Social Policy in Ontario

Ontario’s long-term care problem: Seniors staying at home longer isn’t a cure for waiting lists

Posted on March 13, 2016 in Child & Family Delivery System

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OttawaCitizen.com – News/LocalNews
March 11, 2016.   Blair Crawford, Ottawa Citizen

As he has as every day for the past three years, 90-year-old Constantine ‘Con’ Luty sits inside his Stittsville home and waits.

The one time fur trader — in the 1940s Luty ran a Hudson’s Bay Company trading post, travelling by dog team along the shores of Hudson’s Bay to trade for sealskins and Arctic fox pelts — is one of the roughly 9,000 people on the waiting list for long-term care in Eastern Ontario.

Frail and afflicted with mild vascular dementia, Luty is cared for by his wife of 63 years, Belva, herself 82, and a stream of home care workers supplied by the Community Care Access Centre (CCAC). Their daughter, Sandra, drops by almost every day to pitch in. Three other children, scattered a bit further away around the Ottawa Valley, help out when they can.

This is how Ontario’s Home First system is supposed to work, keeping seniors in their own homes for as long as possible before they need one of the limited and costly beds in long-term care. The Lutys get six hours of home care service a day, largely because Con is still recovering from a lengthy stay at the Queensway Carleton Hospital in November, but even so, Belva finds life exhausting, stressful and socially isolating. She doesn’t know what service she’ll get when the hospital’s home care commitment ends.

“I have no life. No life period,” Belva says. “I have no social life whatsoever. It’s either doctors’ appointments or something else. Today I have to go and pick up pills.

“We deserve a little bit better,” Belva said. “I don’t think seniors should have to wait for from three to five years for long term care. Usually by that time, they will have died.”

Though few would dispute that seniors want to live in their own homes for as long as possible, much of the push for home care over institutional care comes from the province’s need to cut health costs, both for acute care hospitals and long-term care facilities. But the burden it places on families and caregivers like Belva Luty are immense. Often what drives seniors into long-term care is not their own needs, but rather that their caregiver — usually a younger spouse — burns out or falls ill.

The Lutys are an extreme case. The province says 116 days is the median waiting to time to find a spot in long-term care, meaning half wait longer and half wait less. In the Champlain Local Health Integration Network — a sprawling triangular-shaped region that stretches from Deep River to Cornwall to Hawkesbury — the median wait time to enter long-term care from home is 135 days, four and a half months.

But those numbers can fluctuate wildly, depending on the placement the family chooses. According to figures provided by the CCAC (which measures ‘wait lists’ by showing how long it takes for 90 per cent of those on the wait list to be given a bed), the wait for a basic room at Carleton Lodge near Manotick is more than 2,000 days (five and a half years)). The Peter D. Clark Centre in Ottawa has nearly 400 people on the list for its basic rooms, with a wait of more than two years.

At the Lutys’ first choice for Con, Bonnechere Manor in Renfrew, it takes 1,152 days to move up the list to get a basic room. At their second choice, Granite Ridge, just down the road from their home, it’s 580 days.

In early February, the Lutys’ hopes were buoyed when they were told a spot was expected to open soon for Con at Granite Ridge. A week later he had dropped to ninth in line since seven other ‘crisis admissions’ had jumped ahead of him in the queue.

“This is a very stressful process for all,” says Sandra Luty. “My mom has to go through the loss each time and my dad has to deal with the potential change. They actually told my mom the only way he would be considered a crisis is if my mom dies or was unable to care for him.”

If you’re in hospital and waiting for a spot in long-term care, the wait is about half that of someone waiting at home. But the cost of these patients to the health care system is enormous.

It’s not unusual for Queensway Carleton Hospital to have 50 seniors spread around the hospital and filling its 30-bed Alternate Level of Care (ALC) ward — a holding spot for patients whose acute illness is under control but who are too sick to go home and don’t have a bed in long-term care either.

“We’ve got patients who have been waiting here more than 400 days,” said Leah Levesque, vice-president of patient care at the QCH.

“We would like (those beds) for the patients who are needing them and if there was an alternative location for those patients to go, they would go there. But there is no capacity for those patients to go anywhere. It’s not only a challenge for Queensway, it’s a challenge for any acute care facility.”

At the Ottawa Hospital, 14 per cent of the hospital’s acute care space is taken up by non-acute patients, said Dr. James Worthington, executive VP of medical affairs. (Not all are elderly. Some of the most difficult ALC patients are those with severe behavioural issues that can’t be managed in the community.)

“It not really showing any signs of improving,” Worthington said. “We may be down from our historical highs, but the impact on acute care is really, really significant.”

And the wait times in hospital are getting longer. In 2004, the median wait time in Ontario to enter long-term care from hospital was 18 days. In 2013-14, it was 69 days.

Changing seniors’ trajectory

The province has tackled this problem with its Home First program, a policy meant to keep the elderly in their homes longer to reduce the demand for beds in hospital or long-term care homes. That means getting people to change the way they think about long-term care, says Chantale LeClerc, CEO of the Champlain LHIN.

Five years ago, the Champlain LHIN had the longest wait times in the province for long-term care. Now it sits in the middle of the pack, longer than 34 day median in Southwestern Ontario, but well below the nearly province-leading 300-days in Mississauga.

“First and foremost it’s been changing the mindset in the region so that people understand that home is where seniors want to be and that we as health care providers have a responsibility to do everything possible to support seniors who want to stay home,” LeClerc said.

“We had to change the trajectory for seniors. The trajectory was often, you were living at home, you were doing fine, something happened — like you fell and broke a hip or got pneumonia — you ended up in hospital. You were admitted, you deteriorated while you were in hospital, then someone decided there’s no way you can go home. We’re not even going to try. We’re going to put in papers to go to a long-term care home, and there you sat.”

