Christian Labour Association of Canada

Beds Are Not Enough

The Hidden Crisis in Ontario’s Long-Term Care Facilities

Executive Summary

It has been said that a society’s treatment of its elderly is a hallmark of that society’s values and priorities. Thanks to an ambitious plan to expand Ontario’s complement of long-term care beds, many of this province’s seniors can look forward to being housed in beautiful, newly-constructed nursing homes and homes for the aged. But bricks and mortar cannot tend to residents who need daily, hands-on care. The provincial government’s plans to add 20 000 new long-term care beds are not accompanied by plans to deal with an already-acute funding and staffing problem. The government has commissioned a study comparing staffing levels in Ontario with those in other jurisdictions. This report should be released, and the government should take steps to link the allocation of funding dollars to increases in care levels, as well as improve the system for measuring those levels.

Christian Labour Association of Canada (CLAC) is an independent, non-partisan trade union. Among its 25 000 members are about 5000 of Ontario’s long-term care workers. Responding to the concerns of those workers, the union struck a Task Force to examine staffing and care levels in the province’s nursing homes and homes for the aged. The Task Force consists of five CLAC staff representatives and eight front-line health care workers. After gathering input through eleven public hearings and via written surveys, the Task Force has identified some of the most critical problems facing long-term care in Ontario–and is making recommendations for significant change.

Recommendations to Employers

- a new emphasis on training, with greater flexibility to accommodate staff education; paid in-services, longer orientation periods, and incentives for employee upgrading

- establishment of clear policies to deal with residents who have behavioural or psycho-geriatric concerns, including the refusal of admission to such residents who pose a risk to other residents or staff

- the creation of a pool of part-time workers by health facilities in each community, with employees orientated at multiple facilities and centrally dispatched

- increased information to family members, enabling them to bring concerns or compliments directly to the Ministry of Health and Long-term Care’s Compliance Officers

- a concerted campaign among employers to increase the complement of volunteers in the long-term care sector

Recommendations to Family Members

- increased involvement by family members in care, and reporting of compliance violations to the Ministry of Health and Long-term Care

- appropriate time spent when "shopping" for a facility for a loved one, including spending half a day in the building observing regular activities

- the use of a "Family Member Checklist", created by the Task Force

Recommendations to Employees and Unions

- efforts to negotiate lengthier employee orientation periods and paid in-services

- development of a joint strategy to seek wage parity between long-term care employees and hospital workers

- an emphasis by employees, especially long-term employees, on continual upgrading of professional skills and knowledge

Recommendations to Educational Institutions

- elementary schools should increase the exposure of students to long-term care settings through visits, activities, and curriculum units

- secondary schools should develop or expand co-op programs with long-term care facilities, and emphasize the sector in career guidance activities

- colleges which provide health care training should require a longer clinical portion and any clinical shifts worked should be of full length and with a realistic workload

Recommendations to the Government of Ontario

- adequate funding should be provided immediately and specifically directed at staffing; at a minimum, funding should be equivalent to that received by correctional facilities

- staff-to-resident ratios should be established; minimum numbers of full-time employees should also be required

- the Ministry of Health and Long-term Care should regularly survey residents’ families about quality of care and release the results publicly

- increased funding for outdated facilities, and stepped-up inspections of such facilities

Beds Are Not Enough

The Hidden Crisis in Ontario’s Long-Term Care Facilities

Recommendations for Action

A task force report prepared by the Christian Labour Association of Canada
May 2, 2001

Introduction

"When I first started to work in the nursing home, I had time to sit and talk with the residents. I could admire a sweater that a resident was knitting or view the latest pictures of grandchildren and great-grandchildren. That was 15 years ago. Today, my partner and I have to get 30 residents out of bed and ready for breakfast—in an hour. There’s not enough time to wash and dress them, much less spend time being human with them. We’re not into caring for people—our workplace is more like a warehouse or an assembly line."

These emotional comments, coming from a veteran health-care aide working at a private nursing home, summarize the input received by the Christian Labour Association of Canada’s Health Care Task Force.

The Ontario government has taken major steps towards the expansion of the province’s long-term care system. In April 1998, the Ministry of Health and Long-Term Care announced plans to add 20,000 licensed beds, which would result in the construction of as many as 175 new facilities. This massive expansion will require an investment of $650 million dollars over an eight -year period.

