Report on a Study to Review the Levels of

CITY CLERK

Clause embodied in Report No. 10 of the Community Services Committee, as adopted by the Council of the City of Toronto at its meeting held on October 2, 3 and 4, 2001.

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Report on a Study to Review the Levels of Service and Responses to Need in a Sample of Ontario Long-Term Care Facilities and Selected Comparators

(City Council on October 2, 3 and 4, 2001, adopted this Clause, without amendment.)

The Community Services Committee recommends the adoption of the following report (August 27, 2001) from the Acting Commissioner of Community and Neighbourhood Services:

Purpose:

To provide a summary of the issues identified in and arising from the level of care study released in June 2001. The level of care study was a joint initiative involving the Ontario Association of Non-profit Homes and Services for Seniors (OANHSS), the Ontario Long-Term Care Association (OLTCA) and PricewaterhouseCoopers, funded by the Ministry of Health and Long-Term Care (MOHLTC).

Financial Implications and Impact Statement:

There are no direct financial implications arising from this report.

However, the report from the level of care study identifies that Ontario ranks last behind other European and North American jurisdictions in the amount of nursing and therapy services delivered to long-term care residents. Further, the level of care per diem paid in Ontario is the lowest in the country.

Government funding has not kept pace with the increasing needs of residents and the recent level of care study clearly demonstrates the need for increased operating funding. Both OANHSS and OLTCA have communicated to the MOHLTC that the funding provided to long-term care facilities is inadequate. If funding is not improved, the level of care and service will continue to decline and ultimately Ontario's citizens in long-term care facilities will be provided with inadequate care. There is an opportunity for City of Toronto Council to communicate its position on the inadequacy of long-term care funding to the MOHLTC.

Toronto City Council October 2, 3 and 4, 2001

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Community Services Committee

Report No. 10, Clause No. 9

Recommendations:

It is recommended that:

(1) the City of Toronto reiterate its strong concern to the provincial government regarding the inadequacy of the funding for long-term care facilities;

(2) the City of Toronto request that the Ministry of Health and Long-Term Care increase its base funding to long-term care facilities by a minimum of 20-25 percent over the next three years, with the majority of the increases targeted to the nursing and therapy envelopes;

(3) the City of Toronto reiterate its position that legitimate cost differentials must be addressed in the funding formula for long-term care facilities;

(4) the City of Toronto request that all temporary funds established to address cost differentials, such as the high wage transition fund, be continued until a permanent funding solution is found and implemented; and

(5) the appropriate City officials be authorized and directed to take the necessary action to give effect thereto.

Background:

In 1997, the MOHLTC committed to increase funding to long-term care facilities and agreed that the sector should undertake a study to review the level of services being provided in long-term care facilities in Ontario compared to similar residents in other jurisdictions. In 2000, OANHSS and OLTCA received $100,000.00 funding from the MOHLTC to undertake the required study and contracted with PricewaterhouseCoopers to conduct the data collection, analysis and report preparation. The report was completed in January 2001 and presented to MOHLTC officials in February 2001. The report was released to the public in June 2001. The report compared long-term care in 10 jurisdictions (three Canadian provinces, four U.S. states and two countries in Europe), and it ranked Ontario last in meeting the needs of residents in nursing homes and homes for the aged.

The PricewaterhouseCoopers report identified that dramatic changes have occurred in Ontario's long-term care system since 1993, since the current system for identifying funding levels for long-term care was introduced. The report confirmed that the objectives of the level of service review were:

(1) to determine the existing acuity of a sample of long-term care residents;

(2) to determine the current amount of services (direct and indirect for nursing, therapies, and accommodation) provided to a sample of residents in long-term care facilities in Ontario; and

Toronto City Council October 2, 3 and 4, 2001

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Community Services Committee

Report No. 10, Clause No. 9

(3) to determine how the existing acuity and levels of services in Ontario compare to similar residents/patients in complex continuing care facilities (chronic care) on Ontario as well as to long-term care facilities in other Canadian provinces, the U.S. and European jurisdictions.

The key question that the study was intended to address was "how does the level of services (nursing, aide and therapies) provided to residents of Ontario's long-term care facilities compare to the services received in other long-term care and continuing care settings"? The jurisdictions selected for the study were: Ontario (long-term care), Ontario (complex continuing care), Saskatchewan, Manitoba, Michigan, Maine, Mississippi, South Dakota, Sweden, Finland and the Netherlands.

In terms of the demographic characteristics of the study population, the majority of long-term care facility residents in all jurisdictions were female, with the highest proportion of females in Finland (81 percent) followed by Ontario (76.6 percent). Ontario residents were among the oldest (82.1 years), with the youngest population in a jurisdiction being 74.1 years.

The PricewaterhouseCoopers report clearly indicates that differences exist between the needs of residents in Ontario's long-term care facilities and the level of care and service provided to them, compared to all other jurisdictions in the study population. In general, there is a greater gap between the needed care and service and the provided care and service in Ontario long-term care facilities, for both nursing and other therapy services. In general, Ontario long-term care residents have similar, and in some cases, higher need characteristics compared to residents in other jurisdictions.

