Managing scarcity in long term care

Managing scarcity can be very time consuming.

Ontario has been wrestling with rules around managing the shortage of long-term care beds, trying to find ways to meet sometimes contradictory objectives of freeing up hospital beds, reuniting spouses, accommodating veterans, prioritizing crisis placements and placing people on the wait list based on their assessment scores.

While the province is not shy about sharing their success in having recently reduced such waits, the Auditor General of Ontario (AG) is clear about the reason why – new criteria for admission is excluding between seven and 12 per cent of nursing home applicants. Unless the province is planning on continually tightening eligibility, the short-term wait list reduction is likely a one-time event.

The average length of stay in a long-term care home is about three years – that means about 25,000 of 76,000 beds become available each year. 32,000 people are on wait lists for their preferred nursing home. 40 per cent of those on that list are already in a long-term care bed but are still waiting to get into the home of their choice. According to the 2012 Auditor’s report, about 15 per cent die waiting to get into a home at all.

If you are a crisis client, the median wait time from assessment to admission is 94 days – or about three months. Moderate needs clients are waiting between 10-14 months, and most others are left waiting for years. A little better than one in three are getting initially placed in the home of their choice. Most would find this to be an unacceptable state of affairs.

A growing elderly population is pushing demand but the McGuinty government has stubbornly resisted adding beds – the supply of beds has only increased by three per cent between 2005-2012 while wait lists have increased by almost 85 per cent. Further almost half the beds are in older homes to be upgraded over the next decade. Few want to be housed in older homes where standard accommodation includes four residents to a room.

Much has already been made of the disconnect between privately run homes that are permitted to designate as many as 60 per cent of beds as preferred accommodation (which are presumably more profitable to the owners) when 60 per cent of demand is for standard (and government subsidized) accommodation. That dynamic suggests better off seniors can get into a home much faster than those without financial means.

Long term care beds were once considered a more affordable alternative to hospitals. Now the province is looking to other community options to reduce the public cost of long-term care. You have to wonder whether the province plans to find a cheaper alternative to home care once a significant percentage of seniors end up there. We fear that alternative will be no care.

The AG notes there is some room to maneuver but it’s limited. Health Quality Ontario reports that in 2010/11 about 20 per cent of long term care residents could have stayed in their homes or be placed elsewhere in the community. It is likely that as new residents come into the system at higher levels of acuity (due to new admissions criteria) that this number will be further reduced. Of course the province will have to do better in providing community supports to ensure these clients aren’t left home alone.

The auditor also notes wait lists could be reduced by checking in with residents who are not in their first-choice of home. Some, having established relationships within the home they have been assigned, decide to stay where they are rather than undertake another disruptive move.

We are also wondering how staff are coping as the province drives acuity upwards with little funding to reflect the increased workload demand. For residents this could be a critical quality issue.

As ambitious as the Ministry has been about providing community alternatives, clearly the deplorable wait lists demonstrate that it has not been nearly enough. Further, the AG notes that between 2012 and 2021 the number of Ontario seniors aged 75 and older will increase by 30 per cent. And if that’s not enough of a warning, the demographic bulge known as the baby boom will start to turn 75 in 2021, which is when the real fun begins.

As much as Deb Matthews dreams of never having to build another nursing home, reality is already crashing in.

In 10 years that reality could become unbearable.