Category Archives: Long Term Care

“Care as a relationship” is key to good long-term care: research

What are long-term care residences around the world doing right?  That’s the question an international research team travelled across North America and Europe to find out.

Led by Pat Armstrong and Donna Baines, researchers visited nursing homes in Canada, Germany, Norway, Sweden, the United Kingdom and the United States, looking for practices that make long-term care centres feel like home to their residents.

diablogue fotoTheir findings won’t surprise long-term care workers. Good long-term care means building strong care relationships between residents and their care providers. Strong staffing levels, good working conditions, secure jobs, proper levels of public funding, full-service kitchens with in-house food service staff, and sensible standards – not onerous bureaucratic one-size-fits-all rules – lead to excellent care for residents.

The research by Armstrong and Baines resulted in a highly-readable, information-packed book called Promising Practices in Long-term Care: Ideas Worth Sharing (2015). A collection of short and moving vignettes from 13 long-term care homes is accompanied by solid statistics and eight recommendations for promoting care as a relationship. (Download it free here.)

Removing private profit leads to better care

The researchers found that non-profit nursing homes with adequate public funding were more likely to have better working conditions.  The links between good working conditions and strong care relationships with residents are obvious:

  • Adequate staffing levels ensure that staff have time to interact with residents;
  • Permanent, secure jobs with stable work schedules help residents get to know regular staff who care for them at predictable times;
  • Paid sick leave allows staff to rest when sick and avoid infecting residents at work;
  • Good wages, hours of work, benefits and pensions reduce staff turnover, which ensures continuity of care;
  • De-emphasizing excessive paperwork and charting allows staff more time to interact and socialize with residents;
  • Offering staff continuing education increases their ability to provide quality care for residents;
  • Having all services provided by in-house staff instead of contracting it out (e.g. food service, cleaning and laundry) results in better quality and more personalized care for residents.

These findings are in line with a recently-published study by the Journal of Post-Acute and Long-Term Care Medicine showing that for-profit nursing homes in Ontario have 16 per cent higher death rates and 33 per cent higher hospitalization rates than non-profit facilities.  For-profit homes also have higher rates of falls, incontinence, and use of restraints.

Focus on good food

The way to our hearts may not be solely through our stomachs, but good food makes a big difference to quality of care, Armstrong and Baines found.  Many of the promising practices in their book revolve around food.

Time and again, they found that long-term care residences where all meals are prepared, cooked and served onsite by their own staff provided much better meals, and better overall care for residents, than those who contract out food services.

When food is cooked onsite, residents can smell it cooking. It stimulates their appetites and makes them look forward to meals. Directly-employed food service staff get to know individual residents’ likes and dislikes. They interact with residents at meal and snack times, creating another continuous care relationship.

When food service is contracted out, strict meal times must be observed because contractors enter and leave at set times. But when in-house food service staff have food available all day long, or even 24 hours per day as it was in one residence in the book, there is no pressure for all residents to eat at exactly the same time.

This takes a lot of pressure off of other care staff as well. Care relationships are built through conversations and exchanges during and in between routine care tasks. In homes with flexible meal times, personal support workers don’t have to rush through care routines to get residents to the table by a set time.  That leaves time for relationship and trust-building.

In a care home in Germany, residents were even encouraged to help with the food preparation as they were able, with food service and personal care staff nearby to assist when needed.  This created a social atmosphere between residents and care staff, and fostered residents’ independence.  In a residence where food preparation and service is contracted out to private companies, this kind of interaction doesn’t have a chance to happen.

Time to care: Relationships over bureaucracy

Decreasing staffing levels lead to lower quality care, which then leads to bureaucratic rules requiring excessive documentation and the regulation of what should be common sense.

Personal support workers in Ontario often have to do well over an hour of routine charting every day – time they could spend assisting and interacting with residents.  In contrast to this, one Manitoba nursing home visited by the research team “charts by exception” – in other words, they only document occurrences that are out of the ordinary or things they specifically need to track.  This gives them time to build care relationships with residents.

