Ministry Reports

Commitment to Care :  A Plan for Long-Term Care in Ontario

Prepared by Monique Smith, Parliamentary Assistant, Ministry of Health and Long-Term Care
Spring 2004

Executive Summary  (Continued)

Improving quality of life

We need to reintroduce the concepts of "home" and "care" into daily life for the over 70,000 residents who live in long-term care (LTC) homes in Ontario. We are challenged in achieving this goal by changing demographics and the increasing acuity of resident care that is now placing a greater burden on long-term care facilities.

Ensuring home administrators have the necessary management training, and that they adopt and integrate a care philosophy in the everyday practice of the home, is an important step in achieving daily quality of life for residents. Implementing nursing best practices is also important. It was our observation that those homes that were providing exemplary care with few or no compliance issues, had organized their staff into multidisciplinary, resident-focused teams, who met frequently to discuss and resolve issues.

Enhancing institutional life by engaging families, volunteers and by better integrating LTC homes into the vibrancy of the surrounding community is a recommended strategy.

More educated and aware consumers, more volunteer coordination, mandated Family Councils, working in partnership with Residents' Councils, an emphasis on creating more of a home environment, the sharing of best practices, and more attention to new dementia therapies is required. Further, we recommend a reinstatement of the previous reunification policy to keep couples together in the same facility.

Ensuring public accountability

To implement systems that deliver confidence to the public, openness and transparency in our complaints process is needed. In addition to the previously announced toll free ACTION line and unannounced annual inspections, we recommend immediate action on serious non-compliance cases in a very short time frame. Mandatory yearly resident and family satisfaction surveys should be implemented and a public website created.

Creating a positive duty for all LTC home staff and the general public to report abuse or suspected abuse under new legislation is needed. This legislation should include penalties for non-reporting and whistleblower protection. The creation of a third party advocate or ombudsman to act as a watchdog and advocate on behalf of seniors would be welcomed by the public. Better Ministry collection, analysis and use of data is also vital to ensure public accountability.

New standards, inspection and compliance

The public expects tougher enforcement and swift compliance. Because the current compliance system is not meeting public expectations for ensuring the safety and wellbeing of our seniors, and because LTC operators have also complained that the system is not clear and consistent, the Ministry should create a separate inspection function with clearly articulated enforcement measures. A new risk framework should be designed that identifies graduated offences with contingent triggers and with resulting sanctions including fines. It should focus on public notification and reporting.

Quality of life depends on ensuring our seniors receive high standards of care and be treated with dignity. There must be clear, measurable, enforceable, resident-focused standards with enforceability of standards being key.

The Ministry should make increased use of service contracts and accountability agreements with LTC service providers to spell out reporting requirements and strict compliance to existing standards. The Ministry should target homes with a poor track record or chronic non-compliance. A home's track record must be considered in any future funding decisions, including bed allocations and bed transfers. Finally, homes with a record of good performance should be given a gold standard designation and consideration given to allowing those homes to go to biennial inspections.

To ensure appropriate levels of care, particularly for seniors living with dementia, smaller community-based homes that provide 24-hour staffing and support (non-profit residential alternatives) should be considered.

Improving staffing and continuity of care

Demands for funding are high, although some groups indicated more of a need for a reallocation of existing funding. Increased staff funding and a move towards ensuring more full time staff to provide consistent, resident-knowledgeable care is recommended, even as we recognize the Province's current financial constraints. More nurse practitioners in LTC homes, more attention to activities / activation staff and increased dietitian time would improve the quality of life and care. These resources must be tied to specific outcomes and an annual audit must be undertaken to ensure that the funding designated for specific roles or resources is in fact spent on the intended priorities.

Reinstating the one bath per week standard and doubling it to two baths per week is recommended, consistent with individual preferences, as is returning to the requirement that homes have a 24-hour registered nurse on duty. In the short term, dollars must be concentrated in resident care and therefore any future spending for care should be tied directly to the nursing and personal care envelope to ensure the money goes directly to frontline care.

The Ministry should consider making minimal training a requirement for personal support workers, as well as ensuring higher standards of management expertise for administrators. In addition, all staff should be required to have training in understanding the needs of the elderly, specifically training regarding abuse, communication skills, dementia and palliative care. The Ministry should encourage the use of existing programs offered by the Registered Nurses Association of Ontario, the College of Nurses, the Registered Practical Nurses Association, the Alzheimer Society and others. Finally, strategic efforts need to be developed to promote the long-term care sector as a desirable career option as staff shortages and pay inequities are constant challenges.

New legislation and a review of funding models

Any increase in the accommodation cost for residents in LTC homes should be limited to no more than the cost of living annually. Further, in order to respond to the needs of all seniors, further discussions around the 60 / 40 preferred / basic bed split should be held to respond to the clear need of seniors on waiting lists. The Ministry should also review the proposed new beds that have yet to be developed and determine the actual need, weighing potential penalty costs, potential savings and possible reinvestment in other areas.

A review of redevelopment projects should be undertaken to ensure whether redevelopment is necessary to meet resident needs and if so, whether the proposed design will assist the home to better achieve its care priorities.

Consolidation of the three facility Acts (Nursing Homes Act, Homes for the Aged and Rest Homes Act, and Charitable Institutions Act) is needed to ensure uniform standards of care, uniform enforcement, and uniform penalties, as well as to address the issue of elder abuse. Legislation to enable residents in LTC homes and those with Power of Attorney to access their medical files and records should be developed.

Complaints about the current funding process are prevalent throughout the system. In the short term the Ministry should carefully articulate and firmly enforce the boundaries around the funding envelopes. The current ad hoc 'pots of money' approach that has developed over the years needs to be addressed. As well, the current Case Mix Index (CMI) system is problematic. We recommend a review of the entire funding system in the next fiscal year to establish a model that provides homes with a base level of funding for consistency, while still allowing some flexibility for fluctuating levels of care. Stable, consistent funding should ensure more full time, resident knowledgeable staff and a consistency of care.

The Minimum Data Set (MDS) would assist with evidence-based decision making, increased accountability, patient-focused care planning and a better integration of systems. This new approach would allow for continually assessing the needs of a home above a basic funding level.

This report is a result of visits to over 20 homes and meetings with close to one hundred stakeholders and people active in the long-term care community. It forms a starting point for our "revolution." It is hoped that this report and these recommendations will support those homes that are doing a wonderful job of caring for seniors and begin to address the concerns raised around those homes that are falling behind.

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Spring 2004 / CAT #7610-2241610

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