Theresa Ainsborough sat slouched in a wheelchair outside her hospital room on a Monday afternoon in March, as her daughter coaxed her to take another bite of a tuna sandwich.
The 92-year-old had recovered from the bout of pneumonia that sent her to Southlake Regional Health Care Centre in Newmarket, north of Toronto, in early February, but she was still too frail to return home. The pneumonia had worsened her dementia, and she needed the support of a nursing home, but there were no beds available. With nowhere else to go, she was stuck in the hospital, with no appetite for lunch and few opportunities for exercise or social stimulation – and becoming weaker by the day.
“She just went downhill,” said her son, Bill Ainsborough. “We did not think she was going to make it.”
A shortage of community-based care has made hospitals the default place for many elderly patients in Canada. These patients, known as alternate-level-of-care (ALC), no longer require medical intervention and are waiting to be placed in home care, a rehabilitation program or a nursing home.
Lying in a bed in a noisy, unfamiliar environment designed for short-term stays causes these patients to lose 5 per cent of their capacity a day, say medical experts. And there’s an impact on the health care system too: Beds occupied by ALC patients deplete resources for the critically ill, and are one of the root causes of emergency ward backlogs in many hospitals across Canada.
The problem predates the coronavirus pandemic, but two years of COVID-19 have made it worse, as the health care system struggles with a shortage of family doctors, not enough walk-in clinics and an unprecedented number of nurses leaving the profession. Many emergency departments are dealing with lengthy wait times, and in some cases, temporary closings.
The crisis has become especially acute in Ontario, where 10 hospitals have temporarily closed their emergency departments since the end of June, forcing patients to travel longer distances for medical care.
It is not just rural or community hospitals that are feeling the strain of staffing shortages.
The intensive care units at Toronto General Hospital, which treat cardiac, cardiovascular and cancer patients and accommodate the country’s largest transplant program, are operating either at capacity or close to full. The hospital issued a “critical care bed alert” to staff two weeks ago, and it became public on Tuesday.
“So much of what’s driving the overwhelming situation in the ED is a lack of ability to move people from emergency departments to inpatient beds, because many of the beds are occupied by people who could be better cared for elsewhere,” said Katharine Smart, president of the Canadian Medical Association. “It’s impacting everything.”
ALC patients occupied 17 per cent of the nation’s acute-care beds in the fiscal year ended March 31, 2021, according to the Canadian Institute for Health Information (CIHI). They spent 24 days on average in hospitals across Canada that year, about the same number as before the pandemic, when overcrowding in hospitals was already a chronic problem.
The situation is bleaker in Atlantic Canada. In Nova Scotia, ALC patients spent 52 days on average in hospitals in fiscal 2021 – more than twice the national average, CIHI data show. Provinces with more community-based housing options for the elderly tend to fare better. Saskatchewan, for example, has the highest number of long-term care beds per capita among all the provinces. Its hospital stays averaged only 16 days for ALC patients – the lowest in Canada.
In Ontario, many hospitals are planning to free up acute-care beds and move patients more seamlessly through the system by forging closer ties with the long-term care sector, either by building their own nursing homes or partnering with owners of for-profit chains. ALC patients spent 23 days on average in hospitals in the province during fiscal 2021.
“It is profoundly in the interests of acute-care hospitals to have access to long-term care,” said David Walker, professor of emergency medicine and policy studies at Queen’s University and author of a 2011 Ontario government report chronicling the province’s ALC challenges. “When 20 per cent of their beds are occupied by people who shouldn’t be there, and in many cases are harmed by being there, they can’t carry out their mandate.”
Ontario is the only province where hospitals already own and operate some nursing homes. But they are small players, with just 6 per cent of the province’s 78,800 long-term care beds. At the same time, they are under growing pressure to find ways to care for seniors while keeping them from congesting hospitals. The number of ALC patients in the province’s hospitals climbed to 4,933 in May from 3,229 in the same period a year ago, according to Ontario Health.
The dire situation leaves Canada’s most populous province playing catch-up with other regions in the country that have brought different types of health care services under one roof, so that practitioners no longer operate in their own silos. The collective push by hospitals in Ontario to expand beyond their traditional acute-care role will not completely solve their ALC problem, but it can suggest a way forward to a broader transformation of the health care system that will meet the care needs of an aging population.
