THERE are some fundamental issues with senior living and care for the frail and elderly, including with ‘aging at home’ and in assisted living.  These issues are now rapidly bubbling to the surface with the COVID-19 pandemic hitting an already vulnerable population.  

My concern right now is that there’s not only plenty of finger pointing but also a lot of band-aiding.  In my opinion, what needs to happen is a systematic review. Equally, we need to give some homes and homecare agencies kudos for doing a great job. Although the reports released by the military into five of Ontario’s LTC homes have highlighted the worst of the worst, they do not represent all. There are some LTC facilities doing a good job with what they are given; they have organization and proper leadership at the helm.  There are also retirement homes (which are operationally different to LTC facilities) who are doing a tremendous job. Yes, there are some that frankly have no business either managing, operating, or owning a care facility but this also can be said for homecare and frankly any business. The Government put licensing in place to ENSURE that any neglect or abuse was immediately addressed and that residents have rights. These regulations should weed out those offenders and rapidly make change, so why hasn’t it? Especially as there have been extensive concerns raised by family, staff and experts for decades about the desperate need for improvements in LTC. Why has it continually fallen on deaf ears? Why have previous governments not made reform a priority? Why has it been allowed to be on the back burner, or as an afterthought? And does it really all come down to money? I am very happy to see that Premier Ford has activated an emergency order allowing the government to step in and manage seven LTC homes to try and mitigate any further distress or incident. And equally I do genuinely wonder if private ownership of LTC facilities should be banned. I am encouraged that the government does appear to be genuinely invested in overhauling the system and has put this at the very top of their current agenda. 

Owning a LTC facility as a private business is a challenge and one that most independent ‘one’off’ owners struggle with, simply because they get into this business believing it’s a good revenue source. Often what happens is they cannot manage the day to day business, clinical care, HR, regulations, and occupancy development that is required not to mention the customer (resident) services that should be a huge part of the business. Just like all businesses there are good and bad business owners, and by ‘one-off’ I mean independent companies as opposed to huge groups or conglomerates that have hundreds of buildings in their portfolios.

I can debate all day on this but the simple fact is there needs to be reform. We all know this and I am very glad to hear from Premier Ford that he is rightly looking to do this ASAP. The introduction of The Incident Management System Long-Term Care Table and its subsequent extension is an important and immediate contribution to site level, at-need issues, but for the bigger picture – for the overarching look at the system itself, we need to keep the ‘politicizers’ and financial gainers out of the equation. There are too many corporate operators with an agenda and there are too many politicians looking for a political angle, and they frankly know little about how the system has worked and is working and what best practice is. The big players lobby the government and because of the volume of their portfolios they are invited as subject matter experts on matters of legislative change. Similarly, there are others from hospitals or physicians chiming in that may not have good insight either.  Politicians who make this an election issue will stall progression on this as well. 

Again, the next step for the province will be to put together a truly independent advisory board as soon as possible. The ON Minister of Health, Merrilee Fullerton outlined on 19 May that there will be an independent Commission into LTC, beginning in September. The members on that board need to be chosen wisely, with a full look at their backgrounds and why they should or shouldn’t be involved. If we truly care about seniors care in this province any folks with an agenda should not be there.  As part of this, they should also create a task force to interview and collect data/feedback from all players including owners, operators, managers, front liners, doctors, case managers, families, and the senior residents themselves. And depending on the model of data collection, look at the trending issues, and formulate the framework for planning.  In a little over two weeks, the military tasked to lead the stricken care homes has managed to audit and report back their findings. They’re continuing to work for a minimum further four weeks, and doubtless within that time, will contribute to improving the quality of life for the residents. But, it certainly comes to something that a province (provinces to include QC) had to ask the federal government for military intervention, and the military running LTC going forwards is not an option or a solution. But learning from them, could be. The advisory board would be wise to keep a member or two members of the military Senior Nursing teams as part of their counsel.   

Personally, I find it deplorable that it took the military to come in and do this right. This in itself speaks volumes to our bogged down bureaucracy and our approach to creating systemic change in an efficient and effective way. We need to move forward immediately with critical improvements.

These include:

1 – HR 

PSWs are some of the hardest working people and so utterly undervalued.  Not to mention there is a HUGE shortage. This brings me back to homecare. There is no regulation to 

homecare so anyone can start a homecare business without any licensing or oversight. This means that every time a homecare business opens and employs PSWs for at home personal care, the talent pool gets watered down and spread across so many different employers. We talk about lack of personnel in eldercare; this is part of the problem.  There is no efficiency when it comes to deploying skilled caregivers because they are spread out all over the place. This 100% affects the quality and consistency of care that we know our seniors need to have a quality of life.   

HR includes pay for workers (and increasing pay for workers), the number of PSWs, RPNs and RNs on shifts; the distribution of those shifts. It means better organization, collaboration, and relationships with the employers. It includes the ability to have a management open door policy where any worker can be heard without fear of reprisal or dismissal. It means better communication between management and staff, and equally, between managers and families. It includes training and more training and even more training, so everyone knows what to do and there is no ambiguity – from the dishwasher in the kitchen to the executive director.

