Ontario Long Term Care Homes: comparing fundamentals

Finding a Long Term Care (LTC) Home

Seeking admission to a long term care (nursing) home for yourself or a loved one in Ontario, Canada is a process regulated by the Province of Ontario Ministry of Health and Long Term Care. The process is administered by the local CCAC (Community Care Access Centre) in the area where the person seeking admission resides.

If you are not already familiar with the process read the web page Find a long-term care home, Information about, and how to find and apply to a long-term care home 

The above link will tell you how to do the next step: contact the CCAC (Community Care Access Centre) in the area where the person seeking admission resides. A care coordinator will help you determine eligibility and whether an LTC home is the right decision. If it is, they will then tell you to choose up to five homes. That is when your work really begins.

Assuming all the above is now behind you, the rest of this article provides pointers for some things to look at when making comparisons between homes.

Points to compare between LTC homes

You can find a list of LTC homes in say, the Newmarket area, at the Ministry of Health and Long Term Care web page: Reports on Long-Term Care Homes.

Go to the web page and click on the link, 'Find by location'.
This takes you to the page Search for LTC Homes By Location

Enter whatever town is of interest to you into City/Town and click next.

This takes you to the page Long-Term Care Homes Search Results. If you entered 'Newmarket' you would see a list of 4 homes to choose from and compare, each with a link that takes you to that home's report page with two tabs, one for the home profile, the other for the home's inspection reports in descending chronological order. You may want more of a choice. In that case, instead of specifying the town, enter the county/district.

Inspection Reports

The inspection reports should be of particular interest to you.

1  Resident Quality Inspection reports are reports from annual inspections by the Ministry of Health and Long Term Care, and are the most thorough. Inspection findings are presented as Written Notifications (WN). A WN may conclude with a Voluntary Plan of Correction (VPC) or, more seriously, a Compliance Order, Director Referral or Work and Activity Order:

DR – Director Referral

CO – Compliance Order

WAO – Work and Activity Order

Not all WN's are equal. Use common sense to distinguish something like stained upholstery or missing ceiling tiles or wrong menu courses from  noncompliance that poses risk of harm to residents as with improper control of drugs and medication and broken wheel chairs or doors not locking with the correct protocols allowing dementia residents to wander.

2  Critical Incident Inspection reports are typically as a result of a resident experiencing some harm. When this happens, the home administrator is required by law to report the incident within a fixed period of time. The Ministry will look at the report and decide whether or not to follow up with an inspection to more fully investigate what happened and whether the home is following all required procedures.

3  Complaints inspection reports are as a result of Ministry follow up on an official complaint lodged by a resident or family member. Complaints are often made in confidence. There is a strict code against retaliation and abuse.

Sample list of inspection reports

In my casual observations I have found there is generally, on average, an inverse proportion between the number of critical incident and complaint reports and the length of the wait period for admission. It would appear that the most desirable and well-run homes typically have the longest queues for admission.

Health Quality Ontario Reports

In addition to the inspection reports which are focused purely on compliance with the Long Term Care Homes Act and associated regulations, there are some other important indicators that you will want to look at that focus more on quality of life. Health Quality Ontario (HQO) currently reports publicly on four quality indicators for individual long-term care homes. These indicators relate to four health topics:

• falls
• incontinence
• pressure ulcers
• the use of restraints

Once you know the name of the home for which you want to see this report, go to the HQO web page for individual homes

http://www.hqontario.ca/public-reporting/long-term-care

Click 'By Home' and then enter the first few words of the home name to get a list to choose from. Choose the desired home and click 'Search'.

You will see a table that shows how the home compares with the provincial average on each quality of life indicator. You can also see whether the home is improving over the previous year's performance and how it compares with the optimal benchmark.

Example of Health Quality Indicators

So now, you have looked at inspection reports and quality indicators for some homes and discovered that comparing homes in this way is not a trivial undertaking.  Once you find a 'maybe' home, phone the home and arrange a tour. Web sites for most CCAC's offer a list of questions to enquire on. You can find a very comprehensive tour checklist here: www.nursinghomeratings.ca/downloads/NursingHomeTourChecklist.pdf

or here:

http://www.orcaretirement.com/wp-content/uploads/2013/04/Visit-Checklist.pdf

Most people who do the tour do not ask questions. Don't be timid or afraid. You don't have to ask every question on the check-list, but know beforehand which are the important questions for you. If you do not feel comfortable asking in front of other people, confirm that you can phone later and ask your questions.

There is a lot of information here. I sincerely hope this is not too confusing. Just take your time to work through the steps. 

