The Fixing Health Care series presents 10 common problems faced by patients in Canada, along with 10 solutions that the authors argue can be achieved within our existing publicly-funded health system. While the ‘problem’ scenarios in the series are fictional, the authors offer these examples to echo the patient experiences they have encountered through their work in health care and social services.
The Problem: Across Canada, there is a dangerously poor quality of care in many long-term care homes
Aviva’s mother had been living in a nursing home for about six months when the pandemic started. There were not enough gowns or masks available to staff in the home when COVID began, and it was no surprise that both residents and staff started falling ill. Most of the rooms in the home had four residents and the virus just ripped through the building. About a third of the residents died and at least half of the staff became infected or were in isolation because they were close contacts of staff or residents who were infected.
Aviva’s mother caught COVID and, luckily, recovered quickly, but the staff shortage continued. Some days residents had only one meal provided. When Aviva and her family finally got in to see her mother, she was in a terrible state. She had lost about 15 pounds, she had not been bathed in over a week and she had not been out of bed in a long time. Aviva knows that the pandemic was hard on long-term care home staff, but her mother suffered from total neglect during the first six months of the pandemic.
The Fix: Canada must implement a seniors’ strategy with universal standards and adequate funding for long-term care
The tragedies suffered by many Canadian long-term care home residents during the early stages of the COVID-19 pandemic were horrific. Not only did many residents contract the virus, official investigations later discovered that dozens of people had died from neglect. During the first few months of the pandemic, long-term care home residents accounted for 81 per cent of COVID deaths in Canada, a rate far higher than that of any other developed nation. By the spring of 2021, as the pandemic reached its one-year anniversary, 16,000 long-term care home residents across the country had died. Most upsetting is the fact that we could have avoided this national tragedy altogether if we had addressed structural problems in our nursing homes that health experts had been flagging for years.
How can Canada use the lessons learned during the pandemic to prevent high rates of death from flu, COVID or the next airborne virus in long-term care homes?
First and foremost, the current state of long-term care housing across Canada carries a misnomer – for many people living in these facilities, a long-term care “home” feels nothing like a home, but instead an institution. This is especially the case in Ontario. In 2019, more than 30,000 of Ontario’s 78,000 LTC beds were in older nursing homes, where up to four residents could be housed in the same room. One analysis of pandemic deaths found direct correlations between overcrowding and COVID-19 mortality in these homes (a directive issued by the provincial government now prevents three or four people from sharing a room). In a 2020 briefing document, Ontario’s Ministry of Long-Term Care acknowledged that the physical design of older LTC homes can “create challenges for providing quality of care for residents,” noting a “lack of privacy” in rooms where beds might also be placed “far from windows,” a lack of accessible washrooms, no airconditioning, “cramped” common spaces, and “small or centralized dining rooms making movement and feeding difficult.”
These structural problems are not uncommon, especially in central Canada. Quebec’s nursing homes (Centres d’hébergement de soins de longue durée, or CHSLD) have for decades been routinely exposed as dilapidated facilities “where old people go to die,” as one doctor told The Globe and Mail. A series of exposés published by La Presse in 2004 found that 400 people had died from neglect in Quebec nursing homes in the decade prior, sometimes from circumstances that were shockingly similar to 2020′s COVID-19 outbreaks, including dehydration, malnutrition, and inadequate hygiene.
Issues related to staffing in long-term care homes had already been identified by governments prior to the pandemic as well, with many long-term care homes often operating below the number of staff required to adequately care for the number of residents in a home. LTC operators “reported missed baths, missed personal care, and a lack of toileting, among other basic care functions” as common occurrences in homes, an Ontario Ministry of Long-Term Care staffing study noted in 2020. “It was reported that PSWs are often rushed and therefore cut corners to optimize the time they have available. As a result, residents may experience increased falls, levels of depression, infections, errors, complaints, anxiety, and conflict. A labour union reported [in 2019] that two-thirds of PSWs and nursing staff that were polled reported that they had to tell a resident they did not have time to take them to the washroom, and the resident would then have to wait.”
The health care sector is in broad agreement that Canadian nursing homes are in desperate need of funding for full-time staff (as noted in the essay in this series that highlights the problem with personal support work in Canada, contracts are often part-time or casual) and must adopt a staffing model that provides four hours of care each day to all residents (the current average is 2 hours and 45 minutes a day). While Ontario recently ratified the Fixing Long-Term Care Act, we believe it takes the wrong approach as the province plans to measure hours of care for LTC residents in aggregate across the health care system, as opposed to mandating four hours of care each day for every resident at the individual LTC home level.
