This is the final part of Global News’ special series Care Gone Wrong: Inside Ontario’s nursing homes. Click here to learn more about the series.
While the coronavirus pandemic has put a spotlight on obvious failures in long-term care in Ontario and across Canada, experts say change will require a re-imagining of the entire system in addition to ambitious and expensive reforms.
Experts also say that without change, the system as it currently exists will only struggle further as it strains under an aging population.
Over 38,000 people are already on a wait list for care, according to Ontario Long-Term Care Association CEO Donna Duncan, and the number of Ontarians over the age of 80 is expected to double within 13 years.
“We need legislation, absolutely. We need regulation, absolutely. We need inspections, absolutely,” Duncan said.
“But we also need to ensure that we’re building a model of care that will evolve with who our residents are and what our residents’ needs are, that will evolve as technology evolves, that will evolve as health care evolves.”
Critics have long been raising concerns surrounding staffing shortages, a lack of beds, inadequate care and the overall well-being of residents and staff alike.
It was only last summer when a commission of inquiry into Canada’s only known health-care serial killer delivered its final report, which found that under the current system, Elizabeth Wettlaufer‘s crimes would not have been discovered had she not confessed.
Less than a year later, Ontario’s long-term care system was faced with a new tragedy: COVID-19.
“When it was becoming clear that 80 per cent of Canadians who died in this pandemic were living in our long-term care homes, we had all of our provincial and federal leaders coming out saying, ‘The system is broken, we’re going to fix it and we’ll do what it takes,'” Dr. Samir Sinha, director of geriatrics at Toronto’s Mount Sinai Hospital, said in November.
“But fixing it means billions of dollars of investment.”
Global News’ Care Gone Wrong? Inside Ontario’s Nursing Homes series has provided an in-depth look into what led to this crisis point and what could have been done differently. Now we turn to what the future may hold for long-term care in the province.
Provincial plans, national standards
Universal health-care in Canada — which does not currently include dentistry, optometry or prescription drugs — is federally legislated through the Canada Health Act, but the actual organization and delivery of services is governed on a provincial and territorial basis.
Each province and territory has its own ministry of health with different health insurance plans, but all of them have to adhere to certain criteria and conditions set out under the Canada Health Act.
Recently, the federal government has expressed interest in increasing its involvement in long-term care across Canada.
In mid-October, Prime Minister Justin Trudeau announced plans to push for standardized rules for the level of care in long-term care homes. In the fall economic update announced Nov. 30, Ottawa announced up to $1 billion for a Safe Long-term Care Fund in the hopes of providing further protection to residents.
The incumbent Progressive Conservatives
The first wave of COVID-19 devastated long-term care homes in Ontario, prompting a request for assistance from Canadian Armed Forces members, who later reported shocking conditions at homes they were sent to, including “blatant disregard” for infection control measures, mistreatment of residents and a level of care described as “horrible,” according to documents obtained by Global News.
In mid-July, Premier Doug Ford announced the province was changing the way it funds long-term care home expansions in a bid to spur construction.
A $1.75-billion investment would go towards 8,000 beds and 12,000 renovated beds in a five-year span, which is a decrease from the 15,000 new long-term care beds and 15,000 renovated beds promised in 2018.
While there would be fewer beds overall within five years, the funding formula was changed to pay builders more. It also included grants to cover up to 17 per cent of up-front capital costs, in an effort to entice companies to build new homes, all of which would be required to have air conditioning.
“We need to tear down and redevelop old homes and we need to build new ones. We need thousands of new long-term care beds, and we need them fast,” Ford said at the time.
The province also launched an independent commission to investigate what went wrong in long-term care and to report back by April 30, 2021. The commission released early recommendations in October, which included requiring a minimum of four hours of care per resident each day, up from the current two hours 45 minutes.
In November, Ford committed to requiring an average — not minimum — of four hours of direct care for residents each day by 2024-25.
He also said the province will need to hire “tens of thousands” more personal support workers, registered practical nurses and registered nurses to provide care.
The official Opposition Ontario New Democratic Party
The NDP has released an eight-year plan for long-term care in Ontario, in addition to a private member’s bill from London–Fanshawe MPP and home care and long-term care critic Teresa Armstrong, which focuses on immediate reform.
