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Proposal to Bring Long-Term Care in Ontario under Government Management

Proposal to Bring Long-Term Care in Ontario under Government Management

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OPSEU has sent the following position paper on the reform of long-term care to Premier Doug Ford, Minister of Health Christine Elliott and Minister of Long-Term Care Merrilee Fullerton.

OPSEU has also issued released a news release on the paper.

Introduction:

The COVID-19 (Coronavirus) pandemic has exposed the cracks in the health care system that health care workers, labour organizations, and other stakeholders have long been pointing to as unsustainable and dangerous. Subsequent governments, both federal and provincial, have encouraged the encroachment of private sector management and interests in our health systems, while simultaneously underfunding the health care envelope. The culmination of these processes is most clear when looking at the current crisis in long-term care in Ontario. As of writing this, over 1,200 people in Ontario have died from COVID‑19 while receiving care in long-term care homes, while the government is reporting 2,703 active cases amongst residents, and 1,677 active cases amongst staff. Research reported by the Ontario Health Coalition shows that outcomes in for-profit facilities are worse than those in non-profit and municipally run homes.[1]

This crisis in long-term care is multifaceted and exists across multiple levels of government. At the federal level, the exclusion of long-term care, and other systems such as home care which help to prop up long-term care, from the Canada Health Act have allowed the proliferation of privately operated services. While that is an issue that must be resolved at the federal level, provincial governments must take it upon themselves to ensure the long-term care system is designed to respond fully to the needs of patients while also providing safe, stable, and fulfilling jobs for health care workers. For-profit care results in higher costs to residents, lower quality of care, and worse conditions for workers. The Ontario government must proceed with a review of long-term care, and fully bring it and the other aspects of the health system that support it, under public management with ample funding.

This report documents the current state of COVID-19 in LTC facilities in Ontario, provides broader context for the significant faults and gaps in Ontario’s LTC system, and argues for long-term care to be properly funded and fully publicly operated.

Current state of COVID-19 in Long-Term Care in Ontario:

As noted above, infection rates in long-term care homes that operate on a for-profit basis are much higher, and have had notable health and safety issues regarding the availability of PPE. It is expected that the number of fatalities in long-term care facilities will continue to rise as the pandemic continues. While the Ontario government has implemented emergency orders to limit workers to a single long‑term care facility as a means of reducing cross-site contamination, this has not addressed the structural issues at play in long-term care that force workers to hold multiple part-time positions.

Ontario Context for Long-Term Care:

Ontario’s population is aging far more quickly than our health care capacity has been expanding. According to a report by the Financial Accountability Office (FAO), from 2011-2018 the number of long‑term care beds increased by 0.8 per cent, while the number of Ontarians aged 75+ increased by 20 per cent.[2] While the Ontario government has committed to increasing the number of beds in LTC, the growth rate for Ontarians over age 75 is expected to outpace the growth in available beds. The FAO also projects that the government will have to create 55,000 new LTC beds by 2033-34 to maintain the waitlist at 36,900, as need for long-term care is expected to continue increasing.[3] As Ontario’s population continues to age, investments into high-quality long-term care will need to be made. OPSEU believes investing that money into a publicly funded and operated long-term care system is not only more fiscally prudent than continuing to allow for-profit interests to run amok, but also allows for greater oversight, higher quality of care for residents, and safer working conditions for workers.