Registration and Accreditation

All LTC homes in Ontario have to be registered with the Ministry of Health and Long Term Care and are subject to inspections by the Ministry. In addition, some homes seek accreditation from bodies such as CARF and Accreditation Canada. These are standards bodies that assert with accreditation that a long term care home has certain procedures and protocols in place and abides by them. These operational procedures and protocols are in addition to those required for registration by the Ministry of Health and Long Term Care. The Ministry does not require accreditation but encourages LTC homes to acquire accreditation by granting certain funding premiums to accredited homes. Intuitively one would think that this should be a good thing. However, when it comes to complaints and critical incidents there are both accredited and non-accredited homes with a high rate of these inspections just as there are both accredited and non-accredited homes with a low rate. I recommend placing a higher reliance on your own due diligence in reviewing inspection reports rather than merely presuming that an accredited home will automatically have a better record in this regard than a non-accredited home.

I base the above advice on a statistical analysis that I did comparing accredited and non-accredited homes. You can review the two-part analysis in the following videos.

English Housing Survey: Does it Mean Anything for Seniors in Ontario?

A report titled, Home solutions to our care crisis, was published in the United Kingdom by the Papworth Trust in November, 2012. The report is the distillation of 640 responses from their English Housing Survey conducted to see how unsuitable housing can affect people's lives. A secondary aim of the survey was to help increase awareness of home adaptations as a solution to the care crisis for the disabled being experienced in the UK.

Home adaptations would include such things as: bathroom conversions, grab rails, kitchen alterations, ramps and level access, widening doorways.

You can read the full report here: Home solutions to our care crisis
http://www.papworthtrust.org.uk/sites/default/files/homesolutionstoourcarecrisis_121113100850.pdf

Noteworthy statistics

One in 4 respondents reported that they could not get around their home safely.
Two in 5 people said that a lack of facilities for the disabled in their home meant they needed help to do everyday things like cooking.
Two thirds of people who had not received a government Disabled Facilities Grant (DFG) had never heard of it.

Here in Ontario, or Canada generally, do we have any reason to think that we would not get responses similar to those in the UK?

Financial benefits of home adaptations

Analysis by the London School of Economics suggests that the annual spend on governmental Disabled Facilities Grants of around £270 million is worth up to £567 million in health and social care savings and quality of life gains. Put differently, every £1 spent on Disabled Facilities Grants is worth over £2 in care savings and quality of life gains.

A study by Bristol University, on behalf of the Office of Disability Issues, found that home adaptations can help prevent or defer entry into residential care. Just 1 year’s delay means a saving up to £26,000 per person, less the cost of the adaptation (which averages £6,000). (Can somebody tell me the cost per person per year for long-term care in Ontario?)

Falls by older people in the UK cost over £1 billion a year. A fractured hip can cost the state an estimated £28,665. Compare this with the cost of installing grab rails, one effective way of reducing risk of falls.

In Wales, the Government has estimated that a programme to help older people remain living independently in their own homes has saved the NHS and social care budgets over £101 million since it was set up 10 years previously.

Home Adaptations: A Cost or an Investment with a Return?

There is a common mindset that presumes any initiative requiring money is a money-grabbing cost to the tax payer that should be fought tooth and nail. It should be evident from the above that judicious implementation of home adaptations is actually an investment that should produce a return in both financial savings and quality of life.

(This report titled, Home solutions to our care crisis, was published in the United Kingdom by the Papworth Trust in November, 2012. Does anyone know of any similar studies conducted anywhere in Canada, especially Ontario?)

Corrections, Corrective Actions and Preventive Actions: What is the difference?

Corrections, corrective actions and preventive actions: What is the difference between them? When should you do which?

In under 10 minutes this light-hearted presentation addresses these questions with examples from the auto industry and a long-term care nursing home.

Hospitals grinding to halt because of stranded seniors, CMA head says

In a press release put out today the head of the Canadian Medical Association, Dr. Christopher Simpson, a cardiologist at Kingston General Hospital, describes 'gridlocked' hospitals around Canada struggling to make room for incoming patients with acute medical problems because so many older patients needing chronic care and having no other place to go are taking up about 15% of the acute care beds.

"Thousands of older Canadians are taking up acute care beds at $1000 a day even though they are well enough to be discharged because they have no place to go."

"There either isn’t a long-term care bed available in their area or there aren’t the support services they need to live at home. About 15 per cent of acute care beds in Canada are taken up this way.

“We are warehousing them. We do the best we can. But it’s not anywhere near good enough.”

Video quotes from Dr. Christopher Simpson can be downloaded from this link:
http://www.skyflyproductions.com/CMA-AMC

Aging - the effect of stereotypes

Researchers have reported, in the journal Psychological Science, that an implicit intervention can work subliminally to strengthen older people’s positive age stereotypes that leads, in turn, to stronger physical functioning. Put simply, physical functioning in seniors can be improved by exposing them to positive age stereotypes. The less explicit this exposure the better.

Read the study in Psychological Science

Read the New York Times blog article about the study, The New Old Age

Read Dr. Mercola's take, When it comes to Aging Well, It's Mind Over Matter

Time to Care: Seniors' Long Term Care

Most of us have heard friends, acquaintances or people more remote from us tell horror stories about some or other events that have taken place in a long-term care home, or read something in the newspapers.