Society’s treatment of its elderly is a hallmark of its values. Many of Ontario’s seniors can look forward to being housed in beautiful, newly-constructed facilities. But bricks and mortar are no substitute for the men and women who provide daily hands-on care. Evidence suggests that these workers are worn out, stressed, and facing an increasingly impossible workload. New buildings are pointless if we fail to provide adequate staffing levels to care for our aging population.

For many years, the long-term care sector has been out of the spotlight. While the public, media, and various levels of government focused on concerns with doctors and hospitals, nursing homes and homes for the aged have seen a gradual but dramatic increase in their residents’ care needs. Those demands have not been met with a corresponding increase in staffing.

A hidden crisis exists in Ontario’s long-term care facilities, and the situation continues to deteriorate. Action is required by all stakeholders—employers, employees and their unions, family members, volunteers, and the general public. As in any publicly-funded system, however, it is the government that has the greatest ability to make necessary changes happen quickly. New licensed beds and the buildings to house them are a necessity. But if Ontario’s treatment of the elderly is indeed a hallmark of its values, beds are not enough.

Adding new capacity without increasing staff levels simply means Ontario will have 20,000 more licensed spaces with insufficient care levels. The quality of long-term care will be further diminished, rather than corrected.

Time For Action

For those working in the sector, investigations and talk about the issues have become tiring. The cumulative affect of dealing with a restructuring of the Ontario long-term care regulatory and funding system in the mid-nineties; a near decade of spending restraint policies affecting the entire broader public sector; and an aging resident and staffing demographic have created an atmosphere of frustration and cynicism. This mood is readily acknowledged by all of the players in the system, yet everyone professes powerlessness to address the issue on their own. Neither has a shared identification of the problem led to a shared commitment to resolution.

There are more than systemic problems that need addressing, and this report attempts to honestly assess the challenges facing all of the parties: government, employers, unions, workers, families, and our educational system. Yet we cannot escape two overriding themes that threaded through everything this task force heard:

1.There is no relationship between the total dollars allocated to the system and the care needs required. From anecdotal evidence comparing other jurisdictions, it would appear that care levels in Ontario rank comparatively low. In the summer of 2000, the Ministry of Health together with the two employer industry associations in summer of 2000 jointly commissioned a study to determine levels of service related to acuity in long-term care facilities in Ontario and other jurisdictions. We urge the parties to release that report and initiate changes which will link the funding available for care to the changing care level required.

2.The Alberta Classification System, introduced in Ontario in 1993 as the method of measuring resident acuity, is costly to administer and does not provide requisite fairness in the distribution of funds. Facilities are spending scarce resources in creating paper trails that hopefully will lead to increased resources in the next year.

It is impossible for us to measure exactly how many dollars are needed to improve the system to an acceptable standard. However, the amount will not be insignificant.

It is too easy to simply say all of the problems of the long-term care system will be solved through the spending of more public dollars. This report presents specific proposals from front-line workers that suggest how available dollars can be spent more wisely and distributed better. But without adequate funding that corresponds to the changes in the system itself, there is no meaningful solution to the problems faced by Ontario’s long-term care system.

The Staffing Challenge

Much public discussion has taken place in Ontario in recent years about a looming shortage of registered nurses (RNs). No part of the health-care system is feeling this pinch as much as the long-term care sector. Registered staff are attracted to hospitals because of higher wages and to the growing home-care sector because of flexible hours and the opportunity to work one-on-one with patients. According to government estimates, Ontario will face a shortage of 113,000 RNs within ten years.

Anecdotal evidence suggests that long-term care facilities are suffering not just from a shortage of RNs but also health-care aides (HCAs) and personal support workers (PSWs). These workers form the backbone of nursing care in any long-term care facility and are becoming more difficult to find and retain, as are registered practical nurses (RPNs).

According to a random sampling of 800 CLAC members working in 12 facilities across Ontario, the shortage is set to worsen. Data for the group shows that 75 per cent of full-time workers are over 40 years old while 25 per cent are over 55.

With the addition of 20,000 new licensed beds over the next few years, the staffing concern goes from challenge to crisis. Currently, some 43,500 employees work in Ontario’s long-term care sector. Government figures estimate the expansion will add 27,500 positions—a personnel increase of 63 per cent, although this estimate might be unrealistic. Each licensed bed currently has a 0.76 employee equivalent. At current staffing levels, 20,000 new beds should result in 15,200 new workers in the sector.

