Nursing home placement — Who has the greater crisis?

Yesterday we looked at the challenge of CCACs is managing scarcity amid too few available nursing home beds in the province.

One of the ways of placing a client into the nursing home faster – albeit with a three-month median wait – is to declare them a crisis priority.

The Long Term Care Act specifically requires that crisis clients be prioritized on the basis of urgency of need, but the question is whose need?

The Auditor General of Ontario (AG) looked at this issue and revealed there are many ways in which an individual can become a crisis priority, including simply taking up space in a hospital that has itself been declared “in crisis.”

“All patients waiting for a LTC home in this particular hospital are generally given crisis priority,” the AG’s annual report states. In fact, on a four level scale, these patients would rank number one.

A hospital gets a “crisis” designation when it experiences severe bed capacity pressures.

When this happens, the AG notes it causes other patients to wait longer for a nursing home placement, including those waiting for beds in other hospitals. That includes patients who may have much higher assessment scores.

Of two Community Care Access Centres (CCAC) the AG looked at, there was a combination of nine hospitals declared in crisis during the year – one such hospital was designated as being in crisis for most of the year.

The CCACs have the same geographic boundaries as the LHINs. To put this in perspective, most CCACs would have about 10 hospitals to refer to. That means roughly half of the hospitals were experiencing such bed pressures as to receive that designation over the course of the year. Clearly, long-term care is not the only part of the health system under duress.

So many clients are given a crisis designation that the CCACs admitted to the AG that “all crisis clients have high needs, so it is often hard to distinguish whose needs are more important.”

They freely admit that it often comes down to the judgement of CCACs, including the perceived “caregiver burden” and how much the family is pushing them. The AG writes: “Caregiver burden considerations can give one client priority over another whose needs are more urgent and whose caregivers are less insistent.”

While the government’s home first policy is supposed to put clients waiting for placement in hospitals and community on equal footing, the AG notes that “the median wait time province-wide for 3A and 4A hospitalized clients was about half that of people waiting in the community.”

Reuniting spouses in long-term care homes is also supposed to be a priority, many activists and family members insisting it is cruel to separate a couple in their final years. These patients are ranked second in priority if they are in separate long-term care facilities. Similarly, veterans have priority for their years of service to the nation. “4B” spouses and veterans are not required to have any documented care needs.

Let’s keep in mind that this entire system is in place and very difficult decisions are made around placement priorities because there are simply not enough beds.

As we stated yesterday, there are 32,000 clients on wait lists for their preferred homes, 19,000 who are presently waiting in the community. Turnover is about 25,000 beds per year.

For CCACs it’s come down to a matter of choosing whose crisis is greater than others.

How are Priorities Decided?

Level 1 — Crisis: Clients require immediate placement, such as a client with dementia whose primary caregiver dies; or a client waiting in a hospital that the LHIN has declared “in crisis” to free up beds.

Level 2 — Reunification of spouses/partners who already reside in a long-term care home. Priority is given based on the date of application to a long-term care home.

Level 3A & B — For clients who are of, or whose spouse/partner is of, the same religion, ethic origin or linguistic origin that the LTC home specializes in.

Level 4A & B — For other clients who are eligible for a higher priority level but have high care needs, are waiting in hospital, or are residing in another LTC home that is not their first choice.  4B is for spouses who do not have care needs but wish to reside with a spouse/partner who is already in a home.