Why long-term care needs to improve

CUPE and OCHU are campaigning for a legislated minimum average of four worked hours of nursing and personal care per resident per day in long-term care (LTC) facilities.

Key points:  [1] The relevant population is increasing rapidly; [2] New beds are not being created at the same pace; [3] Resident acuity and impairment are increasing; [4] Increasing acuity requires more care; [5] The province of Ontario provides less funding and less care than other provinces; [6] Expert research supports our proposal; [7] The experience of CUPE members in the homes provides some of the most compelling evidence of the need for more care. 

History:  In the past, Ontario did have a standard of care, but it was taken away by the Mike Harris Progressive Conservative government.  At the time of its abolition the standard was insufficient – it was set at only 2.25 hours per resident per day.  Since that time the homes have changed dramatically: residents are much more impaired.

The Ontario Health Coalition has helped organize a broad consensus among labour and community groups to campaign for improved staffing.  CUPE is doing its part to make this a reality.

Increasing demand:  The 85 and over age group is the key demographic for LTC.  When their numbers go up, need goes up.  In the five years between 2006 and 2011 the number of people 85 and over increased 34% in Ontario.  By 2016 the Ministry of Finance forecast that those 85 and over will have increased by 67% over 2006.  Moreover, a larger portion of this group will be over 90 (70% of the total, up from 50%).

Rapidly changing demographics has driven up need. This is compounded by an aggressive government strategy to cut costs by removing as many patients as possible from hospitals.

Faltering Supply:  The Auditor General reported in 2012 that the number of long-term care beds in Ontario grew only 3% over the seven years from 2004-5 to 2011-12.  That means an annual average growth rate of 0.42% — or 319 beds per year.

That falls well short of population growth.  But much more importantly, it falls far short of the growth of the relevant population — the elderly.  Or as the Auditor General states:  “An increase in the number of LTC home beds of 3% during that period has not kept pace with the rising demand from an aging population.”

The Conference Board has concluded -- based on the utilization rate by age and the Government of Ontario’s population projection -- that 238,000 Ontarians will be in need of long-term care by 2035. That is 161,000 more than the 77,000 LTC beds existing now.

Ontario would have to create 8,000 new beds per year, on average.  That is over 25 times the current rate of new bed creation rate of 319 per year.  Even if Ontario was creating beds at five times its current rate, utilization of LTC will still have to be cut in half.

The lack of new capacity means that LTC residents getting into a home are much sicker. The increasing acuity of residents will continue to deepen for at least the next two decades, in all likelihood.

Restricting access to only the sickest:  With few new beds, wait lists grew rapidly, growing to over 35,000 by 2010.  With this,   the time spent waiting for a LTC bed grew rapidly.  The government’s response to this was to restrict access to the wait list through legislation.  Only the sickest would even be allowed to wait for a LTC bed.  The Auditor General notes:  “the number of people waiting decreased by almost 15% between March 2010 and March 2012.  This was primarily due to the stricter eligibility criteria in the new Act.”  In effect, the wait list was reduced by about 5,000 through the tighter criteria.

Sicker residents:  At around the same time the government stopped reporting the Case Mix Measure (CMM) – which was the main way of reporting the level of acuity (or illness) of the residents.  Despite this, other measures clearly show that residents have a much higher acuity.

•       Activities of Daily Living (ADL) scores are increasing (meaning residents have more impairment with activities of daily living).  Between 2009-10 and 2013-14, ADL scores have increased by 7.8%.  In 2013-14, ADL scores increased by 2.5%.   

•       MAPLe data also suggests increasing acuity.  (MAPLe is an assessment used to prioritize an individual’s need for home care services and long-term care placement.  There are five groupings of impairment measured by the MAPLe scoring: Low, Mild, Moderate, High, and Very High.)

•       New entrants into LTC have much higher levels of impairment according to MAPLe scores.  In the last quarter of 2009- 10, 76% of new admissions had high to very high levels of impairment; 35% high and 41% very high.  By the end of 2013-14, 83% of new admissions had high to very high levels of impairment.  Almost all
the growth was in the very high category, with admissions of this group growing 3.9% per annum.  The impact on the overall resident population is clear:  more residents with high or very high impairment — with almost all the growth in
the very high impairment category

•       The not-for-profit homes (OAHNSS) indicate that a wide range of psychiatric illnesses and dementia are increasing, typically in the 2-3% range per year.  Surprisingly, they report that the occurrence of “cognitive impairment” is declining at a rate of 1.3% per year.