In the nursing homes visited in Germany and Sweden, there was a greater focus on putting “more life into days than extending the days of life.”  A certain level of risk is accepted in exchange for quality of life.  Residents engage in activities that encourage independence, like food preparation using knives, or walking about instead of being pushed in wheelchairs. Residents with dementia who wander are watched and redirected by staff instead of being restrained or locked in. Staff have time to sit and talk with residents, meeting their socialization needs, not just their personal care needs.

But these practices require a high ratio of staff to residents.  The German nursing home above had staff to resident ratios as high as 1:3. In Ontario, there are no regulations for minimum staffing levels to ensure that other regulations are met, such as the provision of toileting assistance, repositioning, and other types of assistance.  Some Ontario PSWs are responsible for up to 42 residents at a time.

Good care also requires more staff time per resident. On average, residents in long-term care homes in Ontario currently receive the following:

This is well below the four hours of direct care per day that the Ontario Association of Non-Profit Homes and Services for Seniors recommends.

According to Armstrong and Baines, high quality long-term care could be the norm instead of the exception in Canada, if we had the desire and political will to make it happen. It will require a culture shift – a move from thinking of care for seniors in terms of a business model, to thinking about what long-term care residents need in order to live fulfilling, dignified lives.

Relationship-building cannot be legislated.  But we can create the conditions under which care relationships can thrive by setting minimum staff ratios and care hours per resident, creating better working conditions for staff, committing to strong public funding and removing the profit motive from long-term care.

Grey and Bruce Counties pocket of available nursing home beds

The right care at the right place at the right time. It’s a reasonable goal for the health system, but frequently Ontarians are faced with difficult decisions because they can only access one or two of those three conditions.

Recently we received a call about potential layoffs at a nursing home in Grey County, leading us to wonder why, with so many Ontarians on wait lists for a long-term care bed, this particular home had several beds unfilled. It turned out to be not alone in the region.

In the South West region there is an average of 1,442 people waiting to get into a long-term care home (April 2013) – but that is not uniform. The South West stretches from Lake Erie in the South to Tobermory in the north and the experiences vary dramatically.

While the average wait to get into a long-term care home is 124 days, that is not the case in the northern part of the LHIN where the average wait in Grey and Bruce Counties is less than half at 55 days.

The municipal homes in Grey and Bruce Counties have the longest waits, being among the first choice of those seeking care, but those looking for immediate placement can have their pick from at least five homes. An additional six homes have waits for basic beds that are less than 30 days. Some are as short as four days.

Having this information available is certainly useful to families seeking to find a nursing home, although not all CCACs are consistent about posting such information. The question is, why? We surveyed the CCAC websites under “Long Term Care Options” and found wait time information at four – South West, Toronto Central, Central East and South East. If you are from one of the other CCACs and we missed your information, please let us know!

Living Longer, Living Well: Muddled seniors strategy undermines universality of home care

There have been fewer than the usual suspects applauding the release of Living Longer, Living Well, Dr. Samir Sinha’s anticipated recommendations for a new seniors strategy for Ontario. In the early days of 2013, maybe nobody is yet paying attention.

Appointed provincial lead last year by Health Minister Deb Matthews, Sinha spent much of 2012 travelling the province and consulting with everyone it seems but organized labour (not that we’re bitter).

Promised for December, the subsequent report did not linger long in the Minister’s office before the highlights were released publicly yesterday. The full report is expected in the next few weeks.

Like last January’s provincial strategic plan, Dr. Sinha’s strategy seems to be long on lofty recommendations and somewhat short on logistics about how this all gets done, especially in an environment of considerable restraint.

Depending on where you sit on the political spectrum, you’ll likely find recommendations you like and recommendations that seem completely off the wall.

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Proposal makes it easier for LTC workers to change jobs without new hire requirements

After tightening qualification rules around professions in long-term care, the Ministry of Health is now proposing to make it a little easier for existing nursing home workers to switch employers without having to meet the qualification standards for new hires set out in the recent Long Term Care Homes Act (2007).