This staff report will summarize some key differences as outlined in the PricewaterhouseCoopers report, in order to provide the Community Services Committee and City Council with factual information for decision-making related to long-term care.

Comments:

In Ontario, all long-term care facilities must use the Alberta Classification System on an annual basis to establish each facility's annual funding level. The classification system is a predictive system in that it measures eight indicators of care requirements. MOHLTC assessors visit all long-term care facilities and score the care requirements for each resident residing in the facilities (at the point and time of the classification exercise), by reviewing the written care plans and health care records. The scores are used by the MOHLTC to predict the residents' total care requirements and the relative funding to be provided in the next year.

The PricewaterhouseCoopers report concludes that the eight areas used in the Alberta Classification System do not fully reflect the residents' medical or health status, required treatments, procedures and medications, nor do they adequately address the special needs areas such as rehabilitation, restorative care, mental health care or palliative care. This observation is particularly important, in that the prevalence of dementia, Alzheimer Disease and mental health problems is high amongst Ontario's long-term care facilities. The importance is also compounded by the fact that the co-relationship of medical, mental health, and rehabilitation

Toronto City Council October 2, 3 and 4, 2001

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Community Services Committee

Report No. 10, Clause No. 9

needs in the same individual is not recognized in the funding formula (e.g., an individual with dementia, depression and a recent fractured hip, needing rehabilitation).

(A) Clinical Diagnosis Characteristics:

Dementia and Alzheimer Disease combined were the most prevalent of all diagnoses in the sampled long-term care facilities. Fifty-three (53) percent of residents in Ontario long-term care facilities have one of these disorders. Only Finland (65 percent), Saskatchewan (62 percent) and Mississippi (57 percent) exceeded this proportion. Table 1 below depicts the prevalence rate.

Table 1 - Prevalence Rate of Dementia and Alzheimer Disease Combined

70%

60%

50%

40%

30%

20%

10%

0%

Dementia/Alzheimers

Ontario LTC

53%

Ontario CCC

24%

Sask. Manitoba Michigan Maine

62%

41%

47%

50%

Miss. 57%

S. Dakota

44%

Sweden 19%

Finland 65%

Neth. 34%

It is important to note that the City's 10 Homes for the Aged have a much higher dementia prevalence rate than the provincial average, with 62.8 percent of the Homes' residents having a diagnosis of dementia and/or mental health problems. This is commendable in that the staff in the City of Toronto's Homes has developed the expertise and a positive reputation for excellence in the care of individuals with cognitive impairment and/or behavioural problems. However, it is also problematic in that the provincial funding formula does not recognize the special needs of this population group.

The percentage of residents with dementia and related disorders has significant implications for care delivery, staff training, as well as the development of other therapy programs to respond to resultant anxiety, depression, behaviours and family dynamics. Inadequately trained staff and/or the lack of availability of responsive programs (e.g., restorative care, various therapies) increases the risk of cognitive decline. An increase in dementia and cognitive impairment always means that residents require more care, not less.

Toronto City Council October 2, 3 and 4, 2001

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Community Services Committee

Report No. 10, Clause No. 9

With respect to physical care requirements, the most prevalent physical care diagnoses are arthritis, stroke, congestive heart failure and diabetes. Comparisons across the 10 jurisdictions are depicted in Table 2. Compared to Saskatchewan and Manitoba, there is a slightly higher proportion of residents in Ontario's long-term care facilities with stroke (22 percent) than Saskatchewan's (18 percent) and Manitoba's (16 percent). Arthritis is the next most common physical problem in North American jurisdictions, with 26-39 percent of residents having this diagnosis.

Table 2 - Prevalence of Physical Care Problems

120%

100%

80%

60%

40%

20%

0%

Arthritis Stroke CHF Diabetes

Ontario LTC 30% 22% 11% 19%

Ontario CCC 17% 29% 12% 18%

Sask

32% 18% 18% 12%

Manitoba Michigan

28% 16% 13% 17%

32% 24% 27% 24%

Maine

26% 22% 21% 20%

Miss

34% 25% 24% 22%

S Dakota Sweden Finland

39% 21% 30% 18%

7% 4% 19% 9%

4% 23% 8% 6%

Neth.

17% 13% 22% 9%

Although the City's Homes for the Aged collect data related to resident functioning in different categories, a reasonable comparison may be made. Thirty-one (31) percent of the residents in the City's Homes have a prior diagnosis of stroke and 42 percent have a diagnosis of arthritis or another muscular skeletal disease that limits mobility, independent functioning and quality of life.

These factors contribute to an increase in acuity levels and have a major impact on the efficacy of nursing and rehabilitation care. The objective of good nursing care should be the prevention of complications and the promotion of health, minimizing the need for transfer to acute care centres and more costly treatments and care.

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