THIS IS LONG-TERM CARE 2018 - Ontario Long Term Care Association

THIS IS LONG-TERM CARE 2018 - Ontario Long Term Care Association
THIS IS LONG-TERM CARE 2018 - Ontario Long Term Care Association
It’s natural to want to stay in our own homes as we age, but that
                                isn’t possible for everyone. Many people, particularly those with
                                dementia, will eventually need a level of support and supervision
                                that family, friends, and home care can no longer provide.
                                Ontario’s long-term care homes provide support to more than
                                100,000 people and their families every year. Homes offer 24/7
                                nursing care and supervision, support with daily activities, and
                                a safe, caring environment, helping people live comfortably and
                                with dignity.

                                Who lives in long-term care?
                                Seniors whose dementia           In one-third of residents,    stage in the progression of
                                has progressed to the            this impairment is severe.1   their conditions, when their
                                middle or advanced stages        In recent years the Ontario   health is more likely to be
                                are the core population in       government has been           unstable, they are more
                                long-term care homes. Two        investing more funds in       physically frail, and their
                                out of three (64%) residents     home care and aging-          care is more complex.

                                have been diagnosed with         at-home strategies. New       In particular, an increasing
    OUT OF 10                   Alzheimer’s disease or           residents to long-term        number of residents are
    RESIDENTS                   another dementia. Overall,       care must now have “high”     admitted to long-term care
                                90% of residents in long-        or “very high” physical       at a later stage of their
 HAVE COGNITIVE                 term care have some form         and cognitive challenges      dementia, with increasing
 IMPAIRMENT                     of cognitive impairment,         in order to qualify for       needs for support with daily
                                not solely from dementia         admission. This means that    activities.
                                but from other causes such       people are now coming to
                                as stroke and memory loss.       long-term care at a later

                                Higher needs, more care
                                The Ontario Long Term            described as borderline       years ago. At the same
                                Care Association analyzed        or mildly impaired            time, the number of long-
                                data over the last five years,   (7% decrease).1, 2            term care residents who can
                                from 2011-12 to 2016-17.         There have also been          carry out daily activities
                                During that short time,          steady year-over-year         without assistance has
                                there has been a steady                                        dropped by half, from
           1 in 3               increase in the number
                                                                 increases in the number of
                                                                 people who need extensive     approximately 6% to 3%.1, 2
                                of new residents with
     HAVE SEVERE                moderate and moderately
                                                                 or complete support with      These increasing high
                                                                 everyday activities such as   needs have significant
      COGNITIVE                 severe cognitive                 getting dressed or feeding    implications for the support
                                impairment (6% increase),
     IMPAIRMENT                 with a corresponding
                                                                 themselves. Today, 85% of     that residents need, and
                                                                 long-term care residents      the additional staffing and
                                decrease in the number           need extensive or complete    funding that homes require
                                of new residents who don’t       help with daily activities,   to provide this support.
                                have cognitive impairment,       compared to 77% just five
                                or whose function is

2 This is Long-Term Care 2018
THIS IS LONG-TERM CARE 2018 - Ontario Long Term Care Association
2016-17                                  85%
     2015-16                               83%
     2014-15                              82%
     2013-14                             81%
     2012-13                          79%
     2011-12                        77%
                More residents need extensive
                    or complete support
Over the last five years alone, the proportion of residents who need
extensive or complete support with daily activities such as eating and
getting dressed has increased by more than 7%, from approximately 77%
to 85%. Data source: Canadian Institute for Health Information, Continuing
Care Reporting System (CCRS 2011-2012 to CCRS 2016-2017).

                                                                              A changing culture
                                                                              At the same time that the      are provided through a
 DRESSING        PERSONAL       TRANSFER        TOILET          BED           population is changing,        sensitive understanding of
                  HYGIENE                         USE         MOBILITY        so too is the culture of       each resident’s individual
                                                                              long-term care. Like many      needs and preferences.
                 More residents need support
                                                                              other areas of health care,    Even when someone has
                with important daily activities
                                                                              long-term care was built       advanced dementia, long-
The majority of residents in long-term care need help with daily activities   on what is often called        term care homes provide
such as getting dressed, getting out of bed, and toileting. This figure       an “institutional” model,      a life of purpose and
shows the rise over a five-year period in resident needs for physical         focused primarily on           connection, as the stories
assistance from one or more staff with these activities. The increased        providing physical and         in this report illustrate.
needs for support are accompanied by a need for more staff time, skills,      medical care.                  This is Long Term Care is
and resources to provide care. Data source: RAI-MDS 2011-12 to 2016-17,
                                                                              That is changing rapidly.      designed to provide readers
Ontario Ministry of Health and Long-Term Care, Intellihealth Ontario.
                                                                              Caring for medical and         with a better understanding
                                                                              physical needs is still very   of what homes do, the
                                                                              important, but homes           people they serve, and
                                                                              are shifting to a resident-    some context behind the

                              1 in 3
                                                                              centred or relationship-       headlines.
                                                                              centred approach, where
                                                                              care and quality of life
                              RESIDENTS ARE HIGHLY
                              OR COMPLETELY
                              DEPENDENT ON STAFF

                                                                                                              This is Long-Term Care 2018 3
THIS IS LONG-TERM CARE 2018 - Ontario Long Term Care Association
A caring community