Care needs are also increasingly complex. According to data from the Ontario Long-Term Care Association (OLTCA), 63.9 per cent of residents have a diagnosis of dementia (including Alzheimer’s). This results in a host of increased care needs as brain function deteriorates causing other body functions it directs to deteriorate as well.[4] The same data shows:[5]

  • 90 per cent of residents have some form of cognitive impairment
  • 86 per cent of residents need extensive help with daily activities
  • 61 per cent take 10 or more prescription medications
  • 40 per cent need monitoring for an acute medical condition

This increasing complexity of care needs is unmanageable with the current emphasis on private for‑profit operation of long-term care in Ontario. Downward pressure on staffing levels has resulted in long-term care homes having just enough staff to get by, if there are no emergencies or if nobody calls in sick. There are no minimum staffing ratios set out in the Long-Term Care Act, though previous research has shown that homes should have staffing levels of at least four hours of direct care per day to help prevent negative health outcomes.[6]

There are three types of long-term care facilities in Ontario: private homes that operate on a for-profit basis, public homes that are owned by the government and operate on a non-profit basis, and municipal homes which are public, non-profit homes that are owned and partly funded by municipal levels of government.

Facility Type: Private For-Profit % in Ontario[7]* 58%

Facility Type: Non-Profit % inOntario[7]* 24%

Facility Type: Municipal % in Ontario[7]*. 16%

*Note: Two per cent of facilities are classified as “Other.”

All long-term care homes have two funding streams. The first is through transfers from the provincial government via Case Mix Index (CMI) funding. The CMI is an index of the needs of the resident population at the home each year. These funds are allocated to cover expenses like food, accommodation, health care services, and medical needs. The second funding stream is from residents themselves. Residents are able to pay to top up their accommodation from basic to semi-private and private options. They are also able to purchase goods and services through the home such as cable, Internet, hairdressing, foot care, laundry services and tuck shops. Municipally run homes have a third stream: funding from the municipal government. Because municipalities have a third, and very significant, revenue stream, these homes often have better health outcomes, wages and working conditions.

Whether for-profit, private or municipal, all long-term care homes are chronically underfunded, resulting in a crisis of care. While the funding envelope to long-term care in Ontario has technically increased over time, it still falls well below the levels required to properly maintain staffing and hours of care levels. Increased funding is needed to increase staffing levels and thus, the amount of care each resident receives. Further, the province needs fewer privately run homes that put profits before people to make sure all dollars go directly to health care and aren’t syphoned off the top to help buttress the bottom line of a privately owned company.

As noted above, approximately 58 per cent of Ontario’s long-term care facilities are operated on a for‑profit basis. As well, many of the non-profit homes have management services contracted out to private companies. However, the purpose of private corporations is to make a profit, which is incompatible with providing fulsome health care. As a recent report from the Canadian Centre for Policy Alternatives points out: “Private, for-profit services are necessarily more fragmented, more prone to closure and focused on making a profit… managerial practices taken from the business sector are designed for just enough labour and for making a profit, rather than for providing good care.”[8] For-profit long-term care companies have posted huge profits, while research has shown they typically provide fewer hours of care,[9] and pay lower wages.

The working and care conditions of long-term care homes in Ontario have been the subject of numerous media and union-reported scandals. These include reports of violence between residents, or from residents toward staff,[10] a lack of ministry inspections,[11] and lawsuits from families for concerns around mistreatment.[12] These struggles are symptomatic of the broader issues with long-term care in Ontario.

Quality of Work:

The conditions of the workplace in care settings are intimately tied with the quality of care workers can provide. While for-profit long-term care homes are reporting massive profits, their workers, particularly PSWs who provide the bulk of the care, are paid very little. These workers have the heaviest workloads, but due to a carryover of for-profit logic, they often hold precarious jobs that are part-time, casual, and contract-based. The issues with this have been exacerbated in the context of COVID-19, as the risk of cross-site contamination is greatly increased when workers need to work at multiple jobs in order to make ends meet. While the Ontario government has since implemented emergency orders limiting the number of long-term care homes someone can work at during the pandemic, and encouraged employers to provide full-time hours to employees who can no longer work at their other jobs, this would be far less necessary if the long-term care system was designed to provide full-time employment to frontline care workers. It should also be noted that this sector, and other care sectors, are highly feminized and racialized. The undervaluing of this work therefore further reinforces social inequality along these lines.