In fact, an acute care hospital is one of the least safe places for a frail, elderly person to be, she said. Not only are frail seniors exposed to infection, but studies have shown that a bed-ridden senior can lose up to five per cent of their function for every day they are in hospital.

“Imagine if you were to spend two weeks in hospital, what you would look like when it comes time to be discharged,” LeClerc said.

One way to avoid that is by delivering some “tough love” right in the emergency department. Specially trained nurses can screen seniors when they arrive in the emergency room to make sure only those who truly need acute care are admitted.

“Once they get inside the doors … there is a bit of a sigh relief,” Worthington said. “This is one of the problems. Once they’re in hospital they’re going to get services, but really it’s not the environment or the services they need. We have to have a better way of diverting from the emerg to community resources. Then we have to work on how to continue to grow the resources so our patients can be discharged more quickly.”

And once admitted, patients may find themselves forced up and about in physiotherapy classes to encourage independence and to make sure muscles don’t atrophy.

“Hospitals have put in place a number of initiatives to make sure they are preventing the deconditioning … so that you’re more likely to be able to return home to a community setting as opposed to entering a long-term care home,” LeClerc said.

But if you return home, what then?

Chart – “How Wait Times Have Changed”: < http://wpmedia.ottawacitizen.com/2016/03/0312how-wait-times-have-changed.jpg?quality=55&strip=all >

Chart – “Long Term Care Wait Time by Region”: < http://wpmedia.ottawacitizen.com/2016/03/0312-lt-care-wait-time-region.jpg?quality=55&strip=all >

Chart – “Aging Canadians”: < http://wpmedia.ottawacitizen.com/2016/03/0312aging-canadians.jpg?quality=55&strip=all&w=640 >

The home care conundrum

In 2015, Ontario spent $2.5 billion providing home care to 713,500 clients, 22 per cent more clients than it supported in 2009. In the Champlain LHIN, that translated to $3,957 per client, the second highest rate in the province, according to Ontario’s Auditor General’s report. But even that isn’t enough.

Home First is an excellent strategy, says Worthington, but some complex cases simply can’t be managed at home without intensive support.

“The LHIN has challenged us to use Home First. But it is often difficult for the physicians and the families to accept that they can go home, that the community resources are strong enough to support them. The Home First Program is great, but the amount of resources that can be provided is time-limited.”

Home care is currently provided by the Community Care Access Centre, which dispatches caregivers who can do everything from foot care to help with cleaning and meal preparation. In some cases, home care workers are on call 24/7 and can come in the middle of the night to help with even something as simple as toileting. But understanding the CCAC system can be a nightmare for families like the Lutys. LeClerc acknowledges the problem.

“When I talk to people out in the community, that is the No. 1 concern I hear: How challenging our health system is to navigate and how difficult it is to know where to go for what service.

“A lot of times, service providers don’t work well together. So if you need services from a multitude of providers, you’re the one who’s left trying to get them all co-ordinated and organized so that they can all work together. That is absolutely something that we’re working on,” LeClerc said.

That’s one of the reasons that the province has proposed dismantling the CCAC system and putting the care and control of home care services directly in the hands of the LHIN.

“Too often, health care services can be fragmented, uncoordinated and unevenly distributed across the province,” Health Minister Dr. Eric Hoskins wrote in December in introducing a discussion paper to overhaul the CCAC system. “For patients, that means they may have difficulty navigating the system or that not all Ontarians have equitable access to services. Too often our system is not delivering the right kind of care to patients who need it most.”

What is clear is that the demands for home care and long term care will only increase. Canada’s population continues to age. In 2010, 14 per cent of Canada’s population was age 65 or older and by by 2036, that figure is expected to rise to 25 per cent, meaning one in every four Canadians will be a senior citizen.

A robust and effective home care system can reduce the need to build more and more long-term care facilities.

“In the last year or so, the length of time that people are staying in a long-term care bed has decreased by four months,” LeClerc said. “Four months doesn’t seem like a long time, but it means that people are able to live at home or in their community for four months longer than they used to be able to. Four months averaged out over the number of long-term care beds that we have in this region is the equivalent of bringing about 450 or 500 new beds online.

“If we can help people to stay well and stay comfortably and safely at home for as long as possible, it doesn’t mean that they’ll never need to go into a LT care home, but they will only go in when they need to go in.”

Finally, a space

Con and Belva Luty finally got the call they’d been waiting three years for at the end of February. There was a spot for Con at Granite Ridge. The family had 24 hours to decide. It was a gut-wrenching, emotional decision. Con, who had initially agreed with the move to long-term care, balked.

“They know it’s there and that they want it, but that whole emotional thing is very exhausting for everybody,” said Sandra Luty.

“What do you say to a parent that says, ‘I don’t want to move. This is my home’? I can’t find anything. What can you say when you get that 24 hours … pack your bags. What do you say?”

Con moved into his new home at Granite Ridge on Feb. 25 and so far, things have gone smoothly. He’s gotten to know some of the other residents and the daily walk down the hall for meals has been good exercise. It’s been a tougher adjustment for Belva, who did so much for so long. Now, the house seems empty without Con and the parade of home support workers.

In the end, it was the words of Con and Belva’s 12-year-old grandson, Tyson, who made the difference in the family’s decision. The words were simple and true, Sandra said.

“This is the best thing for both of you right now”

< http://ottawacitizen.com/news/local-news/ontarios-long-term-care-problem-seniors-staying-at-home-longer-isnt-a-cure-for-waiting-lists >

Tags: budget, disabilities, Health, housing, mental Health, standard of living

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