Why long-term care needs to improve

Long-term care: Time to care
CUPE and OCHU are campaigning for a legislated minimum average of four worked hours of nursing and personal care per resident per day in long-term care (LTC) facilities.

Key points:  [1] The relevant population is increasing rapidly; [2] New beds are not being created at the same pace; [3] Resident acuity and impairment are increasing; [4] Increasing acuity requires more care; [5] The province of Ontario provides less funding and less care than other provinces; [6] Expert research supports our proposal; [7] The experience of CUPE members in the homes provides some of the most compelling evidence of the need for more care. 

History:  In the past, Ontario did have a standard of care, but it was taken away by the Mike Harris Progressive Conservative government.  At the time of its abolition the standard was insufficient – it was set at only 2.25 hours per resident per day.  Since that time the homes have changed dramatically: residents are much more impaired.

The Ontario Health Coalition has helped organize a broad consensus among labour and community groups to campaign for improved staffing.  CUPE is doing its part to make this a reality.

Increasing demand:  The 85 and over age group is the key demographic for LTC.  When their numbers go up, need goes up.  In the five years between 2006 and 2011 the number of people 85 and over increased 34% in Ontario.  By 2016 the Ministry of Finance forecast that those 85 and over will have increased by 67% over 2006.  Moreover, a larger portion of this group will be over 90 (70% of the total, up from 50%).

Rapidly changing demographics has driven up need. This is compounded by an aggressive government strategy to cut costs by removing as many patients as possible from hospitals.

Faltering Supply:  The Auditor General reported in 2012 that the number of long-term care beds in Ontario grew only 3% over the seven years from 2004-5 to 2011-12.  That means an annual average growth rate of 0.42% — or 319 beds per year.

That falls well short of population growth.  But much more importantly, it falls far short of the growth of the relevant population — the elderly.  Or as the Auditor General states:  “An increase in the number of LTC home beds of 3% during that period has not kept pace with the rising demand from an aging population.”

The Conference Board has concluded -- based on the utilization rate by age and the Government of Ontario’s population projection -- that 238,000 Ontarians will be in need of long-term care by 2035. That is 161,000 more than the 77,000 LTC beds existing now.

Ontario would have to create 8,000 new beds per year, on average.  That is over 25 times the current rate of new bed creation rate of 319 per year.  Even if Ontario was creating beds at five times its current rate, utilization of LTC will still have to be cut in half.

The lack of new capacity means that LTC residents getting into a home are much sicker. The increasing acuity of residents will continue to deepen for at least the next two decades, in all likelihood.

Restricting access to only the sickest:  With few new beds, wait lists grew rapidly, growing to over 35,000 by 2010.  With this,   the time spent waiting for a LTC bed grew rapidly.  The government’s response to this was to restrict access to the wait list through legislation.  Only the sickest would even be allowed to wait for a LTC bed.  The Auditor General notes:  “the number of people waiting decreased by almost 15% between March 2010 and March 2012.  This was primarily due to the stricter eligibility criteria in the new Act.”  In effect, the wait list was reduced by about 5,000 through the tighter criteria.

Sicker residents:  At around the same time the government stopped reporting the Case Mix Measure (CMM) – which was the main way of reporting the level of acuity (or illness) of the residents.  Despite this, other measures clearly show that residents have a much higher acuity.
       Activities of Daily Living (ADL) scores are increasing (meaning residents have more impairment with activities of daily living).  Between 2009-10 and 2013-14, ADL scores have increased by 7.8%.  In 2013-14, ADL scores increased by 2.5%.   
       MAPLe data also suggests increasing acuity.  (MAPLe is an assessment used to prioritize an individual’s need for home care services and long-term care placement.  There are five groupings of impairment measured by the MAPLe scoring: Low, Mild, Moderate, High, and Very High.)
       New entrants into LTC have much higher levels of impairment according to MAPLe scores.  In the last quarter of 2009- 10, 76% of new admissions had high to very high levels of impairment; 35% high and 41% very high.  By the end of 2013-14, 83% of new admissions had high to very high levels of impairment.  Almost all
the growth was in the very high category, with admissions of this group growing 3.9% per annum.  The impact on the overall resident population is clear:  more residents with high or very high impairment — with almost all the growth in
the very high impairment category
       The not-for-profit homes (OAHNSS) indicate that a wide range of psychiatric illnesses and dementia are increasing, typically in the 2-3% range per year.  Surprisingly, they report that the occurrence of “cognitive impairment” is declining at a rate of 1.3% per year.