It is difficult for facilities to maintain current staffing levels. With the need for a large new group of employees—whether the correct number is 15,200 or 27,500–it may be close to impossible.

The Task Force

The Christian Labour Association of Canada (CLAC) is an independent, non-partisan Canadian union with a lengthy history of representing health-care workers. Today, CLAC represents approximately 5,000 long-term care workers in 80 facilities across Ontario. The union also represents numerous health-care workers in Alberta and British Columbia.

CLAC is acutely aware of the challenges facing Ontario, having previously commissioned two task force studies of long-term care. The 1985 task force report, Serving Our Seniors, looked at Ontario’s nursing homes and made 20 recommendations. In 1990, both nursing and retirement homes were examined, and the report, Living In the Twilight, included 18 recommendations for change.

In August of 2000, CLAC’s provincial Health Care Sector Committee established another task force. The mandate was simple: gather input from stakeholders in Ontario’s long-term care system; assess the levels of staffing and care; and make recommendations for improvement. Through this process, the Task Force was to raise public awareness of long-term care issues and develop practical solutions.

The Task Force was comprised of two health-care aides, one life enrichment aide, three registered practical nurses, and two registered nurses, all CLAC members. Five CLAC staff representatives also participated. (see sidebar for a full listing of task force members.)

Task Force Members

Ed Bosveld, (Chair) Ont. Representative, Chatham
Carolyne Johnson, RN, Brantford
Carol Kerr, RPN, Owen Sound
Rebecca McBeath-Poirier, HCA, Sarnia
Jodi Morrison, RPN, Chatham
Wendy Munro, RN, Owen Sound
Ray Pennings, Public Affairs Director, Mississauga
Irene Simpson, Ont. Representative, Mississauga
Debbie Sims, RPN, London
Cathy Smyth, HCA, St. Catharines
Jeanne teSligte, Ont. Representative, Grimsby
Jim Williams, Ont. Representative, Chatham
Linda Zadilsky, LEA, Kitchener

The Task Force held public meetings in 11 Ontario locations during October and November 2000: Barrie, Brampton, Brantford, Cambridge, Chatham, London, Markham, Niagara Falls, Owen Sound, Sarnia, and Waterloo. While CLAC members were encouraged to attend, invitations were also extended to management, family members, residents, and volunteers by way of posters, advertisements, and media coverage.

The public meetings encouraged maximum input from those in attendance. At the start of each meeting, attendees were asked to fill out an anonymous survey inviting them to share their opinions about Ontario’s long-term care system. The Task Force then made a brief presentation on the state of the system (see Appendix B for outline), ensuring all present were working from the same base of information.

Input was gathered in response to questions asked by Task Force members and during general discussion. This report was prepared based on that input. It does not purport to be a scientific or statistical analysis. Such studies and statistics are available but often fail to include the perspectives of front-line participants. This report represents the perspectives of the front-line care givers, families, residents, and volunteers—those with a vested interest in long-term care—and their suggestions for change. These workers are also citizens and taxpayers who look at the system from a public interest perspective as well.

Survey Results

Surveys were completed by 161 respondents (see Appendix C for copy of survey).

Those surveyed answered a number of questions:

The best feature of Ontario’s long-term care system is . . .

The most common response was staff, indicated by 35 per cent of respondents, most often by employees and the general public and less often by family members and management.

Availability or accessibility was almost as common, at 34 per cent. Employees, family members, and the general public gave this characteristic a high rating.

The worst feature of Ontario’s long-term care system is . . .

Staffing levels are the worst feature, according to approximately 39 per cent of respondents. Lack of funding also rated high at 31 per cent. Both responses ranked either first or second with each group in the survey.

If I could make any change, provided I stayed within current budgets . . .

Respondents were almost unanimous that they would improve care levels by increasing staffing levels. Other suggestions included better staff training, better equipment and facilities, greater family and community involvement, and a reduction in management staffing.

If more money were available, I would spend it on . . .

More than 51 per cent requested increased staffing, with some even suggesting which classifications (e.g., RNs, HCAs) be increased. This was the dominant response of each survey group.

Twelve per cent suggest improved resident care while other responses included facility and supply improvements and better staff education.

Survey respondents were also invited to comment on their experiences with Ontario’s long-term care system:

"As a member of a government project, Family Council, at a local nursing home, good money is being spent for a social worker to facilitate the proceedings for over a year now. And an overnight conference was held in Toronto with the government picking up the tab for three local people (mileage, food, hotel) from each project site. Yet when complaints are taken to management nothing changes: shortage of supplies, minimal equipment, low nursing-to-resident ratios."