The private member’s bill, which has the support of the Registered Nurses Association of Ontario, passed second reading in late October and has been referred to the Standing Committee on Social Policy.
“I’ve tabled (this bill) now, it’ll be the fourth time. Every time it’s tabled, all parties vote in favour of it,” Armstrong told Global News.
“Now it’s sitting in committee… Unless the government calls it out of committee so that we can have presentations, deputations, people speak to it, then it’s going to sit there languishing.”
The NDP’s eight-year plan was released in October as the first plank of its 2022 election platform.
Among the key commitments are: making all long-term care in the province public and not-for-profit; building smaller, modern, family-like homes; increasing pay for personal support workers (PSWs) by $5 an hour; and providing “new and stronger protections.”
The NDP says the plan would cost $750 million annually for one-time capital investments, plus $3 billion annually in operations costs.
The Ontario Liberals and Greens
Over the summer, the Ontario Liberal Party unveiled immediate suggestions for long-term care, including but not limited to: raising standards for care, for example for bathing and food quality; hiring as many PSWs and nurses as needed “to make sure seniors get the care they need”; inspecting all homes twice a year via unannounced visits; and creating a public rating system for long-term care homes.
The Green Party says the province should promise “a complete overhaul of the system to end the chronic underfunding and put the dignity of elders above all else.”
New regulations, improved oversight
York University Prof. Pat Armstrong, a leading researcher in long-term care and co-author of A Higher Standard: Setting federal standards in long-term care and continuing care, published by the Canadian Centre for Policy Alternatives, says there is reason to believe national standards would have a sizable impact.
“We ought to see this as a real possibility for the provinces and territories and not as some kind of restraint. And let’s be frank here: the provinces haven’t done such a great job in terms of long-term care.”
Referencing the recently announced Safe Long-Term Care Fund, Armstrong says “a billion (dollars) seems like a lot, but it’s not nearly enough.” However, she says what’s important is that the money is expected to come with strings attached.
Armstrong hopes those strings will provide incentives to improve care and follow the rules. She adds that countries with national standards, such as Australia, fared better in the first wave of the pandemic.
The Canadian Institute for Health Information reported in June that by May 25, Canada had recorded 5,324 COVID-19-related deaths among residents of long-term care homes. Australia, which has roughly two-thirds the population of Canada, had recorded 28 deaths in LTC by May 25.
“On the other hand, the reports from inside Australia are saying they’re not doing enough to enforce those standards and to require reporting on those standards. So, I think we could learn a great deal from those jurisdictions that are establishing standards and one of the things we need to learn is: you need to enforce them.”
Johanna Lewis, a researcher for the Hamilton-based think tank Cardus, suggests that when it comes to oversight, the focus should be on improving inspections rather than increasing them.
“Front-line workers have been cautioning for years that redundant and unnecessary paperwork is taking time away from hands-on care,” she says.
As an example, Lewis says if there’s not enough technology to go around, “sometimes you have the problem of information being entered on paper” that then has to be re-entered later, “which again eats into care time.”
“What we need to do instead is focus on care outcomes — resident staff experience, systemic safeguards, practical solutions to real problems — rather than having inspectors scrutinize paperwork for errors, which undermines the very quality and protections that we really want in long-term care and that these regulations are intended to preserve, as well as demoralizing staff.”
Experts stress emotional well-being, flexible care
Experts say regulations and oversight need to go beyond the typical quantifiable metrics and also include a focus on residents’ emotional needs.
“We will send in inspectors to look at the heat of our tea, whether our pressure wounds are being properly cared for, all of which is important stuff,” said Moira Welsh, author of the upcoming book Happily Ever Older: Revolutionary Approaches to Long-Term Care to be released in February 2021, and investigative reporter with the Toronto Star.
“But we don’t have anything to ensure that people actually have a right to live in the home and to have activities that give them sustenance and allow them to flourish.”
As part of her book research process, Welsh toured nursing homes in North America and Europe that have “upended the old, traditional care.” She argues that the way forward in Ontario is to provide more options and allow people control over their own lives.
“A lot of people spend years in long-term care without actually feeling the sun on their face or a breeze on them because they’re really locked inside those homes,” she said.
