: My Experiences

This blog will address some of the first hand experiences that my clients and I have had when interfacing with the Long Term Care sector.
1. Younger adults. I worked with a 42 year old gentleman who lived with a degenerative motor disease. He could no longer live on his own and spent several years under Alternate Level of Care (ALC) status in a hospital. This is not a new issue and the Toronto Star wrote an article highlighting some of the challenges.
At that time, there were only 2 LTC’s that identified themselves on the placement selection list as catering to younger adults. I am aware of only one setting that actually had its own distinct unit for younger people rather than integrating them with the general population. It goes without saying that one’s interest in their 30’s is quite different than those of someone in their 80’s. Individuals who are developmentally delayed also face tremendous challenges.
2. Residents with behavioral difficulties. As highlighted in last week’s blog, over 40% of residents exhibit aggressive behaviours stemming from their cognitive condition. There is not enough staff and/or they are not equipped/able to actively problem solve and explore the reason for the outbursts and intervene in a helpful way. Simply put, there is not the time to understand the A,B,C’ of someone’s behaviour (A= antecedent, B= behaviour itself and the C=consequence). There are a handful of settings that are specifically designated to accommodate those with significant behaviourial challenges but again, there simply are not enough spaces to accommodate. There were previous concerns regarding the high number of residents who were on anti-psychotic medications. Health Quality Ontario[1]reported in Ontario in 2017 that almost 23% of LTC residents are on this medication without a diagnosis of psychosis. This is an improvement from the 2015 data that documented 27% of residents were being given this medication.
3. Couples who want to continue to live together also face challenges as bed offerings are rarely two at a time. This was highlighted in a few different newspaper articles
4. LGBT community has also had to provide specialized training to staff however other residents may not all be so welcoming.
5. Securing a linguistic and culturally appropriate setting can also be very difficult. For many in the later stages of dementia, they revert back to their mother tongue. While we are an ethnically/linguistically diverse community, it seems that many of those working within these facilities do not share these language skills.
This blog has highlighted several challenges that families experience daily. I know there are others but these are my starting point. My next blog will highlight some of the steps the Ontario government is taking to hopefully address them.
[1] http://qualitycompass.hqontario.ca/portal/long-term-care/Antipsychotics?extra=pdf (October 2017)

Blog # 4: Looking Ahead

My last 3 blogs have highlighted some of the challenges we are currently facing in our Long Term Care sector. The bottom line is this: there are not enough residential placement beds to address the current and growing demand for those individuals whose care needs can no longer be met within their own home setting.
The answer is not simply an increase in beds but also providing the necessary care and support to residents who occupy these beds. This includes providing a standardized and reasonable ratio of staff to residents to ensure access for individualized 1:1 attention and care. Most critically, staff require additional hands as well as training to deal with residents who exhibit behavioral challenges related to dementia.
In November 2017, Dr. Hoskins, who is now stepping down as Health Minister, unveiled a New Action Plan called “Aging With Confidence”.
In terms of promises directed towards supporting seniors requiring intensive supports (Long Term Care), several areas for improvement were identified including:
 Modernizing Long Term Care (LTC) homes– including eliminating 4 bed wards
 Reducing the wait time for LTC – creating 5,000 new beds by 2022 and will create 30,000 more over next decade
 More staffing and support in LTC- increasing nursing hours, PSW hours and specialized behaviourial training and end of life care. A recommendation of an increase to 4 hours PSW care daily
 Promoting innovation
 Culturally appropriate LTC
 Strengthening safety in LTC
 Strengthening the office of the OPGT
 Improved end of life care- more hospice beds closer to home
All of these initiatives are needed now for a system in crisis; unfortunately the implementation of this appears to be slow and evidence of these improvement are not yet apparent. Have you seen anything that you think is an improvement?
We need to be able to think in broader terms, and consider changes such as dementia only care residences, settings that provide a village- like community, closer proximity of day care settings and the list continues. For most of us, LTC is considered to be at the end of the journey. I know that is not where I want to spend the last chapter of my life if things continue the way they are going. We need to continue to put pressure on the government to do what is right for all of us as we grow older. We deserve better.

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