By: Tushar Sood, Vikita Mehta
Edited by: Dr. Michael Wilson
In Canada, long-term care (LTC) homes offer adults who can no longer live independently a place to live, which is equipped with accessible supports (Liu et al., 2020). While the Canada Health Act mandates that each province and territory provide first-dollar coverage for “medically necessary” physician and hospital services, the costs for LTC homes are typically not fully covered. Consequently, LTC policies, funding, and standards vary across provinces. In Ontario, LTC is governed under the Long-Term Care Homes Act and residents typically provide a co-payment to live there (Liu et al., 2020).
Understanding the State of LTC in Ontario
To better understand the state of LTC in Ontario, it is helpful to compare it to another Canadian province. For example, a recent paper which compared the LTC sector in Ontario with that of British Columbia (BC) found the following (Liu et al., 2020):
- In 2018-19, the average funding per diem per Ontarian resident was $203, about 8.6% lower than that of BC ($222)
- Before the COVID-19 pandemic, BC residents received more hours of direct care per day than Ontarian residents (3.25 vs. 2.71 hours) and were less likely to live in shared rooms than in Ontario (24% vs. 63%)
- LTC in either province is subject to regular inspection, but after 2018, fewer homes in Ontario received comprehensive inspections
- In recent years, the connections between hospitals, LTC, and public health have been stronger in BC than in Ontario
- Similarly, BC’s health system organizational structure has recently been more stable than that of Ontario, which is transitioning from Local Health Integration Networks (LHINs) to a centralized organization, Ontario Health
- While LTC homes in both provinces are managed on either a non-profit or for-profit basis, more LTC homes in Ontario are managed for-profit than in BC (58% vs. 34%)
This last statistic is critical as existing evidence suggests that for-profit homes generally deliver inferior care across several process and outcome measures (Liu et al., 2020). Notably, the vast majority of Canadian provinces and territories have higher proportions of publicly owned LTC homes than Ontario (Waddell et al., 2021).
LTC Crisis in Ontario
LTC in Ontario has long been at crisis levels. In 2019-20, patients waited a median of 145 days to get placed in a LTC home (90 days if their previous location was a hospital and up to 159 days if it was the community) (Health Quality Ontario (HQO), n.d.). The lack of available LTC beds can result in hospital bed-blocking, a situation where hospital patients who are ready to be discharged to a nursing home must delay their discharge as they are unable to find a spot. Ultimately, patients end up staying in a more costly substitute – the hospital (Gaughan et al., 2015). While a modest effect, an increase in LTC homes by 10% would reduce social care delayed discharges by up to 9% (Gaughan et al., 2015). Moreover, there are numerous impacts to consider at the personal level. What does bed-blocking mean for patients? Do they have to stay at the hospital or at home? Does this change their level of support? If staying at home with minimal support, what are the negative impacts on caregivers? These are just some of the many questions we can ask regarding the trickle-down effects of a “universal” LTC system which is not truly accessible to all.
Perhaps this would be less of an issue if there were comparable alternatives, such as home care. Home care is an integral part of the Canadian health care system, allowing individuals to live with comfort, independence, and dignity at their own residences (Yakerson, 2019). However, as Yakerson (2019) reports, the current home care system in Ontario is “underfunded, understaffed, and inequitable in access to care”. Unfortunately, policies continue to be strategically blinded to the harsh realities of this sector, which often involves cost cutting, deregulation, and service privatization (Yakerson, 2019).
LTC and the COVID-19 Pandemic
The COVID-19 pandemic has highlighted the long-standing issues in Ontario’s inadequately funded LTC system. As of December 29, 2021, there have been 23,351 cases of COVID-19 in Ontario LTC homes, with 15,849 of them in residents and 7,502 in staff. There has also been a total of 3,846 deaths in LTC, with all but 13 of them being residents (Government of Ontario, 2021c). Compared to BC, rates of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in Ontario LTC homes have been several times higher, at 7.6% compared to 1.7%. COVID-19 mortality among residents followed a similar trend, with Ontario and British Columbia at 2.3% vs. 0.6%, respectively. Case fatality rates remained similar across jurisdictions, suggesting that similar proportions of residents would die upon contracting the virus (Liu et al., 2020).
During the pandemic, numerous reports were released documenting the rampant physical and emotional abuse in LTC. For example, approximately 85% of Ontario’s LTC homes having repeatedly broke the law with little to no consequences. Common offences included those involving skin and wound care, medication errors, abuse, neglect, and hydration (Pedersen et al., 2020).
Priorities and Options for LTC Renewal
The current Progressive Conservative government in Ontario has made the creation of 30,000 net new LTC beds over ten years a priority, while also pledging to upgrade many more (Government of Ontario, 2021b). In March 2021, Ontario also began accepting applications for 6,000 tuition-free accelerated Personal Support Worker education spots to address staffing shortages (Government of Ontario, 2021a). The current federal Liberal government has committed to funding provinces and territories through its Safe Long-term Care Fund which, in addition to billions of dollars in previous commitments, will support long-term care facilities (Waddell et al., 2021).