The Ontario government’s ambitious expansion of long-term care is accelerating the drive for transformation. Ontario Premier Doug Ford is promising to deliver 30,000 new beds and upgrade 28,000 existing ones by 2028.
Of the 31,705 new long-term care beds the government has announced so far, 4,408 have been allocated to hospitals, allowing them to nearly double their footprint in the sector, a Globe and Mail analysis shows. Several for-profit chain operators are also planning to build new nursing homes on hospital property as part of a campus of care that will offer a range of health services to residents.
The new long-term care beds are urgently needed – 39,000 people in Ontario were on the waiting list for a spot as of March, 2022.
Arden Krystal, chief executive officer of Southlake, is spending much of her time working on plans for a new 320-bed long-term care home to be built on the hospital’s property. She wants the home to include specialty beds for residents with advanced dementia and severe behavioral problems who tend to strike out or be verbally abusive – something that is in short supply in Ontario.
Ms. Krystal said Southlake, which cares for one of Ontario’s fastest growing and aging populations, has a lot of difficulty discharging patients with behavioral problems. ALC patients occupy one in five of the 512 acute-care beds at Southlake.
One way to sustain the system is to give hospitals a more direct hand in developing a long-term care facility, Ms. Krystal said. “The solution to many of our capacity issues actually exists outside our walls.”
The coronavirus pandemic laid bare the urgent need to retool a health care system in Ontario that remains primarily focused on hospitals and with little in the way of community services to prevent the elderly from languishing in acute-care beds.
Hospitals were thrust onto the front lines as COVID-19 tore through the long-term care sector.
The Ontario government asked hospitals to temporarily manage 35 homes where most of the staff were either off sick with the virus or too terrified to come into work.
Hospitals also shared their management resources and expertise in infection prevention and control with many other nursing homes dealing with outbreaks.
The pandemic brought many hospitals and nursing homes together for the first time, an experience that is leading executives in both sectors to deepen their partnership by continuing to collaborate.
“It was a real silver lining in all of the tragedy that occurred,” Barbara Collins, chief executive officer of Toronto’s Humber River Hospital, said in an interview.
Humber was the first hospital dispatched by the Ontario government to temporarily manage a nursing home. Hospital staff arrived at Downsview Long Term Care Centre in Toronto in April, 2020, and formally took over management the following month.
Only 60 per cent of the staff at Downsview were working. The 50 family members who normally came to the home twice a day to help feed residents were not allowed to visit because of pandemic restrictions. Sixty-five residents died of COVID-19, ranking Downsview among the hardest hit in Ontario.
Initially, Ms. Collins said, staff at Humber and Downsview were “battling with each other” but they eventually stopped once they realized just how isolated the long-term care sector is from the rest of the health care community. While staff in hospitals have plenty of colleagues to advise them on best practices, there is often only one physician or infection control co-ordinator working in a nursing home.
Today, Humber is one of three sites where the provincial government itself is building new long-term care homes on hospital property.
The 320-bed Humber Meadows, now under construction, plans to apply for designation as a Butterfly Model home focusing on the individual interests of residents. The model addresses the holistic needs and quality of life for an individual living with dementia.
The hospital is also continuing to work together with Downsview and several other neighbouring nursing homes, including inviting them to participate in leadership training programs. “We call it community of practice,” Ms. Collins said.
The 40 long-term care homes in Ontario owned by hospitals when the pandemic began have fared much better compared with those owned by for-profit, chain operators, which dominate the sector. Of the 4,446 COVID-19 deaths in long-term care homes as of early June, only 108 were in hospital-owned homes. The fatality rate in the hospital-owned homes was just 0.1 per cent, well below the rate of 5.6 per cent for the entire sector. (The government has since changed its public website on COVID-19 cases, making it difficult to get current statistics on individual homes.)
These nursing homes have in-house access to the hospital’s medical expertise, including infection prevention and control (IPAC) specialists, which helped them keep the virus at bay. The IPAC specialist at Norfolk General Hospital in Simcoe, a retirement community in southwestern Ontario, for example, works at both the hospital and its long-term care home, said Kim Mullins, vice-president clinical and chief nursing executive.
“To me, it’s a holistic approach to how we view health care,” she said. “When you’re linked to hospitals you have the IPAC expertise and the agility to be able to help out with staff when there’s a crisis.”