 A     movement to holistic, person-centred care has been
       rapidly evolving over the last decade, changing the
  way we think of disabilities and dementia, as well as what
                                                                 “The change we are experiencing is a
                                                                  change in the culture of LTC; a sweeping,
  we expect from services such as hospitals, home care,           cleansing movement that embraces
  and long-term care homes. As a society, we have been            person-centred care. The picture of
  redefining what good care means for those with
  dementia, and what people really need.                          living life in LTC is changing to a full
  In person-centred care, the focus is on the person’s            recognition of the wholeness of each
  preferences and their emotional and social needs,               person, even those living with severe
  in addition to physical and health care needs. This is          cognitive or physical changes. Teamwork
  a movement away from caring for residents according
  to set schedules and routines, to caring for residents          is flourishing, empathy is growing, a social
  according to their lifetime practices, habits, and              model of living is sweeping over our LTC
  preferences — even if those can be hard to decipher             homes, replacing the institutional model
  in the face of advanced dementia.
                                                                  of care that has existed for decades. Great
                                                                  work is being done across our province!”
  What does resident-centred care look like?                      – Dee Lender, Executive Director, Ontario Association

  Hush, no rush                                                   of Residents’ Councils

  Bloomington Cove, a            residents according to
  Sienna Senior Living home,     their lifetime practices      Staff continuously try           DementiAbility program,
  was the Ontario Long           and habits.                   new programs and care            which has rolled out across
  Term Care Association’s                                      techniques that improve          all Jarlette homes.
                                 Residents are offered         each resident’s quality
  Resident-Centred Home          choices of meals, clothes,                                     The program teaches staff
  of the Year in 2016. In this                                 of life. Craniosacral            techniques for engaging
                                 programs, and bathing.        treatments have led to a
  specialty home, every          A Hush, No Rush care                                           residents with dementia
  resident has a diagnosis                                     reduction of antipsychotic       and introducing activities
                                 philosophy reminds            medications and have
  of dementia.                   staff to adjust the way                                        that leverage their abilities,
                                                               improved speech, appetite,       passions, and curiosities.
  Bloomington Cove has           they approach residents,      and sleep. Doll therapy
  moved away from caring         programs, and physical                                         The idea is that by keeping
                                                               is a particular source of        residents active and
  for residents according        space. This includes          comfort for residents who
  to staff schedules and         supporting natural                                             engaged, they have a richer
                                                               have difficulty falling          quality of life and fewer
  routines to caring for         wake-up times.                asleep, and for those who        challenging behaviours
                                                               experience continuous            that are often a side effect
                                                               pacing as a result of their      of dementia.
                                                               disease; sitting with dolls
                                                               provides them with rest and
                                                               reduces the risk of falls. The    “We had one resident who
                                                               home also uses a technique        was often agitated. We
                                                               called Gentle Persuasive          learned that she always
                                                               Approach to respond               cooked and made sure
                                                               respectfully and skilfully to     everyone else was taken
                                                               the challenging behaviours        care of before eating. So
                                                               that can accompany                we got her involved in
                                                               dementia.                         escorting residents into
                                                                                                 the dining room, clearing
                                                               Focusing on abilities             tables, and helping staff
                                                               Leacock Care Centre,              get dinner ready. She
                                                               a Jarlette Health Services        enjoys the activity and
                                                               home, received the                you could see it gave her
                                                               Ontario Long Term Care            a sense of purpose. She’s
                                                               Association’s Quality             also a great help to staff in
                                                               Improvement Innovation            the dining room!”
                                                               of the Year Award in              – Leacock Care Centre staff
                                                               2017 for its use of the

4 This is Long-Term Care 2018
THIS IS LONG-TERM CARE 2018 - Ontario Long Term Care Association
78,872 BEDS
                                                                                            FOR LONG-STAY
Living and working together                                                                 80,000 STAFF
Dedicated staff in long-        Some homes are also
term care homes provide         experimenting with the use       “As a young nurse,
daily care and supervision      of staff such as porters and     when I found long-         What about
when someone’s needs have       health care aides to support     term care, I knew I was    more staff?
become too great to be          resident care, but these         home. It’s a community:
cared for at home by family     positions are not currently      you build relationships    In late 2017, the
and community supports.         eligible for funding from        with residents and         provincial government
                                the government.                  families that just         committed to an
While the most visible staff                                     aren’t possible in other   additional 15 million
at a home are registered        Residents' Council               settings.” – Candace       care hours per year for
nurses, registered practical                                     Chartier, RN, CEO,         long-term care, to bring
nurses, and personal            Each home has a Residents’
                                                                 Ontario Long Term          the provincial average
support workers (PSWs)          Council, which has powers
                                                                 Care Association           for resident care to four
who provide the daily           under the Long Term Care
                                                                                            hours a day. This is good
health care and support,        Homes Act to approve
                                                               cognitive impairment can     news but a tall challenge,
there are many other people     certain decisions in the
                                                               no longer make decisions     as there is currently a
involved in each resident’s     home (such as the menu),
                                                               about their care, and a      recognized workforce
care and support. Each          provide the resident’s
                                                               family member or friend      shortage in both long-
home has a medical director     perspective and advice to
                                                               serves as the "substitute    term care and home care.
along with other health         the home’s leadership, and
professionals and support       help to support resident-      decision maker" who is       The Association believes
staff in areas including        centred care.                  regularly consulted by the   that this new funding
pharmacy, dietary,                                             long-term care home about    commitment also needs
                                Families and volunteers        the resident’s treatment     to be accompanied by
physiotherapy, occupational
therapy, recreation therapy/    Families are not just          and quality of life. Each    changes to the Long
resident engagement,            visitors; they are a crucial   home's Family Council        Term Care Homes Act
social work, housekeeping,      part of the care team. The     is also empowered by the     that currently puts tight
maintenance, and                majority of people with        Act to advise the home       restrictions on the type
administration.                 moderate to severe             about meeting the needs      of staff and roles of staff
                                                               of residents.                — restrictions that don’t
                                                               Volunteers also support      exist for staff in home
  “Long-term care homes do an amazing job. Your first-                                      care, for example. Long-
  line health care workers, the PSWs, are jewels. There        individual residents and
                                                               programs that enrich the     term care needs more
  aren’t enough of them, and they don’t get rewarded                                        flexibility to be able to
  enough, but they still have the drive to come into           life of the home.
                                                                                            provide the care that
  work every day and deal with me with empathy, which                                       residents need.
  impresses me.” – Bill Jarvis, long-term care resident and
  OLTCA Lifetime Achievement Award recipient 2017
                                                                                            This is Long-Term Care 2018 5
THIS IS LONG-TERM CARE 2018 - Ontario Long Term Care Association
2 OUT OF 3
                                                                                                LONG-TERM CARE
                                                                                                HAVE DEMENTIA

