The endless crisis in Ontario's long-term care

Paul Wells: Ford has vowed to 'leave no stone unturned'. Here's one expert's view of how to fix a crisis that's been unfolding for years.

On Tuesday, Ontario Premier Doug Ford released the military report into appalling shortcomings and abuse at five Ontario long-term care homes. He promised to “move heaven and earth” and “leave no stone unturned” to fix the system of care for tens of thousands of elderly Ontarians. There was no reason to doubt his goodwill, although it’s also fair to wonder why he’d be surprised at the state of a system of which he’s been in charge for two years.

I haven’t followed long-term care in Ontario; my work concentrates mostly on federal government files. But it didn’t take much reading to discover that one Ontario premier after another has been criticized for running a long-term care system that falls below Ontarians’ expectations.

There have been attempts at reform, starting (to pick one jumping-off point more or less at random) with the 2007 legislation that set up the sector’s current regulatory framework. But it hasn’t really matched dollars, or appropriate human resources, to needs, either before or since 2007.

To understand this all better, I called Tamara Daly, a professor of health policy and administration at York University. She runs the university’s Centre for Aging Research and Education. She has studied the evolution of long-term care in Ontario over many decades and compared it with systems in other provinces and other countries. Here’s one of those papers.

In our conversation, which I’ve edited for length and clarity, Daly describes the persistent flaws in Ontario’s long-term care system; the way regulation forces ever-increasing levels of privatization, to an extent that makes Ontario an outlier among Canadian provinces; and the glaring gaps in information and protection, as more and more Ontarians move from hospitals and the protection of the Canadian Health Act to the jurisdictional black holes of long-term care.

READ MORE: How prepared was Canada?

One thing we’ve learned over and over again is that the coronavirus that causes COVID-19 exploits pre-existing conditions, whether in patients or in health-care systems. “COVID has been exceptionally good at revealing all of the fissures in our system,” Daly told me. “It’s moved in and it’s exploited all of those very well.”

Q: You saw the reports on what the soldiers saw in long-term care homes. The first question is, does it surprise you?

A: No.

Q: Why not?

A: Because I have also read through the variety of incident reports that are publicly available on a government website. When a home is not in compliance with particular regulations, they get written up. Those reports are made public. And when the ministry responds to those reports, like whether or not the home is now in compliance, that also gets publicly reported.

There’s also supposed to be a number of routine inspections that the ministry does. They haven’t been doing those in the past year. As part of their routine inspections, they are also supposed to be looking for incidents of non-compliance with the regulations.

Q: I watched Premier Ford’s news conference. He promised to “move heaven and earth” and “leave no stone unturned” to “fix the system.” I’m afraid my first bit of skepticism was about how easy the system would be to fix. So I did a quick set of Google searches. Basically one Premier after another, pull up the clip file on long-term care, and I get the distinct impression there was never a golden age.

A: No, there hasn’t been.

Q: What’s the story of long-term care in Ontario over our lifetimes?

A: One of the big changes that happened with the passage of the 2007 legislation was that we combined what used to be the charitable homes, the public homes and the nursing homes all into one stream. We put them into one basket of regulation. And we put all of these homes under the same set of rules for getting people into those homes. The reason that this is important for this sector is because the charitable and nonprofit homes, municipal homes, and the nursing homes used to do something that was slightly different. So the other types of homes used to provide more of a model for frail elderly people who would typically reside in those homes for a very long period of time. Whereas the nursing homes, there was a higher level of acuity, so people needed more nursing care.

When the combination happened, what also happened was, we also had a shifting outside of hospitals. People that would normally be cared for in hospitals were increasingly being cared for in these places. We moved long-term care into this position where it was expected to be a substitute for a higher level of acuity.

But the staffing models have never kept pace with that. One way I can bring that home is that a lot of people with COVID have gone into hospitals, they might be in an ICU, for instance, and the ratio might be one registered nurse to four patients in an ICU. Well, in longterm care homes across this province, a 36-unit part of a nursing home might have one registered practical nurse. Not an RN, a registered practical nurse. And on the day shift, you would probably have four PSWs. So a 1-to-9 PSW ratio. Sometimes it’s as high as 1 to 12. So we have these residents with much higher levels of needs, but we’ve not kept pace with the staffing.

And then COVID comes along and those residents aren’t allowed to go to hospital. They’re not being transferred to hospital for a variety of reasons. There might be a decision around “Do not resuscitate,” it might be because the hospital doesn’t think that there would be any additional benefits. But you now have people who are having the same sorts of experiences with so few staff. It’s not even fair. And I think that in a lot of places, the working conditions in the for-profit facilities are often, at an aggregate level, of poorer quality than if you were in a non-profit or in a public home, a municipal home. Things like permanent staff, rates of pay, access to benefits, even the number of staff, because municipalities and nonprofits put extra money into providing care and the for-profits are not doing that.

So the staffing levels were already very minimal when you compare between the different ownership types. But on top of that we’ve heard from our research participants that for-profit facilities tend to rely more heavily on temporary and casual staff. “Agency staff” is sometimes another term that’s used. And the reason that this is important: because those staff don’t understand what each resident needs.

If you’ve read the military report it talks about someone not knowing that one person is supposed to get the right consistency of food. The reason that’s important is because of choking. If you feed somebody the wrong consistency they can aspirate the food, right? So staff  have to know residents. A lot of residents have dementia. They can’t speak, perhaps, or they wouldn’t be able to communicate that they were getting the wrong sort of care. So continuity is really important. Good charts and good record-keeping is really important. That was another one of the things that was highlighted. And so when you have poor working conditions, you have a discontinuity of care and you make it more likely that things will go wrong, even in normal circumstances.