Norfolk plans to add 48 new beds to the 80-bed home, which is connected to the hospital by a ramp. When residents in the home need blood work or an X-ray, they are just a wheelchair ride away, Ms. Mullins said. The hospital also shares its kitchen and housekeeping staff with the home.
At Atikokan General Hospital in Northern Ontario, a wall separates acute-care from the 26-bed long-term care home. It plans to add 22 new beds to the home. Jorge VanSlyke, chief executive officer of Atikokan, said placing the hospital and the long-term care home in lockdown well before the government issued directives banning visitors kept the virus out of both. Ms. VanSlyke also immediately began testing staff every week, allowing it to catch one member sick with the virus during the first wave and stop it from spreading. She also restricted staff to working either in the hospital or the long-term care home. “We wanted to insulate our nursing home,” she said.
Kevin Smith is a pioneer of Ontario’s nascent efforts to build an integrated health care system. As chief executive officer of St. Joseph’s Health System in Hamilton back in 2011, he presided over a corporate restructuring – the first of its kind in Ontario – that saw its services span home care, long-term care, rehabilitation, hospice and traditional acute care through its two hospitals.
From his current perch at the helm of University Health Network (UHN) in Toronto, Dr. Smith is continuing to make navigating between hospitals and back into the community as seamless as possible. UHN is known for its big acute-care hospitals, including Toronto Western and Toronto General, but it also operates a rehab institute, a hospice, programs for street people and a long-term care home. UHN is planning to add 192 new beds to Lakeside Long Term Care Centre in Toronto, nearly tripling its current size.
“We have to be backing each other up,” Dr. Smith said. “This is not a one-way street. Hospitals need that partnership with long-term care.”
He cautioned, however, that acute-care practitioners cannot go into long-term care homes with an “institutional arrogance and a funding arrogance.” It’s important for them to remember, he said, that hospitals get $800 to $1,000 in government funding a day for each bed, compared with just $249 for each long-term care bed.
As well, Dr. Smith is all too aware that the crisis engulfing the province’s hospitals makes bringing about change to the health care system all the more challenging. It is not unusual for UHN’s Toronto General to issue a “critical care bed alert,” he said, but it is typically in force for just a day or overnight. However, he said, the latest alert has been in place for two weeks as fewer staff at the hospital, fatigued after more than two years of the pandemic, treat not only the “sickest of the sick,” but a growing number of people living in downtown Toronto.
“People are tired and worn out,” he said. “It’s been a long road.”
With most of the new homes hospitals plan to build still on the drawing board, it will take up to three years before they are ready to open their doors to new residents, including those occupying hospital beds.
Extendicare, a for-profit chain operator of long-term care homes, is working in partnership with the Ottawa Hospital on a program that is helping the hospital clear its beds of ALC patients. Extendicare has set up a 55-bed transitional care unit in one of its nursing homes in Ottawa for hospital patients waiting to move to long-term care or home care. The hospital provides medical services for the patients and Extendicare provides meals, activity programs for patients and housekeeping. The unit will expand to 100 beds in September.
“We think the hospital partnership model is really strong,” said Michael Guerriere, chief executive officer of Extendicare. “It gives the resident access to physician services and oversight that they wouldn’t normally have.”
The partnership is another example where hospitals in Ontario are pushing to expand beyond their acute-care walls in a system that is less integrated than in other provinces. In British Columbia, Alberta, Saskatchewan and Manitoba, regional health authorities are responsible for overseeing all facets of the system, including hospitals and long-term care homes. Because these entities control the funding and staffing for health care, they can respond more quickly to problems and divert resources to where the need is greatest, said health care experts.
“The idea that the same person who is in charge of how the hospital operates is also accountable for how home care and long-term care operates gives you some sense of cohesiveness,” said BC Seniors Advocate Isobel Mackenzie.
Back at Southlake’s transitional care unit, where Mrs. Ainsborough was, physician David Srour said he has witnessed the toll that hospitals take on the health and social well being of ALC patients. The unit is in an older section of the hospital, where the halls are narrow and its 16 patients sleep two to a room. Call bells ring at all hours, which “messes up” patients’ day and night cycles, he said.
During a tour of the unit on a sunny afternoon in late March, it was thrumming with activity, as hospital staff and family members tended to patients who needed assistance eating lunch. Fortunately for Mrs. Ainsborough, a spot opened up a few days later in a nursing home near Southlake. Since moving there, she’s been doing much better, said her son Bill.
“it was like winning the lottery.”
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