Considering the pandemic’s severe impacts on the LTC sector, major parties in the recent 2021 Canadian General Election also made many promises, despite LTC being under provincial jurisdiction. For example, the governing Liberals supported increasing the wages of personal support workers in the LTC sector as well as hiring 50,000 more workers, providing $3 billion to improve LTC homes, and allocating $3 billion to ensure provinces and territories provide a certain standard of care in their LTC homes. The Conservatives promised $3 billion over three years to renovate LTC homes. Some of the NDP’s promises included ending private for-profit homes, setting national standards for LTC and home care and regulating them under the Canada Health Act (funding tied to meeting standards), spending $5 billion of LTC systems, and committing to increasing the Canada Health Transfer. The Greens also pitched placing the LTC system under the Canada Health Act, ending for-profit LTC business, creating a dedicated Seniors’ Care Transfer, and boosting wages and training of LTC workers (Maclean’s, 2021). There is clear consensus that more needs to be done, but there remains debate as to how things should change moving forward.
Given this, what should governments do next? This is not a simple problem – it is complex, multi-faceted, and requires collaboration across jurisdictions to draft and implement effective evidence-informed policy. At the McMaster Health Forum, we have conducted a series of LTC Crisis and Renewal COVID-19 Living Evidence Profiles (LEPs). These documents collect and synthesize information regarding supporting LTC renewal during and after the COVID-19 pandemic. They are intended to inform policymakers’ decisions regarding this sector. To access these documents, visit https://www.mcmasterforum.org/find-evidence/products/project/covid-19-living-evidence-profile-2-what-is-known-about-preventing-and-managing-covid-19-outbreaks-and-about-supporting-renewal-in-long-term-care-homes.
Gaughan, J., Gravelle, H., & Siciliani, L. (2015). Testing the Bed-Blocking Hypothesis: Does Nursing and Care Home Supply Reduce Delayed Hospital Discharges? Health Economics, 24(S1), 32–44. https://doi.org/10.1002/hec.3150
Government of Ontario. (2021a, March 8). Ontario Colleges Now Accepting Applications for Accelerated Personal Support Workers Program. Ontario Newsroom. https://news.ontario.ca/en/release/60593/ontario-colleges-now-accepting-applications-for-accelerated-personal-support-workers-program
Government of Ontario. (2021b, March 18). Ontario Making Historic Investment to Modernize Long-Term Care. Ontario Newsroom. https://news.ontario.ca/en/release/60796/ontario-making-historic-investment-to-modernize-long-term-care
Government of Ontario. (2021c, December 29). Long-term care homes. COVID-19 (Coronavirus) in Ontario. https://covid-19.ontario.ca/data/long-term-care-homes
Health Quality Ontario (HQO). (n.d.). Long-Term Care Home Wait Times in Ontario. Health Quality Ontario (HQO). Retrieved December 29, 2021, from https://www.hqontario.ca/System-Performance/Long-Term-Care-Home-Performance/Wait-Times
Liu, M., Maxwell, C. J., Armstrong, P., Schwandt, M., Moser, A., McGregor, M. J., Bronskill, S. E., & Dhalla, I. A. (2020). COVID-19 in long-term care homes in Ontario and British Columbia. CMAJ, 192(47), E1540–E1546. https://doi.org/10.1503/cmaj.201860
Maclean’s. (2021, July 23). 2021 federal election platform guide: Where the parties stand on everything. Maclean’s. https://www.macleans.ca/rankings/2021-federal-election-platform-guide/
Pedersen, K., Mancini, M., Common, D., & Wolfe-Wylie, W. (2020, October 23). 85% of Ont. Nursing homes break the law repeatedly with almost no consequences, data analysis shows | CBC News. CBC News. https://www.cbc.ca/news/marketplace/nursing-homes-abuse-ontario-seniors-laws-1.5770889
Waddell, K. A., Wilson, M. G., Bain, T., Al-Khateeb, S., Bhuiya, A., & Lavis, J. N. (2021). Appendices for COVID-19 living evidence profile #2 (version 2.5): What is known about supporting renewal in long-term care homes? McMaster Health Forum. https://www.mcmasterforum.org/docs/default-source/product-documents/living-evidence-profiles/covid-19-living-evidence-profile-2.5-appendix_what-is-known-about-preventing-and-managing-covid-19-outbreaks-and-about-supporting-renewal-in-long-term-care-homes.pdf?sfvrsn=be026212_7
Yakerson, A. (2019). Home Care in Ontario: Perspectives on Equity. International Journal of Health Services, 49(2), 260–272. https://doi.org/10.1177/0020731418804403