Long-term care (LTC) homes are expected to be that – homes that are safe, healthy settings for the most vulnerable members of Canada’s population. However, this is not always the case. There have been reported incidents of severe staff shortages and turnover, as well as resident abuse and neglect. Approximately 40% of LTC homes in Canada are built to physical design standards of older homes that are not appropriate for the needs of today’s elderly residents who require complex care1.
This blog focuses on Ontario as an example of one LTC system under stress. The existing pressures in Ontario’s system, particularly the shortage of personal care workers (PSWs), have been exacerbated by the outbreak of COVID-19. COVID-related deaths in LTC homes represent 64.5% of all deaths in the province as of June 13, 20202. By the end of April, the situation was so dire in five homes that the Ontario government requested military assistance in providing medical care.
In Ontario, LTC provides access to 24-hour nursing and personal support services and a variety of supportive services (such as physiotherapy)3. More than a quarter of Canadian seniors4 (aged 65 years and older) live alone and prefer to age at home. Typically, LTC residents are admitted when they are no longer able to live safely at home and/or family can no longer care for them.
a. A Profile of Resident Acuity
Ontarians have expressed a clear desire to age at home in their communities. In 2007, the province initiated its Aging at Home Strategy, which included enhanced community supports to enable Ontarians to live independently at home for as long as possible. This has resulted in the LTC system receiving residents who are more vulnerable, frail and elderly, and have complex care needs. Among LTC home residents:
- The average age is 83; 82% are 75 or older and 54.7% are 85 or older
- Almost 90% have a form of cognitive impairment, with 32.8% of those being severely impaired and 63.5% having dementia
- Approximately 86% require extensive or complete support for assistance with activities of daily living
- 85.8% require the use of at least one mobility device, with half using a wheelchair with assistance
- 44% exhibit some degree of aggressive behaviours
- 53% are totally or frequently incontinent5
b. Facility Design
Ontario has 626 LTC homes and close to 78,000 residents in care6. According to the Ontario Long-Term Care Association (OLTCA), slightly less than half of the homes (300) are older, resembling the institutional environment of a hospital. This design does not support the complex care needs of residents, best practices for dementia or infection control, desires of today’s residents for a home-like environment, or the number of residents using wheelchairs.
c. Staffing and Funding Shortages
According to Miranda Ferrier, president of the Canadian Support Workers Association, personal support workers (PSWs) make up 85% of the staffing in LTC homes. PSWs help residents with activities of daily living (e.g. eating, dressing) and personal hygiene (e.g. bathing, toileting) and provide nearly two of the three worked hours of care each resident receives daily, with nurses providing the remainder.7
In December 2019, the Ontario Health Coalition released a report8 on the acute shortage of PSWs causing short-staffing in LTC homes. With PSWs providing much of residents’ hands-on care, the shortages resulted in inadequate time to provide even basic care for residents.9 The PSW programs offered by a number of Ontario colleges reported decreased enrollment in communities experiencing the most acute shortages. PSWs are leaving the profession to work in hospitals or other industries, such as retail, where the workload is less and the pay equal or better.
Not only are PSWs in short supply, but nurses are also in shortage – partially because LTC homes compete with hospitals to recruit and retain nursing staff. The workload, lack of advancement opportunities and stigmatization of LTC as a workplace combine to make recruitment and retention of nursing staff problematic.
d. Oversight of Quality and Safety
In 2010, the Ministry of Health and Long-Term Care (MOHLTC) established the Quality Inspection Program of LTC homes. The Long-Term Care Homes Act (LTCHA) sets out more than 400 criteria to ensure that all homes comply with standards and provide quality care. The comprehensive annual inspection program was scaled back in 2019 to focus on critical incidents, specific complaints and inspection follow-ups. This change does not allow for the identification of systemic issues in the quality of care. Furthermore, meeting regulatory standards does not measure the quality of resident life.
The conditions created by outdated structures and staffing shortages in LTC homes were only exacerbated by the pandemic. In April 2020, Ontario’s premier requested the assistance of the Canadian military in five LTC homes that were struggling with outbreaks of COVID-19 infections. After two weeks in the homes, the military wrote a letter to command detailing its observations of the situation in each home. The observations were so serious that the military shared the letter with the province. Ontario’s premier has promised to have an independent commission into the LTC sector in the fall.10
A month after the public release of the military’s letter, the Registered Nurses’ Association of Ontario (RNAO) published a report that questions the need for another investigation. Despite all the recommendations made in the last two decades of reports, little has been done to implement them.11
LTC homes are faced with the reality of providing quality care with limited resources. The two largest risks areas that homes can focus their resident safety efforts on are falls and wound care. Every LTC home should have clear policies and protocols for fall prevention and skin integrity. Staff should be made aware of their role in reducing falls and skin breakdown. Staff meetings can be used as opportunities to share adverse event data (e.g., the number of falls per month and percentage of those falls resulting in serious injury) and best practices, and reinforce the staff’s role in managing these resident risks.
Canada’s LTC homes currently face significant challenges in supporting a basic level of care and quality of life for their residents. Both a human resource strategy and infrastructure funding have been advocated for several decades by a number of professional associations and government inquiries to address these challenges and help homes address resident risks and quality improvement.
1 Canadian Association of Long Term Care (CALTC). (2018). Tackling the aging crisis. Retrieved at https://caltc.ca/wordpress/wp-content/uploads/2019/06/CALTC-Election-Document-2019-Digital-ENG.pdf
2 Government of Ontario. (2020). How Ontario is responding to Covid-19. Retrieved at https://www.ontario.ca/page/how-ontario-is-responding-covid-19#section-0
3 Government of Ontario. (2007). Long Term Care Act. Retrieved at https://healthydebate.ca/2012/07/topic/community-long-term-care/long-term-care
4 Statistics Canada. (2016). 2016 Census. Retrieved at 2016 Census. Retrieved from https://www150.statcan.gc.ca/n1/pub/75-006-x/2019001/article/00003-eng.htm
5 Canadian Institute for Health Information (CIHI). (2019). Continuing Care Reporting System (CCRS) 2018-2019. Retrieved at https://www.cihi.ca/en/quick-stats
6 Ontario Long-term Care Association (OLTCA). (2019).This is Long-term Care 2019. Retrieved at https://www.oltca.com/OLTCA/Documents/Reports/TILTC2019web.pdf
7 Mitchell, Alanna. (April 7, 2020). Fear and exhaustion: Working as a PSW in long-term care during the
coronavirus. Retrieved at https://www.macleans.ca/society/fear-and-exhaustion-working-as-a-psw-in-long-term-care-during-the-coronavirus/
8 Ontario Health Coalition (OHC). (December 2019). Caring in Crisis: Ontario’s Long-Term Care PSW Shortage. Retrieved at https://www.ontariohealthcoalition.ca/wp-content/uploads/final-PSW-report.pdf
10 Mialkowski, C.J.J. Brigadier General. (May 14, 2020). Op Laser – JTFC Observations in Long Term Care Facilities in Ontario. Retrieved at https://www.macleans.ca/wp-content/uploads/2020/05/JTFC-Observations-in-LTCF-in-ON.pdf
11 RNAO. (June 2020). Long-term Care Systemic Failings: Two Decades of Staffing and Funding Recommendations. Retrieved at https://rnao.ca/sites/rnao-ca/files/RNAO_LTC_System_Failings_June_2020_1.pdf