For years, provincial governments have responded to revelations of poor living and working conditions in LTC homes with outrage, inquiries, and new rules and regulations. But the funding required to provide appropriate facilities and staffing for our aging population has not materialized. Without appropriate standards and sufficient funding, Canada’s refusal to properly acknowledge that it has a rapidly expanding population of people over the age of 75 will continue to result in the warehousing of some of our most vulnerable citizens. The consequences of inadequate standards and funding became starkly apparent during the COVID-19 pandemic but should have been a source of concern long before.
Canada needs a national seniors’ strategy that will progressively provide increasing levels of care for our elders as they age. This initiative will not be inexpensive, but Canadian governments have a moral obligation to provide for our most vulnerable citizens and we can afford this time-limited increased expense.
Other developed countries have demonstrated what’s possible when a national government provides a framework for adequate senior care. Germany, Japan and Korea are widely regarded to have the world’s leading national systems for senior care, largely due to their universal programs for long-term care insurance (LTCI), which operate in a similar manner to Canada’s employment insurance program, in that every citizen contributes to LTCI over the course of their lifetime. As noted in a 2020 analysis by Ito Peng, Canada Research Chair in Global Social Policy, a key distinguishing feature of more successful countries’ long-term care programs is that they prioritize home care and community care for seniors, as opposed to funneling most senior health care funding into an institution-based model. Citizens are provided with various levels of care in aging according to their needs and long before becoming incapacitated, allowing more people to avoid requiring LTC residency altogether. “This is one reason why these countries, unlike Canada, were able to avoid high numbers of COVID-19 related deaths in LTC homes,” Ms. Peng noted.
For those Canadians who eventually require long-term care, the good news is that a process is underway to define a national standard for seniors’ residential care. Chaired by geriatrician Dr. Samir Sinha, this working group is expected to deliver recommendations by the end of 2022 for appropriate staffing, facility standards and essential infection-prevention measures. Once established, Canadians must demand of their governments that these standards are implemented across the country.
As the Fixing Health Care series has outlined, by focusing on transitional care facilities to rehabilitate hospitalized people before they need nursing home admission, by improving home care delivery and working conditions for personal support workers and other LTC staff, and by encouraging the development of naturally occurring retirement communities, we could delay and even reduce the need for individuals to be admitted to LTC homes (this would also help to reduce the current wait times for LTC beds – Ontario, for example, had about 40,000 people on its LTC waitlist at the start of the pandemic). To this point, in 2021 the Canadian Medical Association (CMA), in partnership with Deloitte, released an economic analysis of what our aging population could cost Canada’s publicly funded health care system in the future. The report found that if Canada made better use of home-care services for seniors, the country could move 37,000 Canadians out of LTC homes and save around $794-million a year by 2031. Additionally, moving alternate level of care (ALC) patients out of hospital beds into home care or long-term care settings could save Canada an additional $1.4-billion each year by 2031.
However, the CMA report also noted that while some policy changes could lead to savings, “they are simply unable to counter the significant jump in future costs that is forthcoming from our aging demographics.” The report notes that demand for residential care will likely increase from 380,000 patients in 2019 to 606,000 patients in 2031. Home-care demand will increase from 1.2 million patients in 2019 to roughly 1.8 million patients in 2031.
Overall, our growing population of seniors will likely double the cost for home-care and LTC, increasing from about $30-billion in 2019, to about $56-billion by 2031, a compound annual growth rate of just over five per cent. This increase in costs will flatten and start to decline in 2031 with the natural attrition of the baby boom generation, but this doesn’t mean we can continue to just ignore this issue for another decade. Despite the substantial increase, the growing costs of caring for Canada’s seniors will slow down sharply in the next decade.
And so we arrive, once again, at a fundamental question – how much is the dignity of our fellow citizens worth? For years, Canadians have been collectively horrified at stories of neglect, often amounting to the abandonment of some of the most vulnerable members of our communities, within long-term care homes. In 2019, the Ontario Long-Term Care Association reported that 90 per cent of the province’s LTC residents had a cognitive impairment, while 86 per cent needed “extensive help with daily activities” including getting out of bed, eating, and using the washroom.
Our response as Canadians shouldn’t be merely to pity those who have complex health conditions and require professional care, but to respect our fellow citizens’ right to be treated at the highest quality standard of care in our publicly funded system. We must have a universal health care system both in name and in practice – Canada can certainly afford it. We must prioritize the implementation of a seniors’ care strategy that has the appropriate national standards and funding for our aging population.
About the authors:
Dr. Robert Bell is professor emeritus in the Department of Surgery at the University of Toronto, former Deputy Minister of Health for Ontario, and former CEO of the University Health Network. Anne Golden is past president of the United Way of Greater Toronto and the Conference Board of Canada. Paul Alofs is former CEO of the Princess Margaret Cancer Foundation. Lionel Robins is past chair of the Princess Margaret Cancer Foundation, and a board member for the United Jewish Appeal Federation and the Betel Senior Centre.
More from the Fixing Health Care series:
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