  The specialty of dementia care
                                                                                                Physical space
 A     lzheimer’s disease and other dementias
        are complex, progressive, and
  ultimately fatal conditions. When families
                                                Providing personal care and medical
                                                treatments requires a specialized approach
                                                because dementia is often accompanied by
                                                                                                The design of a home’s
  can no longer manage to care for their        challenging behavioural symptoms, also          environment is important
  loved ones at home, long-term care homes      called responsive behaviours (see more          for improved privacy,
  offer the support and services they need,     about behavioural symptoms on page 8).          dignity, and quality of life.
  along with expertise in dementia and          When people with dementia don’t                 Nearly half of Ontario’s
  end-of-life care.                             understand what is happening, they may          long-term care homes
  The general perception of dementia is         react negatively when staff approach            are due for significant
  that it primarily involves memory loss        to help with daily activities or medical        renovation or rebuild
  and confusion. What’s not well understood     treatment. They may refuse verbally or          in order to meet current
  is that as the brain deteriorates because     physically to have a bath, to eat a meal,       design standards that
  of the dementia, the organs that it directs   or to have a dressing changed. Even             include more private rooms
  will deteriorate as well. As the disease      something as simple as hair combing             and more lounges, wider
  progresses into middle and later stages —     or a fingernail trim can be confusing or        hallways, and smaller, more
  which is usually when most people come        frightening, triggering angry or fearful        intimate dining rooms in
  to long-term care — they have lost            responses, including physical aggression.       every resident area.
  the ability to speak or understand            Caring for someone with dementia requires       The right design can also
  speech, to accurately interpret what’s        a compassionate understanding of the            help to reduce dementia-
  happening around them, and to care for        many different ways that the disease can        related behaviours. Resident
  themselves. For example, they may no          affect each individual, and experimenting       altercations are more likely
  longer recognize that they need to eat,       with behavioural management strategies          in older homes, where
  or what utensils are for.                     that soothe the resident’s symptoms,            four-bed rooms, crowded
  People in these stages of the disease         improve his or her quality of life, and allow   hallways, and limited
  need extensive or complete help with          staff to provide care.                          lounge space create an
  daily activities such as personal hygiene,                                                    environment that lacks
  toileting, and eating. The vast majority                                                      privacy and is too close
  of people also have two or more health                                                        for comfort.
  conditions that require treatments and                                                        The provincial government
  medications.                                                                                  is providing a capital
                                                                                                redevelopment program to
                                                                                                help older homes redevelop,
    “Roughly 70% of people who live with dementia will eventually live                         but there are still a number
      at the end of their lives in a long-term care home, because                               of barriers, including
      of the nature of the disease. Long-term care is an excellent setting                      insufficient construction
                                                                                                funding and excessive
      for palliative care for people with dementia, while of course                             municipal development
      understanding that people are still living life to the fullest.”                          charges, that are making
     – Mary Schulz, Director, Education at Alzheimer Society of Canada                          it difficult for all homes
                                                                                                to participate.