"We have six-to-nine minutes to wash a resident; on nights, we allow ourselves 15 minutes to do a proper job. I would never have a family member live at this nursing home."

"I am two years from retirement myself and would hope when I get ready for long-term care there is money and staffing and beds to look after me."

"Staff on the whole are very caring for the residents but they feel rushed with not enough time to do extra things like apply makeup, walk with residents, sit and visit and really get to know them. Residents are people too and need to feel that the facility they are living in is their home and not that they are on an assembly line."

Problems and Solutions

Ontario spends, on average, $128 per day on inmates in its correctional facilities (source: www.ontla.on.ca/library/issuegway/ig23.htm). By contrast, an average nursing home, with a Case Mix Index (CMI) of 100, receives $96.55 per day. Despite the fact that many residents need around the clock hands-on care, funding for inmates is, on average, $31.45 per day, or 32.5 per cent, higher. If funding for residents increased to match the amount spent on prisoners, long-term care facilities could provide over one full extra hour of nursing care per resident per day.

The input received by the Task Force suggested that lack of adequate funding is not the only problem. The Task Force drew on the experience of its members and the public to craft a series of practical recommendations for improving long-term care in Ontario. These recommendations are directed at the five major stakeholders: government, employers, family members, employees and their unions, and educational institutions.

Recommendations to Employers

1. Long-term care staff today care for residents who in past decades would be confined to a hospital. Medical devices such as catheters, intravenous tubes, and respirators are becoming more common, as are psycho-geriatric conditions. Employees are not always sufficiently trained to handle these new challenges. Training on interpersonal and communication skills is also important. A 1999 joint employer-CLAC study highlighted how investing in these skills improved employee morale, resident care, and ultimately paid economic dividends as problems could be better solved with less reliance on outside assistance. (Caring for our Seniors, 1999).

_ Recommendation: that employers not only emphasize training but become more training-friendly. Greater flexibility is needed in accommodating reduced schedules or leaves of absences for educational reasons. Staff should be paid for in-services attended at their facility, and management should arrange for other employees to be brought in to cover those attending training. The orientation period for new employees should be lengthened and incentives provided to encourage staff to continually upgrade their skills.

2. With hospital cutbacks and the closing of psychiatric institutions, long-term care facilities are struggling to cope with residents who have severe behavioural or psycho-geriatric issues. The health and safety of staff, residents, volunteers, and family members is at risk.

_ Recommendation: that employers establish a clear policy on the admittance of residents with behavioural and/or psycho-geriatric concerns and refuse admission to individuals who pose a risk. Employers must also be prepared to deal with residents whose condition deteriorates to the point of being a danger to others.

3. Many facilities are struggling with staff shortages while, at the same time, part-time employees are forced to work in two or three facilities to earn a living. This causes scheduling nightmares for all facilities because staff are unavailable for scheduled or call-in shifts due to employment obligations elsewhere.

_ Recommendation: that the various long-term care facilities in each community work together with hospitals and other agencies to create a pool of part-time workers. These workers should be orientated at multiple facilities and schedules coordinated using a central dispatch system.

4. Family members feel frustrated when they raise concerns to managers but see no action. Employees have observed that family members are more activistic today and have more time to spend visiting loved ones. As one long-time employee said, "Family members used to be middle-aged, with jobs and kids at home and little free time. Now, they’re often seniors themselves, are retired, and have time to spend. It’s a new dynamic."

_ Recommendation: although some information is provided to families, many are not aware of how to bring concerns and compliments directly to the Ministry of Health and Long-Term Care. This can be done via postings and brochures that help family members contact a Ministry compliance officer.

5. Volunteers play an increasingly important role in long-term care. Numerous family members and volunteers pointed out that without their help certain essential tasks wouldn’t be performed. At the same time, the demand for volunteers by other organizations remains high.

_ Recommendation: that facility managers plan a concerted campaign to increase the complement of volunteers working in long-term care facilities.

Recommendations to Family Members

6. Family members collect valuable data on the level of care provided their loved ones when they are actively involved. But their inability to act on this information causes frustration and a feeling of powerlessness.

_ Recommendation: that family members make every effort to be involved in the care of their loved one and report compliance problems to the Ministry of Health and Long-Term Care.