The restrictions placed on LTC beds and hospital care has also dramatically driven up the acuity of home care patients overseen by Community Care Access Centres (CCAC).  In just four years the percentage of patients with CCACs  who have higher care needs increased from 37% to 64% and lower need patients declined from 63% to 36% (see chart below).  Now the province is moving to remove low need patients from the CCACs altogether, so the CCACs can focus on higher need patients. 

Bottom line:  LTC residents are getting sicker and sicker.  Government policy to restrict hospital and LTC capacity mean that resident acuity will continue to increase.

Ontario staffing falls short:  New data  published by the Canadian Institute for Health Information (and based on a mandatory survey undertaken by Statistics Canada) indicates that staffing at Ontario long-term care facilities (LTC) falls short of other provinces.  Of all the other provinces only B.C. has fewer “health care staff” (i.e. PSWs, RPNs, RNs, but also including therapists, recreation and activity staff, and some other health care staff). 

The rest of Canada has 15.1% more health care staff per resident than Ontario. 

Ontario also has fewer higher paid health care staff than the other provinces — fewer RNs, but especially fewer RPNs per resident.  RPNs (or LPNs) are 26% of LTC health care staff across Canada, but only 19% in Ontario.  The Canada-wide ratio of RPN staff to RN staff in LTC facilities is 1.96 to 1.  But in Ontario, the ratio is only 1.67 to 1. 

Also significant, across Canada, there are 13.4% more administrative and support staff (i.e. non “health care” staff) per resident compared to Ontario. Clearly, housekeepers and dietary staff are not making up for the lack of nursing and personal care staff.

Some of the under staffing in Ontario may be rationalized by the somewhat higher proportion of facilities classified as “Type II” in Ontario rather than Type III or higher.  (This report deals with Type II or higher facilities, excluding Type I facilities such as retirement homes in Ontario.  Type II facilities “require” 1.5 to 2.5 hours of care per resident per day, while Type III require 2.5 hours or more).  In Ontario 69% of facilities are rated as Type II, while across Canada 44% are rated Type II.  However, given the very modest role hospitals play in Ontario, it is hard to believe that the residents in Ontario LTC are less in need of care than elsewhere.  Notably, 52% of residents in Ontario facilities are 85+, about the same as the cross-Canada percentage of 51.7%.  Ontario also has a similar percentage of all LTC beds and LTC staff as it has as a percentage of the all-Canada population.

Provincial funding:  Provincial funding per resident is 5.88% more in other provinces.  That equals $2,486 more per resident per year.  Private, municipal, and other funding makes this up.

Expert research:  Research commissioned by the US Congress and carried out by the Center for Medicaid and Medicare Services (CMS) is widely recognized as the most comprehensive and academically sound research to date on the subject.

•       The CMS found that a minimum staffing level of 4.1 worked hours per resident day is required to avoid jeopardizing the health and safety of LTC residents.

It is important to point out that the CMS-recommended minimum,

• Refers to worked hours, not paid hours (e.g. holidays, sick time).  Paid hours are 15 to 30 per cent more than worked hours.

• Includes only hands-on nursing and care aides.  Support services (food, cleaning, laundry, maintenance, clerical, and others) play a vital role and need to be reflected in staffing standards.

• Refers to the level needed to “avoid jeopardizing the health and safety of residents.”

The minimum level required to actually improve quality of care is about 4.5 to 4.8 worked hours per resident per day the CMS reports.

Safety:  Unfortunately, need for better staffing often comes up through assaults and deaths.  With increasing illness of patients, there are aggressive residents.  Attacks occur on other residents sometimes resulting in deaths.  In the night time staff is particularly thin, with Personal Support workers sometimes dealing with 30 or more residents. 

Assaults also occur on staff.  Too often abuse is considered as part of the job.  It is not.  

Recent focus groups with CUPE LTC members reported the following comments:

•       Verbal abuse is everyday, all day.