6 This is Long-Term Care 2018
THIS IS LONG-TERM CARE 2018 - Ontario Long Term Care Association
Making connections
  Behavioural Supports Ontario (BSO)                           Long-term care homes care for the physical, medical,
  Some excellent behavioural management                        social, spiritual, and emotional needs of their residents.
  programs have been implemented in recent years               People who have dementia have all these needs, but they
  that are helping to reduce behavioural symptoms              may need help in tapping into the activities, memories,
  and improve residents’ quality of life. Homes have           and relationships that provide them with a sense of
  been using a variety of strategies with success.             purpose and meaning.
  One of the biggest contributors to homes’ ability
                                                               Long-term care homes use a variety of therapies
  to implement behaviour management strategies is
                                                               including personalized music, art, and animals to help
  a provincial program called Behavioural Supports
                                                               improve mood, reduce pain, and reduce dementia-related
  Ontario, because it is accompanied by the funding
                                                               behaviours. These activities create moments of pleasure
  to hire and train specialized staff teams.
                                                               for people with dementia, and treasured moments of
  BSO rolled out in 2012 in a limited number of                connection with their families and staff.
  homes, and has been shown to be effective in
                                                               But it’s not just these
  supporting the shift to a behaviour management
                                                               therapies that are making a
  approach and in reducing severely aggressive
                                                               difference. Many residents
  behaviour, antipsychotic use, and restraint use.3
                                                               were accustomed to an
  In the 2017 provincial budget, the government                active life with multiple
  committed to fund BSO teams in each of the                   responsibilities. It can give
  province’s 625 long-term care homes.                         them a sense of renewed
  These teams are critically needed. Frontline staff           purpose to work alongside
  are juggling the needs of many residents and most            staff to help set the table,
  need to continuously increase their knowledge                sweep the floor, fold towels,
  of how to manage challenging behaviours. BSO                 and water plants. Homes
  teams are their support system — they provide                report that involving
  education about dementia, problem-solve and                  residents in meaningful
  suggest strategies, and help to create a culture             activities typically reduces
  where all staff are focusing on making each day              responsive behaviours and
  better for every resident.                                   allows staff to form closer

Sensitive care, successful care
 Having a blood test can       Maintaining good              accustomed to being in          at bathtime are given a
be upsetting for people with   nutrition and hydration         charge in a health care         personalized playlist on
dementia if someone simply     can be challenging, as          environment. The staff          headsets about 20 minutes
shows up to take blood. One    people with dementia can        gave her a clipboard and        before bathtime and during
home has incorporated doll     lose interest in eating         a checklist, include her        the bath if needed. Familiar
therapy for their residents    and drinking. It can take       in their home’s nursing         music is known to be
to help ease this stress.      some creativity. One home       meetings, and speak to her      pleasurable and calming
About 20 minutes before        discovered that one of their    as a former nurse manager       for people with dementia.
the blood test, staff bring    residents used to love Coca     when they are providing her     Each of these examples
in a doll and involve the      Cola, and found he will take    care. These are familiar and    comes from a home with
resident in talking about      chocolate nutritional drinks    comforting activities that      a Behavioural Supports
it. Then they explain the      if they call them his Coke.     make her feel in control,       Ontario team as part of
blood test is coming, and       A resident who was a          and her resistance to care      their staff. Research shows
ask the resident to show       former nurse manager            has stopped.                    that staff in homes with BSO
the baby how to be brave.      would become agitated and        Many people with              teams feel significantly more
Many residents did this        yell at staff when they tried   dementia are resistant to       supported and capable of
for their own children, and    to provide her care. After      having a bath because they      developing solutions that
it taps into that memory.      observing her behaviour         don’t like to be wet, or they   help their residents and
Mechanical pets are equally    and talking to her family,      don’t understand what is        reduce behaviours
effective for some people.     they concluded she was          happening. In one home,         in the home.3
                               reacting because she was        residents who struggle
                                                                                                  This is Long-Term Care 2018 7
THIS IS LONG-TERM CARE 2018 - Ontario Long Term Care Association
Long-term care homes prefer to call these reactions
                                                                   “responsive behaviours” because the person is responding
                                                                   to a trigger in their environment. Very little of this is true
                                                                   aggression; the behaviour is unfortunately mislabelled
                                                                   by the national reporting system that provides statistics.
                                                                   Aggression implies malicious intent, and this is rarely
                                                                   the case.
                                                                   Behaviour management approaches work well in reducing
                                                                   the frustration and irritation level of individuals as well
                                                                   as the overall level of resident-on-resident tension in
                                                                   a home. This involves finding ways to engage people
                                                                   with dementia in productive activities that tap into their
                                                                   pleasurable memories, current abilities, and sense of
  Understanding aggressive behaviour                               self. Homes also create activities to diffuse common “hot
                                                                   spots” for resident altercations, such as mealtimes. As

 I  n the course of their disease, 80% of residents will exhibit
    behavioural symptoms of dementia, such as pacing and
  wandering, repetitive questioning or actions, uninhibited
                                                                   mentioned earlier, long-term care homes need Behavioural
                                                                   Supports Ontario teams in every home in order to support
                                                                   their work in this area.
  behaviour (including sexual), and irritability. 4 These
  behaviours can unfortunately aggravate and intrude on
                                                                    “When George first arrived, he would yell at residents
  the space of other residents. As dementia destroys social
                                                                    and staff and raise his fist. He’s a big man and that was
  skills and the ability to manage emotions, residents
                                                                    intimidating. We learned from his family that he had
  may react reflexively by hitting, or by using angry and
                                                                    been a real doer, someone who liked to tinker about in
  accusatory responses.
                                                                    the garage. So we built him a cart full of tools and things
  The vast majority of altercations between residents               to tinker with, all attached to the cart with sturdy chains
  with dementia are minor and result from the belief that           so they don’t pose a threat to anyone else. We also gave
  someone is intruding on their space or behaving in a              George the job of sweeping the floor in the dining room
  way that frustrates or angers them. Sometimes the cause           after meals with our staff. He’s a man who needs to be
  makes sense to us, as when another resident wanders               busy and by having these jobs to do, it has significantly
  into their room and rummages in their dresser; many               reduced his anger and frustration.” – BSO team member
  times it does not.