7. When looking at long-term care facilities, family members are usually given a guided tour. But such tours are usually a marketing tool for facilities eager to keep beds full. As such, they do not always provide an accurate view of the facility and the care it offers.

_ Recommendation: that family members take the time to get to know a facility before placing a loved one. They should insist on seeing the whole building, not just portions shown on a tour, and speak with staff, residents, or other family members without management present. Most importantly, a half day should be spent simply observing the routines of the facility, perhaps watching a meal being served.

8. With the time pressure and emotional stress that comes with placing a loved one in a long-term care facility, family members may be at a loss as to what questions to ask and what information to seek. In the turmoil, they may forget to ask how many baths will be given per week or how many staff work on the night shift.

_ Recommendation: that family members use a Family Member Checklist when assessing facilities. This checklist should be made widely available through institutions such as the Community Care Access Centres.

Recommendations to Employees and Their Unions

9. The long-term care sector has been heavily unionized for decades. Many collective agreements have clauses requiring a set number of shifts or hours for the purpose of orientating new employees and have not changed with the gradual increase in care requirements.

_ Recommendation: that unions in the long-term care sector put an emphasis on increasing the amount of orientation required by their collective agreements. Unions should also seek to negotiate clauses that require in-services to be paid and require employers to replace staff attending in-services.

10. Although long-term care employees perform duties closely resembling those in the chronic-care departments of hospitals, wages lag that of hospitals by 16 per cent (based on comparison of RPN rates from 43 long-term care facilities and rates from the hospital "master" agreement.) This is an injustice and a disincentive for employees working in the long-term care field.

_ Recommendation: that unions involved in the long-term care sector cooperate to develop a joint strategy to seek hospital wage parity for long-term care workers.

11. Long-term care is undergoing rapid changes. Demographic statistics based on a sample of CLAC members indicate that the workforce is aging, with many workers employed in the field for over 20 years. While this invaluable experience will be hard to replace, it also means that some veteran staff have not had any formal education in a long time.

_ Recommendation: that employees place an emphasis on continual professional upgrading and training via seminars and courses offered through their employers and through external organizations such as community colleges.

Recommendations to Educational Institutions

12. Many who attended the Task Force’s public meetings expressed frustration with the younger generation’s perspective on long-term care. Concern was voiced that a career in long-term care is viewed negatively by youth.

_ Recommendation: that elementary schools increase the exposure of students to long-term care, via visits, activities, and curriculum units. Such programs should be developed in cooperation with long-term care employer associations.

_ Recommendation: that secondary schools develop or increase co-operative programs with long-term care facilities and ensure that long-term care employment is considered in any career guidance events. At the provincial level, examine the possibility of integrating the Personal Support Worker program into secondary school programs.

13. One reason for the high turnover rate among new staff is the unrealistic expectations given during the educational process. Said one veteran employee, "New hires expect to tuck Grandma into bed, maybe sit and chat with her. Instead, they’ve got five minutes to haul Grandma out of bed, wash her, dress her, and get her to the dining room. There’s hardly time to breathe, much less chat."

_ Recommendation: that community colleges require a longer clinical portion for health care-related programs and that such programs ensure students work full shifts and carry close to a full workload.

Recommendations to the Government of Ontario

14. A majority of the concerns brought forward related to the current lack of funding. Government numbers show the level of resident care required has increased more than 10 per cent since 1992. Funding during that period has not kept pace. If correctional institutions require, on average, $128 per inmate per day to house inmates who don’t require extensive medical and hands-on personal care, then health care institutions cannot function on $31.45 less.

_ Recommendation: that the provincial government provide adequate funding to long-term care facilities and specifically address funding improvements for staffing. The government should, at a minimum, provide long-term care institutions with the same funding level as correctional institutions.

15. Since the removal of the regulation requiring 2.25 hours of nursing and personal care per resident per day, long-term care facilities are left with few minimum staffing requirements. Oddly enough, the Ministry of Health and Long-Term Care sets minimum staffing requirements for dietary departments but not for nursing. After midnight, some facilities with 100 or more residents are staffed by only three or four employees. Regulations setting minimum levels of full-time employees do not exist. In some facilities, the staff complement consists of over 95 per cent part-time workers.

In many facilities, tasks are being reassigned between classifications in a way that further compromises direct hands-on care. Reductions in the staffing levels for dietary and housekeeping staff result in the front-line workers taking on increased responsibilities, by definition lessening the amount of direct care they are able to provide.