The new rules are similar to the grandfathering clause established for personal support workers (PSWs).

Staff would not face the new criteria if they have three years of full-time experience in the same position in the five years preceding the date of hire in a different home. Part-time workers who have the equivalent of three years’ full-time experience over the last seven years preceding their hire would also avoid the new standards.

Regulation 79/10 brought the Act into force July 1, 2010 and with it established educational standards for numerous professions with Ontario’s long term care system.

The proposed amendment affects staff providing recreational and social activities, cooks, food service workers, the designated lead for housekeeping, laundry services and maintenance as well as the lead for recreational and social activities. The proposed amendment also covers the Director of Nursing and Personal Care and the home’s administrator.

In addition, the amendment expands the definition of a qualified dietitian to include those with a temporary certificate of registration, cooks to include those who have completed the institutional cook program, and food service workers who have completed or enrolled in an assistant cook or a cook apprenticeship program.

Deadline for commenting on these proposed changes to the Ministry of Health is January 31, 2013. You can do so by clicking here.

The best of Diablogue in 2012

It’s time for us to take our seasonal break and wish the best of the season to all our readers and posters. Next year will be challenging for health care activists as hospitals continue to shed services to balance their budgets, home care faces unrealistic and high expectations over relatively modest funding increases, bed shortages compound wait times in long-term care and all health providers try to find ways to better work together.

If you are new to our BLOG, or are an occasional viewer, you may have missed some of our postings throughout this year.

Here is a sampling of some of our more popular stories from 2012:

1. In recent days we have been unpacking the contents of the Auditor General’s chapter on long-term care in his 2012 annual report. Much of Ontario’s bed shortage problem is based on the Health Minister’s insistence on holding the line on opening new beds, noting Denmark’s success in diversifying long-term care options. But Denmark still has more nursing home beds per capita than Ontario and has made massive investments in home care. To read more, click here.

2.  When the province introduced its new Long Term Care Act, it was to include stepped up inspection. Problem is, they never hired enough long-term care inspectors to get the job done. Most Ontario nursing homes have not had a thorough inspection since 2009, and some may never see a detailed inspection. To read more, click here.

3. Norma Gunn won a disability rights award this year from the Ontario Federation of Labour for telling her own story about being assaulted at the Ontario Shores Centre for Mental Health Sciences and coping with the subsequent post traumatic stress disorder. A psychiatric nurse at the Whitby-based hospital, Gunn has been at the center of a struggle to reduce incidents of violence at the hospital. In recent days we’ve learned that CEO Glenna Raymond is stepping down in April. Will it be an opportunity for the hospital to press its own reset button on this issue and repair its relations with the staff who work there? To read more, click here.

4. This spring we were in Thunder Bay for a rally around the closure of the Canadian Blood Services plasma donor clinic.  Canadian Blood Services was created following the tainted blood scandal of the late 1980s and the subsequent inquiry by Justice Horace Krever. As we probed the decision by CBS to close down the Thunder Bay donation centre, we began to wonder if all the lessons from the inquiry were truly learned. To read more, click here.

5. One of our most popular stories this year was a posting about corporations stashing away record amounts of “dead” cash and the rich squirreling away billions in tax havens while insisting on further tax cuts. The impact is juxtaposed against a backdrop of hospital cuts across Ontario as the province claims it is broke. To read more, click here.

 6. This was the year that P3s (Public Private Partnerships) came back into the news. This summer we were reminded of how bad the situation is in Britain, the birthplace of these schemes. These so-called PFIs — Private Finance Initiatives — are saddling generations of Britons with a mountain of debt. Worse still, the actual value of these projects is about half the size of the accumulated debt, raising questions about value. Ontario represents more than half of such P3 projects taking place in Canada. To read more about the British experience, click here.

7. Ontario is the only province where the ombudsman does not have jurisdiction over the health sector. In BC the ombudsman has made significant contributions to staffing issues in that province’s long-term care homes. Why not here in Ontario? Click here.