Retention issues abound in long-term care. A jointly published report from the Ontario Health Coalition and Unifor found that “increasing acuity, behaviours including aggression and violence, and injuries were repeatedly raised as major contributing factors to the PSW shortage.”[13] This is further driven home in rural regions where there are shortages of PSWs to work in long-term care homes, such as the shortage at the Pines Nursing Home in the Muskoka region.[14] During this pandemic, workers in health care are constantly being thanked by elected officials, while the work they perform continues to be politically, socially, and materially undervalued. While Ontario has implemented a temporary “pandemic pay” in response to the clear danger of working during COVID-19 and the potential retention issues that come along with it, this is simply not enough. At the very minimum, this pay increase should be permanent. The Ontario government should also consider the wisdom of the provisions of Bill 124, which limits yearly compensation increases to public sector workers, and has further exacerbated the structural retention issues at play in long-term care.

Propping the System Up: the Role of Retirement Homes and Home Care:

The long-term care system in Ontario is propped up primarily by other types of services, such as home care and retirement homes, which are also not covered under the Canada Health Act. Retirement homes, which are privately run, have become a sort of stopgap for the long-term care waitlist. However, retirement homes do not have the capabilities to provide for increasingly complex care, and so resort to contracting in services, often through private home care service providers. These facilities also pay concerningly low wages, with workers often making around minimum wage. Retirement homes also have notorious recruitment and retention problems, as the work is intense and pays very little. These recruitment and retention problems become feedback loops, where a lack of staff on the schedule results in higher rates of stress and burnout, while also having health and safety implications. Housing residents in facilities that are unable to properly support increasingly complex needs results in an even greater strain on long-term care facilities once residents are moved off the waitlist, as health concerns have become more complex than they otherwise would have.

Home care services also function to prop up an underfunded and patchwork long-term care system. Home care providers often go into the homes of people who are languishing on a waitlist for long-term care to administer care they should be receiving in a long-term care facility. By keeping people in their private residences through the use of home care agencies, some pressure on the long-term care system is alleviated. This means people stay in their homes longer, and put off an urgent request for a long-term care bed a little longer. Because home care is privately operated, the primary objective of most service providers is profit. There are numerous concerns about casualization, high stress, and burnout rates amongst workers in home care. PSWs are paid low wages and often only for client visits, meaning the time they spend doing paperwork and travelling can go underpaid. In rural areas especially, a PSW can be expected to travel vast distances, in all kinds of weather.

In the context of tragic death rates in long-term care facilities during COVID-19, it is possible this could encourage an even further uptick in the use of home care services if people choose to avoid moving into long-term care out of fear of infection. While OPSEU believes that patients should receive care in an environment appropriate to the level of care they require, the role of home care in our health care system is too important to leave in the hands of private service providers. As noted above, home care service providers are privately operated, and many are run by for-profit corporations.

The quality of care received through home care should be expected to match the quality of care received in other parts of Ontario’s publicly run health system. Because it is currently heavily decentralized and fragmented, and multiple service providers with their own interests and policies are involved in the provision of care, there is inconsistency built into the home care system. The fee-for-service model that dominates the sector encourages service providers to tailor their policies to focus on increasing the number of visits, rather than ensuring frontline home care workers are given enough time during each visit to fully provide home care services. While more home care clients receive care, the visits are often shorter than they should be due to this, meaning that clients do not end up receiving all the care they need. This is further exacerbated by the spike in demand for home care as hospital space diminishes and long-term care waitlists expand, meaning that most recipients of home care are unable to access as much care as they need.

While home care is not covered under the Canada Health Act, OPSEU believes the Ontario government should take steps to bring home care fully under public management with full public funding. A publicly run home care system could centre on quality of patient care while also ensuring that everyone who needs home care is able to receive it. The aforementioned concerns about casualization, burnout, and turnover of workers in home care could also be alleviated under public management. Operating home care from a perspective focusing on providing the best possible care necessitates ensuring a stable employment relationship. As a publicly operated system the government could foster that stability.