“I have spent years researching viable alternatives and I can tell you that what is happening here in Ontario does not need to be.”
As an example, Welsh shared a story about a retirement home built inside a forest in the southern United States that had a focus on community involvement and “a really strong belief that people with dementia are part of their community, so nobody is separated.”
Welsh says one resident was a former CIA agent who had dementia. She says the man would go for a long walk every day “because in his mind, he was overseas doing reconnaissance.” Volunteers would keep pace behind him and Welsh says at the end of the day he would report to the CEO, telling her the children are safe and she’s safe to leave her office.
“The CEO said to me, ‘Can you imagine what he would have been like if he was locked in a secure unit?” Welsh recalled.
“In a traditional Ontario home, he would be in a secure unit. He’d be angry, possibly violent, and most likely drugged with anti-psychotics to keep him quiet.”
Ontario Long-Term Care Association CEO Donna Duncan agrees that the way forward is to move away from a traditional, institutionalized approach.
“We need to build environments where people want to live, people want to work, and people want to come to visit. So we certainly need to deal with the physical plans of our buildings and really imagine what they could be,” she said.
“We need to change the culture in long-term care. We need to rethink a very rigid, legislated model that has not allowed for evolution in the sector, that has prescribed a model of care that is locked in time and has actually thwarted innovation and renewal and modernization in the homes.”
Even if action is taken now, it will take years to see a significant impact.
It takes three to five years to build a new home, according to Duncan, who is expecting to see a move towards more small-scale, community-focused designs.
“We have some of our members who are developing the butterfly model and they’re building much smaller homes with smaller communities or neighbourhoods in them — very different settings for care.”
The OLTCA, which is an advocacy group that represents more than two-thirds of the province’s homes, is also looking at “campuses of care” that would allow for transitions from retirement or assisted living into more intensive long-term care.
The ‘very real’ staffing crisis
Karen Cumming, co-author of The Indispensable Survival Guide to Ontario’s Long-Term Care System, believes the first step to addressing the crises in long-term care is to address staffing issues.
“PSWs are quitting because they’re so burned out they can’t face going back in there again,” she says.
“Those people are angels on earth and we pay them abysmally.“
Cardus’s Lewis agrees that addressing the “very real staffing crisis, especially the shortage of PSWs,” should be the first priority.
“To become a PSW in Ontario you need to spend eight months full-time in school, which is a very expensive proposition,” says Lewis, who notes that PSWs are overwhelmingly women.
“They have to deal with other things, like child care, so if you’re not working and you also have to pay for child care while being in school for eight months — that’s a big investment, especially considering you might not be able to get full-time work and the pay is not that great.”
Lewis also argued that underpaying PSWs doesn’t even save money and actually increases overall costs “because you get things like really high turnover, which is expensive for facilities” and a “decreased continuity of care,” which can raise health-care costs in other settings due to poorer outcomes for residents.
“When adjusting for inflation, (they’re) making less than they were 10 years ago.”
Cardus, the Hamilton-based think tank, issued a report on Nov. 5 analyzing the NDP’s eight-year plan, which includes a proposal to create an apprenticeship program for PSWs that would allow them to make money while they learn.
The report from Cardus found that the proposed apprenticeship program, as well as supporting more community-based long-term care homes, would “lead to significant improvements to LTC.”
While the Cardus report said a proposed ban of for-profit homes “does nothing to address the structural problems that have led to poor wages and working conditions in all types of homes,” Armstrong’s CCPA report stated that research demonstrates “a pattern of lower quality care in for-profit homes.”
Lewis is hoping that the tragedy of COVID-19 will encourage a transition to smaller settings. She says it can be cost-prohibitive under the current funding model but the pandemic has shown exactly how important it is to design for infection control.
“It’s tragic that it took a pandemic for people to really start to pay attention to the problems that are happening in long-term care, but I do see a very good opportunity for change; for not just tweaks to the system, but for real, deep reform, bold reform.”
— with files from Global News’ Andrew Graham, Rick Zamperin, Amanda Connolly, Mercedes Stephenson, Stewart Bell, Andrew Russell, Ryan Rocca, Rachel Gilmore, and Kerri Breen as well as The Canadian Press’ Shawn Jeffords.