The restrictions placed on LTC beds and hospital care has also dramatically driven up the acuity of home care patients overseen by Community Care Access Centres (CCAC).  In just four years the percentage of patients with CCACs  who have higher care needs increased from 37% to 64% and lower need patients declined from 63% to 36% (see chart below).  Now the province is moving to remove low need patients from the CCACs altogether, so the CCACs can focus on higher need patients. 

Bottom line:  LTC residents are getting sicker and sicker.  Government policy to restrict hospital and LTC capacity mean that resident acuity will continue to increase.

LTC and home care for the most ill

Ontario staffing falls short:  New data  published by the Canadian Institute for Health Information (and based on a mandatory survey undertaken by Statistics Canada) indicates that staffing at Ontario long-term care facilities (LTC) falls short of other provinces.  Of all the other provinces only B.C. has fewer “health care staff” (i.e. PSWs, RPNs, RNs, but also including therapists, recreation and activity staff, and some other health care staff). 

The rest of Canada has 15.1% more health care staff per resident than Ontario. 

Ontario also has fewer higher paid health care staff than the other provinces — fewer RNs, but especially fewer RPNs per resident.  RPNs (or LPNs) are 26% of LTC health care staff across Canada, but only 19% in Ontario.  The Canada-wide ratio of RPN staff to RN staff in LTC facilities is 1.96 to 1.  But in Ontario, the ratio is only 1.67 to 1. 

Also significant, across Canada, there are 13.4% more administrative and support staff (i.e. non “health care” staff) per resident compared to Ontario. Clearly, housekeepers and dietary staff are not making up for the lack of nursing and personal care staff.

Some of the under staffing in Ontario may be rationalized by the somewhat higher proportion of facilities classified as “Type II” in Ontario rather than Type III or higher.  (This report deals with Type II or higher facilities, excluding Type I facilities such as retirement homes in Ontario.  Type II facilities “require” 1.5 to 2.5 hours of care per resident per day, while Type III require 2.5 hours or more).  In Ontario 69% of facilities are rated as Type II, while across Canada 44% are rated Type II.  However, given the very modest role hospitals play in Ontario, it is hard to believe that the residents in Ontario LTC are less in need of care than elsewhere.  Notably, 52% of residents in Ontario facilities are 85+, about the same as the cross-Canada percentage of 51.7%.  Ontario also has a similar percentage of all LTC beds and LTC staff as it has as a percentage of the all-Canada population.

Provincial funding:  Provincial funding per resident is 5.88% more in other provinces.  That equals $2,486 more per resident per year.  Private, municipal, and other funding makes this up.

Expert research:  Research commissioned by the US Congress and carried out by the Center for Medicaid and Medicare Services (CMS) is widely recognized as the most comprehensive and academically sound research to date on the subject.
       The CMS found that a minimum staffing level of 4.1 worked hours per resident day is required to avoid jeopardizing the health and safety of LTC residents.

It is important to point out that the CMS-recommended minimum,
• Refers to worked hours, not paid hours (e.g. holidays, sick time).  Paid hours are 15 to 30 per cent more than worked hours.
• Includes only hands-on nursing and care aides.  Support services (food, cleaning, laundry, maintenance, clerical, and others) play a vital role and need to be reflected in staffing standards.
• Refers to the level needed to “avoid jeopardizing the health and safety of residents.”

The minimum level required to actually improve quality of care is about 4.5 to 4.8 worked hours per resident per day the CMS reports.

Safety:  Unfortunately, need for better staffing often comes up through assaults and deaths.  With increasing illness of patients, there are aggressive residents.  Attacks occur on other residents sometimes resulting in deaths.  In the night time staff is particularly thin, with Personal Support workers sometimes dealing with 30 or more residents. 

Assaults also occur on staff.  Too often abuse is considered as part of the job.  It is not.  