_ Recommendation: that government establish ratios setting the maximum number of residents one employee may be responsible for, similar to regulations long in effect for the daycare sector. The Ministry of Health and Long-Term Care should require that a proportion of positions be full-time. (CLAC’s 1990 report, Living in the Twilight, recommended that at least 50 per cent of nursing positions be full-time.)

16. Measuring resident care requirements and inspecting facilities for compliance with Ministry guidelines are done without the input of family members.

_ Recommendation: that the Ministry of Health and Long-Term Care conduct formal surveys of family members regularly to evaluate the levels of care provided at each facility and publish the results of such surveys.

17. Ontario’s long-term care facilities are not aging well. For instance, some older facilities have multiple floors but only one elevator, resulting in residents lining up to use the elevator to go to the dining room or lounge. Most of the facilities receiving funds under current programs are new facilities or the worst (Class D) facilities. Many facilities are Class C facilities which complied with the 1972 standards to which they were built, but are inefficient in dealing with the needs of today’s resident population. This results in extensive staffing time that is "wasted" waiting for elevators, transporting patients to and from dining rooms, and in other similar activites.

_ Recommendation: that government provide increased funding to upgrade or replace older facilities and increase inspections to monitor the physical condition of existing facilities.

Despite the above recommendations, one significant element the Task Force struggled to address concerned the current classification system and its emphasis on paperwork. Since classifiers only look at documentation and not actual residents, facilities face a dilemma. If staff are directed to spend as much time as possible doing hands-on care, paperwork is neglected and the facility’s Case Mix Index (CMI) drops. A drop in the CMI means less funding and therefore less staff.

Facilities are forced to emphasize paperwork instead of resident care in order to preserve or improve funding levels. Some facilities hire additional staff simply to handle paperwork. While the Task Force makes no specific recommendation on this matter, it urges the Ministry of Health and Long-Term Care to examine this concern further.

Better Care Means More than Beds

Like the rest of Canada and the United States, Ontario faces a demographic reality—its population is aging. Advances in medicine and society’s increasing emphasis on home care help residents stay in their homes longer than ever before. The average age of individuals admitted into long-term care facilities is now 86 years old, up from 73 a decade ago. When admitted, residents require significant hands-on care. At the same time, the closure of chronic care hospitals, psychiatric institutions, and facilities for the developmentally disabled has resulted in an influx of residents, posing new challenges to long-term care facilities and their staff.

The government’s ambitious plan to add 20,000 new beds will ensure access continues to be a positive feature of the long-term care system. An increase in beds, however, does not address the current crisis in staffing. If nothing is done, at best, 20,000 new beds will be added that provide insufficient care. At worst, 20,000 new beds will be added without staff to care for the occupants.

Curing Ontario’s ailing long-term care system requires the work of all stakeholders. The recommendations in this report come from people deeply involved in the system on a daily basis. If implemented, they will go a long way towards improving the treatment of both residents and staff in Ontario’s long-term care facilities.

If, indeed, a society’s treatment of its elderly makes a statement about its values and priorities, significant changes are needed in Ontario, and soon.

Appendix A - Long-Term Care in Ontario: An Overview

Prior to the massive expansion announced in 1998, Ontario’s long-term care sector consisted of 498 institutions: 326 nursing homes (that is, privately-run facilities operating beds licensed by the Ministry of Health and Long-Term Care), 102 municipal homes for the aged (municipally-run facilities operating licensed beds), and 70 charitable homes for the aged. The total number of licensed beds in these facilities is 56,903, with the majority (31,261) in nursing homes.

(Numerous rest homes or retirement homes in the province also provide care for the elderly but are not funded or regulated by the Ministry of Health and Long-Term Care. Such facilities may require operating licenses from municipalities, but they do not contain beds licensed by the Ministry of Health and are often referred to as unlicensed facilities. They were not included in the Task Force study.)

Long-term care facilities depend almost completely on the provincial government for income. Although some revenue comes directly from residents and their families, the Ministry of Health and Long-Term Care regulates all amounts.