•       It’s constant.  Screaming, shouting, name calling and stuff. 

•       We get punched, bitten, scratched, slapped, spit at.  Pinches, scratches,
open wounds, where they’ve broken skin.

•       Sexual comments.  Racial comments.

•       We’ve had residents who grab you and hold you up by the throat.

•       It’s become normal for us to get hit.  We get beat up but that’s our job.
It’s part of your job.

•       Some of the girls got told last week, ‘If you don’t like it, quit.’  You can’t tell me that my job to sit there and have a resident punch me in the face. There’s no compassion. ‘It’s your job.’ Well, no it isn’t. 

Not-for-profit employers echo our call – almost:  The pre-budget submission from OAHNSS, the representative of the not-for LTC homes, does come close to calling for a care standard in their pre-Budget submission.  Recommendation #1 is this:

•       “That the Ministry of Health and Long-Term Care set and fund over the next three fiscal years a system target of 4.0 paid hours of direct care per resident day (PHPRD).” 

OAHNSS wants government to set a “system target” of 4 paid hours of "direct care" over the next three years. This is progress, but falls short of our call for 4 worked hours of nursing and personal care which does not include hours paid as vacation, holidays, sick leave, etc. and also does not include Program and Support Services hours. (And, of course, a “system target” falls short of a demand for a legislated standard.)

Positively, OAHNSS also suggests “the Ministry of Health and Long-Term Care make the development of a measure of year over year change in LTC resident acuity a priority for 2015-16.”  

Other establishment forces move to support increased care:  The government’s Shirley Sharkey report said the government should target 4 paid hours per day by 2012.  More recently, the Long-Term Care Task Force on Resident Care and Safety (2012) highlighted the need for the government to fully follow through on the Sharkey Report recommendations in order to improve the level of safety and care quality for seniors in LTC.  In the words of the chair of that task force, Gail Donner, “There is no doubt that we don’t have enough staff.  It’s past even talking about – you just have to go to a long-term care facility to see that.”

We are making progress:  OAHNSS notes that MOHLTC data indicates we have achieved 3.44 paid hours of "direct care" per day per resident. OAHNSS's focus on "direct care" is a little different than the focus of CUPE and others only on RN, RPN and Personal Support Workers (PSW) hours. The OAHNSS "direct care" hours also includes  Nurse Practitioner hours and hours of care paid out of the Personal Support Service envelope  (for physiotherapists, speech-language therapists, occupational therapists, recreation workers, volunteer co-ordinators, social worker, and registered dieticians).  

OAHNSS however, also does report the actual paid hours of RN, RPN, and Personal Support Worker care.  They are reported at a total of 3.17 hours, about 16 minutes less per day than the OAHNSS "direct care" hours.  Most of that care (2.52 hours) comes from PSWs.   

OAHNSS costs their 4 hours of paid "direct care" at $385 million annually.  Given government’s  intention to impose austerity, this will be challenging.  The increase cited by OAHNSS equals over a third of the total annual increase for all of health care; it is equal to about an 11% increase in total LTC compensation.  

CUPE LTC members want better:  91% of OCHU/CUPE LTC focus group members do not feel satisfied with level of care provided; 97% feel there is not enough staff.  Staff believe they are forced to make unsafe choices:  “Either you follow the rules or you help this resident.”  Compromised care is reported in a whole number of areas:  resident cleanliness, eating, dressings, forcing residents into incontinence, and insufficient infection control.  Sadly, staff report a lack of time to provide the emotional care to residents, who are often at their most vulnerable and in the final stages of life. 

The experiences of LTC CUPE members can be a very compelling argument in favour of more care.

Conclusions:

• The relevant population is increasing  rapidly;
• New beds are not being created at the same pace;
• Resident acuity and impairment is increasing, and, in all likelihood, will continue to increase for years to come;
• Increasing acuity and impairment of residents requires more care;
• Ontario provides less funding and less care than other provinces;
• Expert research supports our proposal;
• Not-for-profit employers and others are beginning to echo CUPE’s proposal;
• Resident safety issues suggest the need for more time to care;
• Our campaign is helping to make a difference;
• The experiences of CUPE LTC members at work provide some of the best evidence of the need for the time to care.

Photo of "Cathy" by Andrew Newton.