Recent focus groups with CUPE LTC members reported the following comments:
       Verbal abuse is everyday, all day.
       It’s constant.  Screaming, shouting, name calling and stuff. 
       We get punched, bitten, scratched, slapped, spit at.  Pinches, scratches,
open wounds, where they’ve broken skin.
       Sexual comments.  Racial comments.
       We’ve had residents who grab you and hold you up by the throat.
       It’s become normal for us to get hit.  We get beat up but that’s our job.
It’s part of your job.
       Some of the girls got told last week, ‘If you don’t like it, quit.’  You can’t tell me that my job to sit there and have a resident punch me in the face. There’s no compassion. ‘It’s your job.’ Well, no it isn’t. 

Not-for-profit employers echo our call – almost:  The pre-budget submission from OAHNSS, the representative of the not-for LTC homes, does come close to calling for a care standard in their pre-Budget submission.  Recommendation #1 is this:
       “That the Ministry of Health and Long-Term Care set and fund over the next three fiscal years a system target of 4.0 paid hours of direct care per resident day (PHPRD).” 

OAHNSS want government to set a “system target” of 4 paid hours of nursing and personal care over the next three years. This is progress, but falls short of our call for 4 worked hours of nursing and personal care which does not include hours paid as vacation, holidays, sick leave, etc. (And, of course, a “system target” falls short of a demand for a legislated standard.)

Positively, OAHNSS also suggests “the Ministry of Health and Long-Term Care make the development of a measure of year over year change in LTC resident acuity a priority for 2015-16.”  

Other establishment forces move to support increased care:  The government’s Shirley Sharkey report said the government should target 4 paid hours per day by 2012.  More recently, the Long-Term Care Task Force on Resident Care and Safety (2012) highlighted the need for the government to fully follow through on the Sharkey Report recommendations in order to improve the level of safety and care quality for seniors in LTC.  In the words of the chair of that task force, Gail Donner, “There is no doubt that we don’t have enough staff.  It’s past even talking about – you just have to go to a long-term care facility to see that.”

We are making progress:  OAHNSS notes that MOHLTC data indicates we have achieved 3.44 paid hours of nursing and personal care per day per resident.  Most of that care (66% or 2.53 hours) comes from PSWs.   

OAHNSS costs their 4 hours of paid care at $385 million annually.  Given government’s  intention to impose austerity, this will be challenging.  The increase cited by OAHNSS equals over a third of the total annual increase for all of health care; it is equal to about an 11% increase in total LTC compensation.  

CUPE LTC members want better:  91% of OCHU/CUPE LTC focus group members do not feel satisfied with level of care provided; 97% feel there is not enough staff.  Staff believe they are forced to make unsafe choices:  “Either you follow the rules or you help this resident.”  Compromised care is reported in a whole number of areas:  resident cleanliness, eating, dressings, forcing residents into incontinence, and insufficient infection control.  Sadly, staff report a lack of time to provide the emotional care to residents, who are often at their most vulnerable and in the final stages of life. 

The experiences of LTC CUPE members can be a very compelling argument in favour of more care.


  • The relevant population is increasing  rapidly;
  • New beds are not being created at the same pace;
  • Resident acuity and impairment is increasing, and, in all likelihood, will continue to increase for years to come;
  • Increasing acuity and impairment of residents requires more care;
  • Ontario provides less funding and less care than other provinces;
  • Expert research supports our proposal;
  • Not-for-profit employers and others are beginning to echo CUPE’s proposal;
  • Resident safety issues suggest the need for more time to care;
  • Our campaign is helping to make a difference;
  • The experiences of CUPE LTC members at work provide some of the best evidence of the need for the time to care.


Cascading cuts result in new home care restructuring

The government is coordinating cascading efforts to move patients from organizations where more care is provided to where less care is provided.  
Home care services removed from CCACs

For hospitals, government funding models and directives have long focused on removing less ill patients. 

In long term care homes, the government quietly raised the criteria for eligibility for the waiting list. They also stopped providing the 'case mix measure' which was the key measure of the increasing illness and acuity of long term care residents. Regardless it is now obvious acuity in the homes is rising rapidly.

But these restrictions on eligibility to hospital and long term care homes have also dramatically increased demand for home care services provided by Community Care Access Centres (CCACs).  CCACs are facing both more demand and much more ill patients. 

The CCACs claim the number of their high care need patients have increased 73% between 2009/10 and 2013/14. As a percentage of total patients, high care need patients have increased from 37% to 64%, while patients with less intensive care needs has dropped from 63% to 36%.

Home care is dramatically changing.