  A word about abuse
  No abuse of a resident is       The definition has a very        All incidents, even when        According to a report by
  ever acceptable. Long-term      low threshold. For example,      staff are uncertain, are        Ontario's Auditor General,
  care homes have a zero-         if a resident with dementia      documented and reported         only a small number of
  tolerance approach to this      swatted away another             to the Ministry of Health       reported incidents that
  very serious issue.             resident's hand when they        and Long-Term Care for          required inspections were
  When the current Long-          both reached for something       follow up.                      considered a “high risk”
  Term Care Homes Act             at the dinner table, homes       More serious incidents          concern by the Ministry.5
  came into force in 2010,        must report this as abuse.       certainly do occur and these    Any incidents of suspected
  it introduced very specific     From a staff perspective,        examples are not intended       or confirmed abuse are
  definitions of physical,        behaviour and language           to minimize the importance      taken extremely seriously
  verbal, and sexual              that might have been             of zero-tolerance reporting,    by long-term care homes.
  abuse, along with new           acceptable a generation ago,     but they do illustrate the
  requirements for reporting      such as calling a resident       types of behaviour that the
  and managing any                “dearie”, is now considered      public might be surprised to
  suspected incident.             disrespectful and requires       find classified as “abuse”.
                                  reporting as verbal abuse.

8 This is Long-Term Care 2018
THIS IS LONG-TERM CARE 2018 - Ontario Long Term Care Association
Not suitable for               Responding to concerns
long-term care
                                In early 2018, CBC aired a misleading series on resident-on-resident violence in long-term
Residents who are known         care. The thoughtful response below was written by Dr. William Reichman, President and CEO
to have severe violent          of Baycrest Health Sciences and former president of the American Association for Geriatric
tendencies do not respond       Psychiatry. Excerpted and reprinted with permission.
to behaviour management
strategies, and they require   Dementia is among the most devastating         Occasionally this aggression can be
the care of a psycho-          health conditions associated with growing      predicted and prevented, but often it is
geriatrician and/or 1 to 1     older, with Alzheimer’s disease being the      remarkably impulsive and occurs very
supervision to keep other      most prevalent cause. Over the past            suddenly. At present, we do not have
residents and staff safe.      several decades, as the ability of families    medications that adequately prevent
In several tragic cases,       to cope with the many stresses of              aggression without also so thoroughly
people who were extremely      dementia caregiving have mounted,              tranquilizing individuals that they
violent were suffering from    long-term care facilities in Ontario and       cannot safely move about, communicate,
a severe psychiatric illness   across the world have become the places        or meaningfully engage in social,
or had a history of physical   we look to in order to best meet the needs     recreational or other activities that
or sexual violence —           of affected patients and to give their         support quality of life.
sometimes in combination       families respite. This is hard, grinding       As a society we have rightly chosen to
with dementia. Long-term       work as patients with dementia need            avoid limiting the freedom of movement
care is not a suitable place   assistance in nearly all activities that       of affected patients living in long-term
for people with severe         the rest of us might effortlessly take         care homes — we do not think it is morally
psychiatric conditions         for granted.                                   right to physically restrain or lock up
or a history of violence,      Along with the cognitive deficits of           in seclusion our loved ones who are
who need specialized care      dementia, in which patients are forgetful,     suffering from terrible brain diseases that
where they are not among       have difficulty communicating, cannot          cause them to behave in ways they would
frail and vulnerable elders.   adequately organize themselves or              likely never choose.
When homes are informed        problem-solve effectively, nearly all          Some believe that more staffing would
of a prospective resident      get confused navigating familiar               solve the issue of assaultive behaviour.
with severe psychiatric        surroundings. At mid to later stages           The reality is that we have very limited
illness or a history of        of severity, these individuals need help       useful data to tell us the extent to which
violence, they are currently   dressing, bathing, eating and having           increased staffing levels for dementia care
not allowed by legislation     their daily care needs met.                    would reduce the occurrence of resident-
to refuse them. This needs     While the work is demanding of all of us       to-resident violence and by what amount.
to change.                     who have dedicated our careers to this         We do know it would likely be impossible
                               field, it is also immensely rewarding and      to completely eliminate the risk if patients
                               of great benefit to families — that is why     with dementia continue to live together
                               we do it.                                      in congregate care settings, such as the
                               One of the greatest challenges in caring       contemporary long-term care home.
                               for patients with dementia is that the         The CBC Marketplace episode titled
                               disorder often results in changes in           Crying Out For Care, which first aired
                               behaviour and emotional control. This is       on January 26, 2018, highlights a serious
                               very troublesome and has to be addressed       public health challenge that will grow in
                               when patients are cared for in their own       importance as the global population ages.
                               homes by family members as well as by          We want to talk about this issue, but it
                               staff in long-term care facilities. People     must be in a responsible, thoughtful way
46% of residents               affected with dementia can get easily
                               excited or upset, be verbally abusive to
                                                                              that informs the public. As a society, as
                                                                              well as focusing on care, we must also
exhibit some level of          others, resist care, are suspicious, and at    focus public efforts on brain health and
                               times, might engage in violent behaviour.      invest resources into the prevention,
aggressive behaviour                                                          diagnosis and treatment of brain diseases
related to their                                                              like Alzheimer’s. Eradicating these
                                                                              threats to our well-being should be a
cognitive impairment                                                          major priority.
or mental health