Role of the Canadian Government:

As has been referenced several times throughout this document, the Canada Health Act does not cover long-term care or home care, which has allowed private interests to dominate those sectors. The Canadian government has an important role to play in addressing the troubling trends discussed in this paper. While health care provision falls under the purview of provincial governments, these services are funded primarily through health care transfers from the federal government. The federal government must commit to supporting publicly funded health care by adding long-term care and home care to the Canada Health Act, and providing appropriate levels of funding to ensure high-quality care.

The COVID-19 pandemic has demonstrated significant gaps in Canada’s personal protective equipment (PPE) supply and procurement. The federal government should ensure that Canada has the ability to manufacture an adequate supply of PPE through domestic supply chains moving forward, while developing a co-ordination plan with the provinces and territories to ensure PPE is available to workers in all sectors. Hopefully, as more research is conducted, treatment options and vaccines for COVID-19 will be developed. It is integral that the federal government, and all provincial governments, ensure that any treatment options or vaccines are publicly provided.

As previously noted, health and safety concerns are prevalent in long-term care, especially along the lines of workplace harassment. Canada has not yet ratified the International Labour Organization’s C190, which seeks to address issues of violence and harassment in the world of work. This ratification must also include a commitment to develop a pan-Canadian health care violence-prevention framework, with funding directed for that purpose. This framework should include labour organizations as key stakeholders and representatives of workers’ voices.

Finally, this pandemic has shown that key gaps in Canada’s employment standards can result in significant hardship. There is currently no federal standard for sick days across Canada, resulting in sick days varying significantly across the country. Workers who are afraid to lose their jobs or lose pay to take time off for illness are put at even higher risk during an event like a pandemic. The federal government should therefore implement a uniform policy of a minimum of 14 job-protected sick days for all workers across Canada.

Conclusion:

The COVID-19 pandemic has shown that the long-term care system is fractured along the lines of privatization, underfunding, and understaffing. The absolute tragedy currently taking place in long-term care shows that the for-profit interests currently driving decision-making in long-term care in Ontario do not put patients first. This crisis should be seen as a moment of clarity, where we as Ontarians can choose what values we want to build into a new long-term care system. The Ontario government must work with the federal government, labour organizations, health care stakeholders, and community members to develop a plan for long-term care that centres on public funding and control, respect for workers, and respect for patients.

Summary of Recommendations:

  1. The Ontario Government should directly operate long-term care and home care as a publicly funded and integrated system, ensuring high quality care and fair work conditions.
  2. Fully integrate home care into a public system designed to keep seniors in their homes for as long as possible and practical, allowing for a seamless transition should residential care become medically necessary.
  3. Long-term care must be brought fully into the public system and regulated according to the principles set out in the Canada Health Act.
  4. Expand and increase federal health care transfers to provinces and territories for long-term care.
  5. Immediately strike an emergency task force, with union representation, to develop a plan to establish a comprehensive universal long-term care system that is fully publicly funded and exclusively not-for-profit.
  6. Implement a long-term care labour force strategy to address the multiple labour force-related problems in the sector including, but not limited to, the problems of inadequate compensation, staff shortages, over-reliance on part-time staffing, management failures, training, and low rates of unionization.
  7. Legislate proper staffing levels to ensure the highest quality of service and hands-on care in long-term care facilities, and properly fund and regulate enforcement.
  8. Raise the compensation floor in the long-term care sector by making all increases in wages and compensation introduced through the COVID-19 pandemic permanent.
  9. Unionize all staff in long-term care facilities to ensure that stronger regulation is reinforced by workers’ own efforts to ensure high standards in the workplace and accountability for resident living standards and employee working conditions.
  10. Commit to building more public health infrastructure, in particular, long-term care facilities to expand the care capacity, by expanding public financing of social infrastructure.
  11. Remove for-profit components of the long-term care system by prohibiting the privatization and/or contracting-out of any service provided to, or in, the long-term care sector, including but not limited to, infection control, cleaning, housekeeping, laundry, food services, and transportation.
  12. Develop a comprehensive ongoing plan and procedures to prevent and address infection outbreaks in the long-term care sector and ensure the implementation of the plan and procedures are regulated, enforced and fully funded.
  13. Implement a uniform policy of 14 paid, job-protected sick days for all workers in Canada.
  14. Ratify International Labour Organization Convention C-190 Concerning the Elimination of Violence and Harassment in the World of Work.
  15. Develop and implement a pan-Canadian health care violence-prevention framework with targeted federal funding to enhance protections for health care workers, with labour included as an essential partner.
  16. Develop stronger anti-racism and anti-discrimination policies and practices in employment, compensation and in the workplace for long-term care workers who are predominantly women, racialized and immigrants.
  17. Ensure that any vaccines and/or drugs for COVID-19 are widely available and accessible publicly.
  18. Develop a national co-ordination plan with the provinces and territories, after the federal government’s review of the management of the National Emergency Stockpile System, to ensure that PPE requirements for all workers in all sectors can be met.
  19. Ensure that Canada develops the ability to manufacture and adequately supply PPE through domestic supply chains in the future.
  20. Build surge capacity into the physical structure of the long-term care homes, and into labour force planning.
  21. Develop guidance for the reconfiguration of space and its functionality to address outbreaks and surge capacity in long-term care homes.
  22. Provide better regulatory oversight and inspections of all public and private health care facilities including long-term care homes.
  23. Enact immediate measures to routinely provide necessary health data to health care unions.

[1] Ontario Health Coalition: https://www.ontariohealthcoalition.ca/index.php/death-rates-in-long-term-care-by-ownership-release/

[2] https://www.fao-on.org/en/Blog/Publications/LTBO-2019. Retrieved May 10, 2020.

[3] https://www.fao-on.org/en/Blog/Publications/LTBO-2019. Retrieved May 10, 2020.

[4] https://www.oltca.com/OLTCA/Documents/Reports/TILTC2019web.pdf. Retrieved May 11, 2020

[5] https://www.oltca.com/oltca/OLTCA/Public/LongTermCare/FactsFigures.aspx. Retrieved May 11, 2020

[6] Pat Armstrong, Hugh Armstrong, Jacqueline Choiniere, Ruth Lowndes, and James Struthers. Toronto, April 2020. Re-imagining Long-term Residential Care in the Covid-19 Crisis.

[7] https://www.oltca.com/OLTCA/Documents/Reports/TILTC2019web.pdf. Retrieved May 11, 2020.

[8] Pat Armstrong, Hugh Armstrong, Jacqueline Choiniere, Ruth Lowndes, and James Struthers. Toronto, April 2020. Re-imagining Long-term Residential Care in the Covid-19 Crisis, p. 6

[9] Hsu, A., Berta, W., Coyte, P., & Laporte, A. (2016). Staffing in Ontario’s Long-Term Care Homes: Differences by Profit Status and Chain Ownership. Canadian Journal on Aging, 35(2): 175 – 189.

[10] https://www.cbc.ca/news/canada/thunder-bay/ltc-information-rally-1.4342278. Accessed May 11, 2020

[11] https://www.cbc.ca/news/canada/seniors-homes-inspections-1.5532585. Accessed May 11, 2020

[12] https://www.cbc.ca/news/canada/toronto/we-want-justice-for-our-mom-lawsuits-filed-against-long-term-care-providers-alleging-serious-neglect-1.4646723. Accessed May 11, 2020

[13] https://www.unifor.org/sites/default/files/documents/document/final_psw_report.pdf Accessed May 11, 2020

[14] https://www.muskokaregion.com/community-story/9348271-muskoka-long-term-care-home-hires-12-psws-in-2-months-amid-area-shortage/ Accessed May 11, 2020