The government has responded to this by eliminating a whole class of "clients" from CCAC care. 

The "Collaborative Care Model" will see less ill home care patients transfer from the CCAC to Community Support Service agencies (CSS).  The CSS agencies will take over clients who are stable, independent, and have low to moderate care needs  CCACs will maintain care for sicker patients (post acute or complex patients). Indeed moving to more acutely ill patients is required by the HBAM funding system.   

In March 2014, the government enacted a new regulation  to allow Local Health Integration Networks (LHINs) to directly fund designated CSS organizations to deliver personal support services. These regulations came into effect on July 1, 2014. Specifically Regulation 386/99 under the Home Care and CommunityServices Act, 1994  was amended to enable lighter needs clients to receive personal support services (PSS) through selected CSS agencies by extending the eligibility criteria and service maximum to all approved agencies

The regulation establishes (barring exceptional circumstances) a maximum number of hours of personal support and homemaking services :
  1. 120 hours, in the first 30 days of service.
  2. 90 hours, in any subsequent 30-day period.

Despite this seemingly generous maximum, the reports we have received is that the changeover to the new regime has gone with reductions in the amount of care.

The CSS organization can directly take on a client now - there is no need to go through the CCAC (the slogan is there "is no wrong door"). 

LHINs  are awarding money for these  new contracts right now.  The Hamilton-Niagara LHIN  recently planned to reallocate $4 million in CCAC funding in 2015/16 to CSS providers in supportive housing and assisted living settings.  That is supposed to provide 127,795 hours of care (at, apparently, a total cost of $23.47 per hour). The providers named were the March of Dimes in Niagara and Hamilton, St. Joseph's Homecare, AbleLiving Services, Capability Support Services, Participation House Brantford,  and Good Sheppard Hamilton. 

The LHIN notes that "In late summer 2014, the HNHB CCAC informed the HNHB LHIN that in order to accommodate increased referrals from hospitals and community for persons needing higher levels of care the CCAC would need to transition persons assessed as requiring lower levels of care to community support agencies."


Ontario elder care: fewer staff, more privatization, more private payment

Ontario LTC falls short of other provinces
New data  published by the Canadian Institute for Health Information (and based on a mandatory survey undertaken by Statistics Canada) indicates that staffing at Ontario long-term care facilities (LTC) falls short of other provinces. 

The Long-Term Care Facilities Survey indicates that Ontario has 0.598 health care full time equivalent staff (FTE) per LTC bed. Canada (excluding Quebec, which is not included in the survey) has 0.641 staff per bed.  

In other words, Canada as a whole has 7.2% more health care staff per resident compared to Ontario.

This despite the relatively low number of higher paid nursing staff in Ontario. RNs and especially RPNs are underrepresented among all health care staff in Ontario LTC facilities, with RNs comprising just 11.5% of health care FTEs and RPNs comprising just 19.3% of health care FTEs. Across Canada the corresponding figures are 13% and 25.6%.

Fewer RPNs to RNs: Ontario has a relatively low number of RPNs compared to RNs in LTC facilities. The Canada-wide ratio of RPN (or, in other provinces, LPN) FTEs to RN FTEs in LTC facilities is 1.96 to 1. But in Ontario, the ratio is only 1.67 to 1.

Fewer support staff: Administrative and support service staff are also more thin on the ground in Ontario, with only 0.225 FTE support staff per bed, while Canada has 0.248 (i.e. 10% more than Ontario).

Some of the under staffing in Ontario may be rationalized by the somewhat higher proportion of facilities classified as "Type II" in Ontario rather than Type III or higher.  (This report deals with Type II or higher facilities, excluding Type I facilities such as retirement homes in Ontario.  Type II facilities "require" 1.5 to 2.5 hours of care per resident per day, while Type III require 2.5 hours or more).  In Ontario 69% of facilities are rated as Type II, while across Canada 44% are rated Type II . However, given the very modest role hospitals play in Ontario, it is hard to believe that the residents in Ontario LTC are less in need of care than elsewhere.   Notably, 52% of residents in Ontario facilities are 85+, about the same as the cross-Canada percentage of 51.7%.

Higher private payment in Ontario: Residential “co-insurance” accounts for 24.7% of total revenue in Ontario, but 23.2% across Canada.  The extra for preferred accommodation accounts for 2.89% of revenue in Ontario, but only 1.92% across Canada. In total private payment accounts for 27.6% of revenue in Ontario but only 25.1% across Canada. Private payment for LTC is high in Ontario. 