                                                                                                This is Long-Term Care 2018 9
THIS IS LONG-TERM CARE 2018 - Ontario Long Term Care Association
OUTSTANDING                      Committed to quality of care
JUST FIVE YEARS                  S  ince 2012, thanks to a new national reporting system, all long-term care homes in
                                    Ontario have been able to track the care they are providing. This new data provides
                                 homes with invaluable information about the quality of care they provide, and how they
                                 compare to other homes. It helps staff to identify where they can improve quality of care,
                                 and helps residents and families to see how their home is performing in key areas.
                                 Recent data analysis shows that over the last five years, homes have made great strides
                                 in improving care outcomes for their residents. In particular, they have made outstanding
                                 improvements in reducing the use of restraints, pain management, and reducing
Restraint use has                antipsychotic medications.1,2
dropped by more
than half


                                       Increase in quality

Nearly 40% fewer
residents are                                                2012-13   2013-14            2014-15

being prescribed

                                                                       Quality improvement at a glance
                                   This graph shows the outstanding work that homes have accomplished in improving quality of care across all
50% fewer residents                areas since 2012, when the data was available to help guide their efforts.
are experiencing pain              The blue bar represents a composite score for the nine areas of care (indicators) that are tracked and reported
                                   publicly: antipsychotics, experiencing pain and worsening pain, restraint use, depression, wounds (pressure ulcers),
                                   falls, and physical functioning (both improving and worsening).6

90% OF                           Long-term care homes do well on inspections
LONG-TERM                        Long-term care home                     Homes take this                           However, at a 2018 meeting
CARE HOMES DO                    operators adhere to                     commitment seriously.                     on workforce challenges
                                 Ontario’s Long Term                     Ministry findings show                    in long-term care, many
WELL ON THEIR                    Care Homes Act, widely                  that the vast majority of                 participants identified
INSPECTIONS                      considered one of the                   homes (90%) do well on                    the inspection process as
                                 toughest pieces of nursing              their inspections.7                       highly demoralizing for
                                 home legislation in the world.          Staff are proud of the                    their teams. They stressed
                                 Homes are inspected                     care they provide,                        that inspections need to
                                 annually by the Ministry                the relationships they                    move away from a punitive
                                 of Health and Long-Term                 build with residents,                     approach to a focus on
                                 Care against more than                  and the work they do                      supporting staff with
                                 600 regulations —                       to meet the stringent                     quality improvement.
                                 with more than 1,000                    requirements of the Act.
                                 requirements — that look at
                                 everything from cleanliness
                                 to resident safety.

10 This is Long-Term Care 2018
A closer look at antipsychotics
The understanding of dementia, and how to provide
appropriate care, has undergone a significant evolution
in the last decade. Many residents come to long-term care
on an antipsychotic medication that was prescribed in the
hospital or community. Until recently, it was believed that
they would need to stay on that medication permanently.
There is now greater understanding that dementia
symptoms wax and wane over time, and someone who
needed an antipsychotic to manage symptoms at one stage
of the disease may not need it later. Antipsychotics still
have an important role in reducing major symptoms for
                           some residents, such as severe
                           aggression or paranoia, so the
                           focus in homes is on ensuring
                           that antipsychotics are used
                           appropriately, not eliminated
                           entirely. The goal is to ensure
                           antipsychotics are prescribed
                           for the right symptoms, at the
                           right dose, and only for as long
                           as needed.

The importance of innovation
Over the next 20 years it is   The Ontario Long Term
anticipated that there will    Care Association is also
be twice as many seniors       leading a major project to
over the age of 75 and, by     implement standardized
extension, a growth in the     clinical guidelines in all
number who need long-term      long-term care homes           Clinical Support Tools
care and other supports.       (see Clinical Support Tools    Long-term care staff would benefit from having
Even with the recent           this page), researching        standardized, evidence-based guidelines and protocols
announcement of another        different models of            that are written specifically by people who know long-term
30,000 long-term care beds     residential care for seniors   care — practical documents that address the real-world
over the next decade, there    (see LTC Plus, page 14),       environment of long-term care.
will not be enough capacity    and leading a Strategic
to meet all of these needs.    Innovation Council of          Last year, the Ontario Long Term Care Association
                               government, academics,         started an innovative project to develop these Clinical
The way to meet the future                                    Support Tools. Ontario’s Ministry of Health and Long-
needs of Ontario’s seniors     and educational partners
                               to generate actionable         Term Care has provided significant project funding and
is by evolving our current                                    the first phase of the project is underway. Guidelines are
ways of doing business,        recommendations to
                               accelerate innovation in       being developed for diabetes, dementia, incontinence,
and taking action now.                                        wound care, end-of-life care, chronic obstructive
Long-term care homes are       long-term care and the
                               broader health sector.         pulmonary disease (COPD), and seasonal influenza/
actively driving innovation                                   respiratory virus prevention.
by leading and partnering      Two major challenges with
to design and test new         innovation in long-term        Long-term care homes have been quick to sign on to
tools and technologies         care are the Long Term Care    participate. They are committed to quality improvement,
to improve quality of care     Homes Act and the current      and eager for tools and support that are tailored specifically
and quality of life and        funding model, as both         for the unique needs of long-term care residents.
reduce administrative          are very restrictive and
tasks for staff, allowing      make it difficult for homes
them to spend more time        to try new ways of doing
on resident care.              things. The Ontario Long
                               Term Care Association has
                               raised this concern with
                               the government.
                                                                                                 This is Long-Term Care 2018 11
The need for long-term care
                                                                   Long-term care is in high demand. As of October 2017,
                                                                   there were nearly 34,000 people waiting for a bed. The
                                                                   wait lists have been growing at an astounding rate in the
                                                                   last two years alone (see below). The average wait time for
                                                                   placement is now 143 days. 8

              625 homes are licensed                               In late 2017, the Ontario government announced that it
                                                                   would be funding 30,000 more long-term care beds over
       and approved to operate in Ontario                          the next decade, with 5,000 of those in the next four years.