The other issue that was highlighted in the report was the lack of resources, you know, the incontinence pads and other things that were being held back or behind locked doors. So staff couldn’t access, maybe, the covers that go over the beds and things like that. We hear that repeatedly in some of our research. Staff talk about not being able to access the resources that they need in order to be able to provide the care. Or they’re worried if they go through too many supplies. That was highlighted.

Q: It sounds like there’s just not enough money in the system.

A: If you think about it in terms of a pie, the pie has expanded somewhat, but the way the pie is allocated is tricky. We use a system called the RAI-MDS: the Resident Assessment Instrument—Minimum Data Set. This is an assessment system that staff members will prepare. These numbers are collected on a continual basis and aggregated and put through algorithms, and that number determines how much of the pie each home gets. If you have residents with higher clinical complexity you get more money. If you have residents that are lower you get less. Money translates into people, into resources to spend on nurses and PSWs.

The tricky part here is that it does become a numbers game. The bigger the organization, the better they are at maximizing their numbers—to capture the highest level of complexity and acuity, and to ensure the highest level of funding. Homes who are not so good at that can end up losing funds—and then not being able to staff at an appropriate level. That’s one thing.

But also the numbers don’t follow individuals. You could have a whole bunch of people that are very acute and complex and they pass away. So your numbers are high, but the new people that have come in, you actually don’t need those resources as much.

So there’s never a perfect alignment between the people that you’re serving and the funding that’s coming in the door. It is an exceedingly complex funding model. And in my opinion it doesn’t translate well into the actual need for human resources.

As a result of that, we have a model that hasn’t kept pace with people’s needs. But it also doesn’t shift to meet the needs of people who have dementia, but not a lot of medical complexity. Dementia takes a lot of staff resources to care for someone, to monitor really well, but PSWs don’t have a lot of time to do the work that they’re supposed to do. So what the military is finding in this particular report, I think, could be found in many of the homes across this province.

Q: You’ve also done the comparative work, comparing Ontario’s system to other provinces and other countries. How does it compare?

A: We are exceedingly understaffed. We pay poorly. We have poor working conditions. We don’t have what the Australians like to call “decent work.” We have a system that is heavily reliant on agency staff, with temporary and casual staff. We have a higher proportion of for-profit chains operating in the province than any other province in Canada. We’re running at about 60 per cent; most of the other provinces like B.C., Alberta, it’s about 30 per cent of their sector. They have a much higher proportion of nonprofits and public ownership of the facilities.

Q: Okay. Premier Ford told reporters today he would leave no stone unturned to fix this. Let’s say his first step is to put you in charge. What’s your recommendation to him?

A: We have to get Ontario to work closely with the federal government to consider a set of national standards that each of the provinces would sign on to. I do agree with Ford that the federal government has to step up in terms of providing funding to the sector. Home care and long-term care have been treated somehow as though they’re not part of health care because they’re not part of the Canada Health Act. They’re considered extended-health services, not insured services. We’ve seen, in the last 20 years, more and more people moved out of hospital, and into home and community and long-term care settings. We have not shifted our system to acknowledge this.

So I would recommend that there be minimum staffing levels. I’d recommend that we favour nonprofit and public provision. I do not understand why we allow profit-taking with vulnerable populations.

Q: How stark is the distinction between public and and and for-profit when we’re in a world where even public facilities contract out a large part of the services that they provide?

A: What happened was the regulatory complexity, and the way that the regulations were imposed, was a way of trying to control profits and make sure that there was still good quality. So we kept amping up the regulations as a kind of a quality-control measure. But as you amp up these regulations, you actually make it much harder for municipalities and nonprofits who are standalone to be able to operate with this regulatory complexity. That’s why I call it “dancing the two-step:” If you keep upping the regulations you make it more likely that you will have for-profit providers managing for municipalities who find they can’t meet the regulatory requirements, or you have municipalities that are contracting out other pieces of it.

It’s vitally important that we think about how to make sure that these are organizations are not a series of outsourced companies—where the building is one company, the management is another company, the food is another, the cleaning is another. Because I think what COVID reveals is that if you don’t have good relationships and good control over all of these different parts of the system, you make it more likely that things will go wrong. COVID has been exceptionally good at revealing all of the fissures in our system. It’s moved in and it’s exploited all of those very well. I think anybody who is really concerned about making sure we can move forward will want to make sure we have organizations that are cohesive and homogeneous, and not contracted-out and full of these kinds of complex organizational arrangements.

What we’ve done with our system is, we’ve downloaded the responsibility of our provincial government onto individual organizations to do the right thing. And when stuff goes wrong, we blame those organizations. But we don’t have data reported at a system level. And we don’t have oversight of the sorts of things that could make a difference.

For instance, we don’t even know how much public funding gets sent to each of these individual homes. We do know that the public spends about $4.9 billion and that funds are collected for accommodations, which does come back into the public coffers from people paying out of pocket. So we know that long-term costs 7% of public health care spending. But we don’t know how it gets allocated between homes and we don’t know how it’s spent or how much profit is taken.

We don’t know how many staff work at a particular facility. We don’t know their turnover rates. We don’t know whether or not their staff are permanent. Do we actually have enough people there to provide the care? We don’t know what kind of individual conversations or agreements are made with each of the large providers. We don’t know how much those providers pay back into political campaigns.

None of this stuff is publicly reported. And I like to say: we have public funding and we have private provision and private data. So we don’t have transparency. We don’t have accountability. Yet we spend a lot of money.

And this isn’t to say that there aren’t some good providers. There are many good providers, those who are doing good stuff. Despite our system, not because of it.