The funding system was revamped in 1993 as a result of a reform of the long-term care system. The implementation of those reforms coincided with a period of government restraint, and as a result, the system has been struggling with an insufficient base. For example, 10,500 residential care beds that were not previously funded were incorporated into the system in 1993, without a corresponding increase in the funding pool. Projected funding increases to the global amount were scaled back as part of government restraint programs, which has eroded the staffing capacity in the system. Regulations previously in place requiring each facility to staff at a minimum 2.25 hours per resident per day have been replaced, originally on the premise that the system would average the 2.25 hours per care. As global funding allocations have not kept pace with inflation and regulatory costs, the staffing levels now fall well below that standard in most facilities, while the care levels have increased by over 10% according to the government’s Case-Mix-Measure indices.

Under its Alberta Resident Classification System, the Ministry of Health and Long-Term Care sends classifiers to each facility every autumn. These individuals are currently Registered Nurses with the College of Nurses of Ontario. They must have had direct resident care experience within the past five years, and experience and knowledge of nursing requirements in long term care or chronic care facilities. They receive special training, which prepares them to examine patient care documentation and gather data from this documentation on each resident in all facilities in Ontario.The data are collected from the documentation provided by each facility and sent for processing where the information is compiled and all residents are categorized from A to G. A resident who is assigned an "A" has relatively little documented care requirements while a resident who has an "F" or "G" assigned has extensive documented care requirements.An example of a resident for whom the documentation reflects the care needs of "A" may have moved into the long-term care facility with a spouse and still can drive their own car, and may only need a reminder from the nurses that it is time to get up and dressed for breakfast. An example of a resident for whom the documentation reflects the care needs of "G" might be a quadriplegic resident requiring staff to totally dress and feed them; two people to take to the toilet (regularly perhaps seven times per day); and two people and a mechanical lift to get them from bed to wheel chair. Many of these residents are totally incontinent of both bowel and bladder requiring nurses to tend to their continence needs throughout the day and night with either frequent clothing changes or the use of incontinent briefs etc. Combined with these high physical needs, some of these residents have intermittent hallucinations which do not respond to medications and require repeated interventions or redirection of thoughts. Some of these residents are either homicidal or suicidal and require 1:1 nursing intervention for literally hours at a time.

Once the Levels of Care Classification process has been completed, the facilities receive an overall rating based on the documented care requirements of the residents, called a Case mix Measure (CMM). The CMM allows comparisons to previous years or other facilities but does not in itself determine the amount of funding received by the institution.

The level of funding received for resident care is determined by a facility’s Case Mix Index (CMI) number, which simply ranks the facility’s care needs in relation to other facilities in the province. The average provincial CMI is always 100. Thus, to use a hypothetical situation, if every facility’s care needs increased by a uniform 10 per cent in a particular year, their CMMs would reflect this, but their Case Mix Indices would not because their needs would not increase relative to other facilities.

Between 1992, when the Alberta system was first used in Ontario, and 1999, the provincial CMM increased by more than 10 per cent (source: Ministry of Health and Long-Term Care, December 20, 1999 memo, "1999 Levels of Care Classification Results"). A facility with the provincial average CMM of 76.31 in 1994 would be assigned a CMI of 100; in 1999, a facility with the provincial average CMM of 83.30 would also be assigned a CMI of 100.

The government provides funding to facilities through an envelope system. Income is specifically designated for a particular envelope, either nursing and personal Care, programming, accommodations, or food.

The nursing and personal care and programming envelopes are "flow through" envelopes, meaning money must be spent on these areas or returned to the government. Unspent funds in the accommodations or food envelopes may be kept by the facility operator as surplus or profit or may be spent in other areas of operation.

The annual CMI assigned each facility determines the level of funding in the nursing and personal care envelope. The example shown here (see sidebar) is based on a facility with a CMI of 100; a facility with a CMI of 90 would receive 90 per cent while a facility with a CMI of 110 would receive 110 per cent.

Facilities receive their CMM and CMI figures near the end of each calendar year. Funding changes based on CMI changes take effect on April 1 of the following year. Since only the flow-through nursing and personal care envelope is affected by the CMI, any significant change results in a change to nursing levels. A facility experiencing a major increase to its CMI will increase nursing levels. But that same facility could see a significant drop to its CMI the following year, leading to nursing staff cutbacks.

The Alberta Resident Classification System became fully operational in Ontario on June 1, 1996. Prior to that date, provincial regulations required each facility to maintain a minimum of 2.25 hours of nursing and personal care per resident per day. For example, a facility with 100 residents would be required to provide staffing that included at least 225 nursing hours per 24-hour day. The current system requires no minimum nursing staffing levels.