       58% of homes are privately owned                              Growth in wait list for long-term care

        24% are non-profit/charitable
                                                                     The wait list for Ontario long-term care is growing rapidly by approximately
                                                                     15% a year. Source: Long-Term Care Home System Reports, Ontario

          16% are municipal
                                                                     Ministry of Health and Long-Term Care, October 2017.

                2% other


    78,872 “long stay” beds provide

                       permanent, residential care                                                                                   25,530

                       to more than 100,000

                       people each year
  SOURCE: Long-Term Care Home System Reports, Ontario Ministry               2015
                                                                           01-15   02-15   03-15   04-15   05-15   06-15   07-15   08-15 09-15   10-15   11-15   12-15     2016
                                                                                                                                                                         01-16   02-16 03-16 04-16 05-16 06-16 07-16 08-16 09-16   10-16   11-16   12-16      2017
                                                                                                                                                                                                                                                           01-17   02-17   03-17   04-17   05-17   06-17   07-17   08-17   09-17   10-17

  of Health and Long-Term Care, October 2017.

  Rebuilding and expanding long-term care
  In addition to new beds,          and rural communities.         this funding has not been                                                                                                           commitment of added
  there is a significant            These communities often        sufficient for many homes                                                                                                           capacity will help support
  program underway                  have limited home care or      to participate, particularly                                                                                                        this goal.
  to renovate or rebuild            retirement home options,       for small homes and those                                                                                                           The Association has
  approximately 300 older           and are typically the only     found in urban areas,                                                                                                               also requested improved
  homes — almost half of            place where frail seniors      which lack available and/or                                                                                                         construction funding, a
  the system’s supply.              can receive support, close     affordable land to build on.                                                                                                        reduction or elimination
  These homes need to               to home and families.          In its 2018 pre-budget                                                                                                              of municipal development
  be upgraded to current            The government currently       submission (More                                                                                                                    charges, the creation
  design standards such             provides all long-term         Care. Better Care), the                                                                                                             of an urban homes
  as sprinklers in resident         care homes in need of          Ontario Long Term Care                                                                                                              strategy, and a small
  rooms, on-site generators,        redevelopment with             Association asked the                                                                                                               homes retention strategy
  and more spacious and             construction funding based     province for added capacity,                                                                                                        reinforced by additional
  private accommodations            on a “per resident, per day”   focused specifically on                                                                                                             operating funding. These
  for residents.                    model, similar to the way      “topping up” redevelopment                                                                                                          additional measures
  More than 40% of all long-        it funds operations. This      projects to avoid the                                                                                                               need to be included in
  term care homes are small,        approach provides equal        need for amalgamation,                                                                                                              the government’s capital
  with 96 or fewer beds,            funding for all homes to       particularly in more                                                                                                                redevelopment program
  and nearly half of these          participate, regardless of     rural and remote areas.                                                                                                             in order to support broader
  homes are located in small        home location. However,        The government’s recent                                                                                                             participation.

12 This is Long-Term Care 2018
Daily rate set by government
                                                                               that residents pay the
                                                                               home for “room and board”
                                                                               (accommodation and food)
                                                                               SOURCE: LTC Home Accommodation
                                                                               Charges Bulletin, Ontario Ministry of Health
                                                                               and Long-Term Care, May 2017.

How long-term care works                                                       PROVINCIAL
                                                                               FUNDING FOR
In Ontario, long-term care is regulated and funded by the provincial           LONG-TERM CARE,
government. Government agencies called Local Health Integration                2017
Networks (LHINs) do the assessments to determine who is eligible
to be admitted to long-term care, and they manage the wait lists.
Long-term care homes in Ontario are owned and operated by a variety
                                                                               $4.1 billion
of different operators including individuals, family-owned businesses,         (7.7% of overall health budget)
                                                                               Approximately $96.26 per
private corporations, publicly traded companies, non-profits and charities,
and municipal governments (municipalities are required by legislation
to operate at least one long-term care home). There’s a wide range in how      resident, per day for nursing and
they function: some long-term care homes are part of large corporations,
while others are stand-alone independents.                                     personal care such as assistance
Each home owner/operator is granted a licence to operate by the                with personal hygiene, bathing,
government, which then provides funding for the staff and supplies             eating, and toileting
to provide nursing and personal care, resident programs and support
services, and raw food (used to make meals). Homes are required to             $11.82 per resident, per day for
follow the requirements of the Long Term Care Homes Act, and are
inspected annually to ensure that they are complying with the more             specialized therapies, recreational
than 600 regulations.                                                          programs, and support services
Residents are required to pay a copayment that ranges between
approximately $1,800 and $2,600 a month, depending on whether                  $9 per resident, per day for raw
accommodation is a basic, semi-private, or private room. In essence, this      food (ingredients used to prepare
resident copayment covers their “room and board”. The government sets
the rate, while offering subsidies to those who can’t afford the copayment.    meals, including nutritional
This payment for resident accommodation is what long-term care homes           supplements)
use to pay expenses such as non-care staff, utilities, and mortgages as well
                                                                               SOURCES: 2017 Ontario Budget; 2017 Long-Term Care
as expenses that support infection control, regular building maintenance,      Home Level-of-Care Per Diem Funding Summary,
and major capital repairs (such as a roof or heating system).                  Ontario Ministry of Health and Long-Term Care.