More care in public facilities: Across Canada, public LTC facilities have 0.76 FTE health care staff per bed, compared with 0.566 in for-profit facilities and 0.632 in non-profit facilities. In other words public facilities have 34% more staff than for profit facilities. Unfortunately these figures are not broken down by province – and provincial differences could play a role in these reported differences (e.g. Ontario has both low staffing and a high number of for-profit beds).

For this study, 609 LTC facilities, with a total of 75,282 beds, reported in Ontario.   Unlike an older, now terminated survey done by Statistics Canada (the Residential Care Facility Survey), the new survey is based only on facilities that provide their residents with a minimum of professional nursing care or medical supervision (i.e. Type II or higher facilities, with at least 1.5 hours of care per resident per day). Also notable:
  • Just under 70% of residents are female in both Canada and Ontario. 
  • 61% of facilities in Ontario are for profit, but only 45% across Canada.  If Ontario is excluded from the Canada-wide percentage, only 30% of Canadian facilities are for-profit.  Indeed, most for-profit facilities are found in Ontario (370 of 591). 
  • A little over half of the total reported LTC beds were in Ontario, roughly equivalent to the population of Ontario compared to the rest of Canada excluding Quebec. Just under half of the total FTE staff were in Ontario (61,923 FTEs out of a total 126,389).
  • The mandatory survey covered April 1, 2013 through March 31 2014.
Photo: freeparking ;-| James E. Barna 1970


Ontario fastest growing province. But public services get zip

Ontario's economy bounds to first among the provinces
Four of the big Canadian banks have come out with new forecasts for the Ontario economy and they all indicate the economy is improving.  

The fall in the price of oil (and, with it, the Canadian dollar) is paying off for Ontario.   

All four banks predict that Ontario will have the fastest growing provincial economy in 2015. 

And all implicitly suggest that the Ontario government's Fall Economic and Fiscal Review is now out of date. (See the chart  below comparing bank and government forecasts.)

On average the banks predict that the economy will grow 0.3% more more quickly in 2014 than the Ontario government predicted in its Fall Economic Outlook and Fiscal Review. Nominal growth (real growth and changes in market prices due to inflation) is predicted to grow half a percent faster.  Similarly, growth is predicted to exceed the government's forecast for 2015 as well, with real growth reaching 2.7% and nominal growth reaching 4.7%.  

By 2015, the new bank forecasts suggest nominal growth will be a little under one percent more than the government's older, fall forecast.

That would mean significant extra revenue for the Ontario government. One percent growth in nominal GDP could mean another $850 million dollars in revenue for Ontario government coffers.  

The recently announced federal government transfer payments to Ontario for 2015/16 (for equalization, health and social transfers) are also much higher than expected.  In fact,  about $450 million more than the $800 million increase the provincial government anticipated for all federal transfers to the province.

With the new growth, the banks are forecasting a significant increase in Ontario employment in 2015, with employment increasing 1.4%, up from just a 0.8% increase in 2014.  Consumer inflation (CPI) is also forecast to fall to 1.4% (down from the government projection of 2% consumer inflation).

The improved outlook from the banks is actually consistent with the government's thinking-- they too have suggested a significant upside for Ontario to lower oil prices and a lower Canadian dollar value.

Who will benefit? It won't be those who benefit from public services.  Despite an improving economy and extra federal cash, the Liberals are sticking to their hard talk on public services.    

Far from real growth, the plan is to cut public services. Indeed, the Liberal government's official plan is to make even sharper cuts in real public services, with 0.6% increase in program spending planned for 2015/16 ($700 million), about a quarter of the cost pressures from inflation and population growth.   

After that it only gets worse, with a minuscule 0.08% increase planned for 2016/17 ($100 million) and minus 0.7% in 2017/18 (minus $800 million).

And there are no signs of any move away from that plan - yet. 

GDP Real
Royal Bank
Bank Average
Ontario Gov.

GDP Nominal

Royal Bank

Bank Average
Ontario Gov.


Royal Bank

Bank Average
Ontario Gov.


Royal Bank

Bank Average
Ontario Gov.

[Photo credit: Lending Memo]

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