It includes policies that are properly written, administered, understood and adhered to. And that also includes those who don’t follow policy and procedures being held accountable.

2 – Governance

Standards, policies and processes are put in place for a reason. However, they are only good if they are implemented and enforced. When dealing with the vulnerable population there is no room for error. There needs to be consequences if providers demonstrate continuous harmful practices and do not make efforts to improve. The facilities listed in this report had numerous negative incidents stretching back years. Inspectors from the Ministry of Health and Long Term Care (MOHLTC) need to have the ability to not only fine these homes but to revoke their licenses.  And if they do revoke the license, to have a solid plan for the care of the senior residents. This may be a manager who is onsite and oversees the operation in collaboration with the owner to determine if they can improve overall standards, and if they can’t, to develop a plan to relocate the residents. There needs to be accountability and transparency, with regular audits, inspections and severe consequences for failing. Equally, it’s not all about inspections. There is an urgent need to stabilize homes currently in outbreak and take immediate measures to ensure the virus doesn’t re-enter in the second wave.

3 – Infection Prevention and Control (IPAC)

There absolutely needs to be specific recommendations for managing pandemics, such as was given in the 2006 report by Ontario’s SARS Commission, yet seemingly not adopted. However, aside from a situation like SARS or Covid-19, each home needs a plan for infection control and they need to practice this continuously similar to a fire drill or first aid training. The reality is that a PSW course takes 6-8 months to complete. As part of the 600 hours of learning, many 

different aspects of the job are being covered. Once students graduate and settle into the workforce, only regularly practiced skills will be honed. If you’re not having to deal with infection control and PPE (personal protective equipment) then you’ll most likely not remember. Add to this managers who may not include IPAC into annual training or orientation leads to PSWs being at a loss when the time comes to utilize those skills, like now. Then add to the fact that 

some homes scrambled to find PPE and don’t have a cleaning/sanitizing plan and it’s a scenario for disaster. I also believe all staff need to be certified in infection control. This includes non-medical staff who also contribute to the overall functioning and wellbeing of the building.

4 – Leadership  

Looking at some of the LTC facilities that I know across Ontario, between both public and private operators, I’m shocked at the qualifications or rather lack of, of their senior managers.  Here in Ottawa, I can say the public non profits typically prerequisite the need for managers to have a higher level of education and experience. Yet, I have also seen first hand some private LTC providers in Ontario who hire people with little education or experience. To the point I had someone ask me questions about how the LTC system worked because they were going to interview with a private provider outside Toronto.  I was genuinely floored.  This individual had taken courses but not completed them and had no relevant experience or knowledge on seniors care, yet somehow he got an interview and ultimately the job!  I honestly question if this individual was hired into a leadership role simply because he was less expensive than peers with higher levels of qualifications. And there once more, we have a fundamental problem….which leads me to;

5 – Funding

There is insufficient money. Period. Every single LTC facility receives the same amount of money from the government per resident, to pay for their care and support. This is $149.95 per day, equating to $54,730 per year which cumulatively is $4.28bn, 7% of the total provincial health care spend. The resident themselves pays between $62.18-$88.82 a day for their meals and accommodation. LTC homes can be owned by private individuals or organizations, as well as by municipal governments (the City of Ottawa operates four premises) and non-profit/charitable groups (religious, cultural). Of the 626 LTC homes in ON, 58%* of them are privately owned. And a private company – a business – runs for profit. So if the same amount of money is given by the government, and the company runs for profit, how are they ultimately utilizing the dollars they receive? How much is going towards patient care, provision of supplies, building maintenance?

Non-profits on the other hand often have a charitable arm, and run a foundation that fundraises to provide additional money and resources ON TOP of what they receive from the government. They also, by definition, do not operate with margins for profit and utilise their funding for all operating expenses. Their additional funds are used to deliver enhanced services or therapies to residents including music programs, spiritual and palliative care and social activities. The money is also used to purchase and install additional medical equipment like ceiling lifts, and for capital improvements like building repairs or enhancements. All money received is reinvested into their community. They also usually have a tremendous amount of support from family and 

community volunteers who run events and programs to actively raise additional dollars. And these foundations are transparent and accountable to their residents and families and list item by item how the money is spent. 

So I certainly believe that funding models need to be addressed going forwards. Should private business be taken out of the equation altogether and only charitable, non-profits or municipalities take over? I’d like to see what that would look like.

Final thoughts

According to the Ontario Long Term Care Association, there will be two million more seniors in ON within the next 25 years, with many of them over 80. There are currently three tier options for eldercare; Home Care – either private or funded (to a point), Retirement Homes (private), and Long Term Care facilities (subsidized). Each sector works in a silo and does not necessarily work together.  Currently there are way too long waiting lists for LTC, which I did not address here. For Long Term Care and quality eldercare to exist and be sustainable, there needs to be cross service engagement and buy-in from all healthcare providers and across government with systems, processes and consequences clearly identified and implemented. To get to this place, simply put, the guidance from which this reform will come, is exceptionally important and should be senior living industry wide…looking also at home care and retirement homes.

*Long-Term Care Utilization Report, February 2019, Ontario Ministry of Health and Long-Term Care; Ontario Long Term Care Association, internal database, 2019.