                                                                                                This is Long-Term Care 2018 13
POST-ACUTE               SPECIALIZED               THE HUB               CONTINUUM               DESIGNATED
           CARE                     CARE                                          OF CARE                 ASSISTED

                  Looking to the future
                  How does our health care system need to evolve to meet the needs of seniors?
                  At the moment there is only one type of long-term care home in Ontario, providing 24-hour
                  personal and nursing care for a population with advanced physical and cognitive decline.
                  There are regulations, admission criteria, and funding models that currently affect the kinds
                  of residents that long-term care homes are able to accept. But with flexibility and innovation,
                  long-term care could offer so much more.
                  In 2011, an expert panel made a number of key recommendations about expanding the
                  current model of care to a number of different options. These models of care build on current
                  long-term care homes and their expertise to provide a broader range of services to Ontario’s
                  seniors. Many of the models have been applied in the United States and other jurisdictions,
                  and some components have been implemented on a small scale in some Ontario homes. The
                  expert panel believed these models could be expanded more broadly in Ontario. Doing this
                  would improve the options currently available to provide care to seniors and free up much-
                  needed beds within existing long-term care homes.
                  Called Long Term Care Plus, these models of care could offer so much more than the
                  traditional long-term care model that is currently funded in the province. Each model
                  of Long Term Care Plus may require additional staff, equipment and training, a different
                  mix of staff, or changes to the physical environment. The Ontario Long Term Care
                  Association is currently researching these models of care and identifying the legislative,
                  regulatory, and policy changes that would be required to allow seniors in Ontario flexibility
                  in the care they need.

14 This is Long-Term Care 2018
About the Ontario
References                                          Long Term Care Association
1.   Canadian Institute for Health Information
     (2017). Continuing Care Reporting System:
     Profile of Residents in Continuing Care
     Facilities 2016-2017. Ottawa: CIHI.
2.   Canadian Institute for Health Information
     (2012). Continuing Care Reporting System:
     Profile of Residents in Continuing Care
     Facilities, 2011-2012. Ottawa: CIHI.
3.   Grouchy M., Cooper N., Wong T. (2017).
     Implementation of Behavioural Supports
     Ontario (BSO): An evaluation of three
     models of care. Healthcare Quarterly,
     19(4) January 2017: 39-73.
4.   Ballard C. (2008). Int Rev of Psychiatry.
     Vol 20, Issue 4: 296-404.
5.   Office of the Auditor General of Ontario.
     (2015). Annual Report 2015. Toronto:
     Queen's Printer for Ontario.
6.   Wilkinson A., Haroun V., Cooper N.,
     Wong T., & Chignell M. (2018). Developing
     a Composite Quality Score to Support
     Performance Improvement in Long Term
                                                    The Ontario Long Term Care Association
     Care. Poster presentation at the Canadian
     Association for Health Services and            is the largest association of long-term
     Policy Research (CAHSPR), May 29-31,           care providers in Canada and the only
     Montreal, QC.
                                                    association that represents the full mix
7.   Office of the Auditor General of Ontario.      of long-term care operators — private,
     (2017). Annual Report 2015, Vol 2: Follow-up
     Reports on 2015 Annual Report. Toronto:        not-for-profit, charitable, and municipal.
     Queen's Printer for Ontario.
                                                    The Association represents nearly 70%
8.   Ontario Ministry of Health and Long-Term
     Care, Long-Term Care System Reports,           of Ontario’s long-term care homes,
     October 2017.                                  located in communities across the
                                                    province. Our members provide care
                                                    and accommodation services to more
                                                    than 70,000 residents annually.
Photo credits
The Association would like to thank the residents   For more information,
and staff of Kensington Health, the O'Neill         please contact
Centre, Schlegel Villages, Woodingford Lodge,
Tilbury Manor and Trinity Village for the photos
used in this report.
425 University Avenue, Suite 500
Toronto, Ontario M5G 1T6
Tel: 647-256-3490

This is Long-Term Care 2018

April 2018

With the exception of those portions of this document
for which a specific prohibition or limitation against copying appears,
the balance of this document may be produced, reproduced and
published in its entirety, in any form, including in electronic form,
for educational or non-commercial purposes, without requiring
the consent or permission of the Ontario Long Term Care Association,
provided that an appropriate credit or citation appears
in the copied work as follows:

Ontario Long Term Care Association. (2018).
This is Long-Term Care 2018. Toronto, Ontario:
Ontario Long Term Care Association.
© 2018 Ontario Long Term Care Association

The Association would like to thank our Corporate Alliance Partners
for their sponsorship of this report.
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