The politics of long term care

I'm a red-blooded Canadian, don't mind trudging through the snow or even shovelling it, but when the weather forecast predicts freezing rain, I stock up on the basics and stay inside. I`m acutely aware that I`m just a fractured hip away from the nursing home. Last year I spent seven weeks in one after a bad fall, and I`m still haunted by the memories of chasing after nurses who forgot to give me my medication, bathroom taps running cold by 7:00 am, television sets blaring game shows all day, and call bells ringing unanswered all night. Does it have to be this way?

Recently, an international team led by a York University researcher set out to discover whether it was possible to provide humane, dignified, affordable long term care. Published in 2015, Promising practices in long term care: ideas worth sharing describes the results of site visits to 25 facilities in six countries, all with GDPs similar to Canada's. The report highlights a panoply of creative initiatives, all flowing from a view of care provision based on a caring relationship, and all accomplished with modest or even no extra funding. Some practices focused on food: preparing meals in-house, using healthy, local ingredients, allowing flexible meal times, enabling residents to access snacks or make a cup of coffee at any time, even involving residents in helping to prepare food under supervision. Others deliberately connected the long term care facility to the larger community, by locating it close to shopping malls and community facilities, or running a daycare centre in the same building, with intergenerational programs involving the long term care residents. Some facilities made smart use of simple technology: vibrating alarms so residents don't hear constant ringing, locked medical cabinets in each room so the halls aren't clogged with medicine carts, wheels on the front legs of chairs. Many facilities made minimal use of casual staffing, so that staff and residents could get to know one another; all staff, including housekeeping and kitchen staff, were considered active members of the care team, and shared responsibility for interacting with the residents. The study concluded that provision of humane, dignified, affordable care would require the following:

• Adequate staff and an appropriate staff mix. Direct care staffing should be set at a minimum of 4.1 hours per resident per day, not to be filled at expense of housekeeping, clerical, and maintenance staff. Since staffing is significantly lower in for-profit settings, ensuring adequate staffing means removing for-profits from care.
• A stable workforce, using permanent rather than agency or casual staff.
• Enough time for staff to communicate and interact with patients in addition to providing care.
• Standards, effectively enforced. Governing bodies should establish basic principles, and leave interpretation up to the care facility. Don't overstandardize.
• Appropriate training and education, especially regarding care relationships. Training should be part of paid time, and frequent enough to keep up with changing populations and demands.
• Appropriate working conditions. It's no use having a well-trained staff if conditions do not allow them to use their judgment or provide the care their training taught them is correct. Working conditions affect the health of both workers and residents. Staff need sick leave, pensions, and a living wage.
• An integrated system. In Canada, it's fragmented, with a division of responsibility among federal, provincial, and local jurisdictions. It's also fragmented by privatization.
• Tolerating some risks. Keep residents mobile as long as possible, instead of placing them immediately into wheelchairs. Let them take part in fitness sessions and ordinary activities of daily living. In Canada, the focus is often on liability prevention instead; care homes are usually understaffed, and falls mean penalties for nursing homes.

What are the chances that we'll see any of these changes in Ontario? Consider this:

• To be eligible for admission to a long term care facility in Ontario, you have to require nursing care 24 hours a day. Yet long term care is not included under the Canada Health Act.
• In Ontario, there are no regulations for minimum staffing levels to ensure that other regulations are met, such as the provision of toileting assistance, repositioning, and other types of assistance. Some Ontario personal support workers are responsible for up to 42 residents at a time. Ontario is the only province that does not have a legislated minimum care standard.
• On average, residents in long-term care homes in Ontario currently receive 3.4 hours of total direct care per day, according to a recent budget submission from the Ontario Long Term Care Association. This is well below the four hours of direct care per day recommended by the Ontario Association of Non-Profit Homes and Services for Seniors, and the 4.1 hours recommended in Promising practices.
• In Ontario, most long term care facilities are run by private for-profit owners. Almost two-thirds of new long-term care beds since 1998 have gone to for-profit companies. In spite of clear evidence of a link between for-profit ownership and poorer care, the government would rather contract long term care to for-profits, and avoid the cost of building new facilities.
• Who speaks for long term care? In Ontario, the most powerful lobby group is the Ontario Long Term Care Association, which represents for-profit care. It has lobbied successfully to promote the domination of the for-profit industry, and the ongoing use of competitive bidding for licences and contracts, triggering a race to the bottom in working and living conditions.

Over the last couple of decades, successive Ontario governments have largely privatized long term care, downsized hospitals, reduced home care, restricted seniors' access to physiotherapy, and imposed a 70% increase in drug costs for seniors living on as little as $20,000 a year. It has become politically acceptable to deprive old, sick people of the services they need. Without political will, public support, and an effective, unified voice, don't expect quality long term care to be there when your time comes. Strap those icers on your boots, do those New York Times crossword puzzles. If you're newly retired and wondering what to do with all those organizational and leadership skills, start lobbying.