8. What would Diablogue be without its bad hospital food stories? Truly if there is one issue that galvanises everyone — including hospital administrators concerned about patient satisfaction scores — it’s bad hospital food. Now the evidence would suggest it’s about more than just tasteless taters and mountains of wobbly Jello. Click here for more.

9. It’s a catch-22. We criticize much that takes place within our public health system. Then we defend the hell out of it when someone suggests we should replace it. This post reminds us of what it is we are fighting for. Click here.

10. Another of our more popular posts this year was the analysis of how former bank executive Don Drummond has skewed his economic projections to make it look like Ontario was in an even worse crisis than actually existed. To what end? Click here.

See you all back in January!

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.

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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.

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Auditor’s Report — Warning flags about diagnostic self referrals

Today’s release by the Ontario Health Coalition regarding the 2012 report by the Auditor General of Ontario: 

Toronto – The Ontario Auditor General’s report released today raises warning flags about inadequate access to care and the perils of for-profit privatization.

The Auditor General found wait times for long-term care that are extraordinary. Crisis clients are waiting more than three months for placement and wait times have tripled. The provincial Ministry of Health response did not mention the lack of long-term care beds, only its plans to download patients into home and community care where funding per client is lower than it was a decade ago.

In Ontario’s privatized clinics (Independent Health Facilities) the Auditor found inadequate monitoring, poor inspections, a lack of financial oversight and inequitable access to care. This is of significant concern as the government is moving more and more services out of hospitals into privatized clinics.

 Among the Auditor General’s key findings:

  • Waits for mammography are up to ten and a half months in some areas of Ontario (page 47) but mammography screening, particularly in smaller hospitals has been closed down and centralized out-of-town.
  • Almost one-third of patients who require follow-up colonoscopies are not receiving them within prescribed wait times, and wait times remain too long.
  • Wait times for long-term care placements have tripled since 2004, with median wait times at 98 days in 2011/12 (page 186). In March 2012 people in crisis waiting for long-term care placements had waited a median of 94 days up to that point; moderate-needs clients had waited 10–14 months; and most other eligible clients had been on the wait list “for years”. Further, during the 2011/12 fiscal year, 15% of clients died before receiving LTC home accommodation (page 187).

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Family Council Network Four launches long term care letter/petition campaign

Tired of broken promises on long-term care?

The Family Council Four Network – the largest of Family Council Networks in Ontario – is organizing a letter writing/petition campaign to improve long-term care.

The Council is asking that Ontario:

  • Immediately increase the number of paid hours of nursing and personal care per resident per day to 4.0 hours – as was promised in 2008;
  • Develop a plan to phase-in future increases to 5.0 hours by January 2015;
  • Establish a licensing body, such as a college, that will develop a process of registration, accreditation and certification for all Personal Support Workers (PSWs).

The Council argues that present PSW training is inconsistent and insufficient to deal with higher physical, psychological and emotional needs of residents.

If you support these goals, you can download a draft letter and petition at:

Edgewater Gardens: LTC Staffing cuts should be a red flag for Ministry, LHIN

We all remember former Health Minister George Smitherman tearfully promising a revolution in long-term care.

That revolution never really happened.

Now we’re beginning to wonder if modest gains made during the Smitherman years are now beginning to be reversed.

It’s been a while since the Ministry has offered us their estimate of hours of direct care nursing home residents are actually receiving. The most recent Ministry data we could find is from 2009.

Nursing homes have received a modest increase in funding this year – the largest amount going to the accommodations envelope (although the biggest percentage increase was for raw food). The smallest percentage increase went to direct care.

Last week Edgewater Gardens in Dunnville gave notice that they are reducing scheduled registered practical nurse (RPN) hours by 75 hours weekly effective February 15, 2013. The non-profit home adjacent to and operated by the Haldimand War Memorial Hospital, is putting a small portion of that back in the form of additional personal support (PSW) hours. The home says it is doing so to be “fiscally responsible,” meaning it’s about money, not about reorganizing the home to improve quality.

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