Someone I was speaking to recently was shocked to see how much disrespect was shown by family members of a home resident toward the personal support worker who was attending to their loved one in the home.

CUPE Ontario published this video on YouTube two weeks ago. It is a powerful statement providing a window from the point of view of nurses and personal support workers.

Do LTC Homes in Ontario or Canada need a 'One Voice' organization?

In the Ontario Long Term Care Network discussion group of LinkedIn, Andréa Catizone posted a link to a blog post: What the Senior Living Industry Can Learn FromThe Evolution of The Hotel Industry. 

Following, are my comments after reading that blog post.

It's an interesting analogy, comparing senior living and nursing homes with hotels/motels but, like most analogies, it limps in some important respects apart from the obvious differences in populations.

1. The hotel/motel industry in the USA is highly competitive as operators try to fill beds that are often empty; every Ontario LTC Home has a rather long waiting list that is largely controlled by the local CCAC which affords special consideration for the most needy, driven in turn by the need for hospitals to vacate beds occupied by non-acute-care patients.

2. The Ontario Long-Term Care Act has resulted in a highly regulated licencing system and corresponding reporting (CIHI, HQO) and inspection systems that ensure, at least in intent, a minimum standard of care and quality of life for residents along with a Residents' Bill of Rights. I don't think that the US hotel system has anything close, does it?

3. The real or imagined need for most Ontario LTC home operators to have a good, strong public relations image has resulted in the quest for accreditation to a standard in certain operational aspects over and above the requirements for a licence from the Ministry. At least one LHIN, I am told, has made accreditation mandatory. Interestingly, a statistical analysis that I did showed no positive correlation between accreditation and regulatory compliance in the 82 homes making up the two LHINs of my study. See LTC Homes and Accreditation, parts 1 and 2 at tcmc Quality Management Serviceson YouTube.

The thing that drove the changes in the USA hotel industry is identified as the interstate highway system. Why? Because it channelled and redirected travellers. I would propose that the equivalent for Ontario seniors is the role played by the CCAC's; that, and the about-to-explode-with-boomers population of seniors. As a result, the change that I anticipate will be the creation of many more for-profit LTC homes as private enterprise sees long waiting lists and a booming senior population as a business opportunity.

The blog ends by asking the question (of US operators), who will step up and create a national "One Voice" organization for all Senior Living operators? The Ontario equivalent is, do seniors' organizations need something beyond OLTCA, OANHSS and the like? It's a good discussion, no doubt, but I don't see the evidence, nor do I hear the public saying that we have an urgent need for one unifying association for Long-Term Care Homes and seniors' care organizations. The pressing discussion in Canada seems to be reported in the latest CMA poll: Canadians want a national strategy for seniors health care:doctors report. 

Long-Term Care Homes, Complaints and Critical Incidents

All Long-Term Care Homes have got the on-going challenges of heading off resident complaints at the pass and preventing avoidable critical incidents. Many have got these pain points satisfactorily under control. Many others are struggling with this challenge and finding that they are triggering unwanted inspections from the Ontario Ministry of Health and Long-Term Care.

The video is best viewed full-screen.

Concerned about the number of inspections for Critical Incidents and Complaints at your LTC Home?

As an Executive Director, or as Chairman of the Board, or Coordinator for Continuous Quality Improvement, or a member of the Quality Committee, or just a staff member with the good of our residents at heart - am I concerned with the number of Ministry of Health and Long-Term Care (MOHLTC ) inspections for complaintsand critical incidents? If this is an area for concern then one or more of three things is probably not happening as well as they should:

Firstly: Are we measuring all the right things? Of course, we are measuring for CIHI and HQO and our own Board meetings, but have we got the metrics in place to red flag the likelihood of an avoidable critical incident occurring, to red flag the future likelihood of one or more resident complaints that could trigger an inspection? In the field of quality management we call this type of metric KPIs, Key Performance Indicators. KPIs are the organization’s "vital signs", the vital few metrics that report on the health of the organization in living out its mandate from and to society. KPIs should not be confused with the kind of quality indicators that are reported to HQO such as falls, wounds and restraints, although KPIs might well incorporate some of those metrics.

Secondly: Are we monitoring effectively? Assuming that we actually do measure those KPIs, are we reporting them in an accountable manner to the right people who are best positioned to effect change – change in our processes and change in our culture? Managers and others in positions of responsibility who are not being fed the information they need to do their job need to report this as a concern up the management chain. Without KPIs you are flying blind.

Thirdly: Are we managing efficiently and effectively? Assuming that we are reliably measuring and monitoring KPIs, are the process owners and managers sufficiently trained, mandated, empowered, resourced and accountable to take the actions necessary to enhance the Quality Management System (QMS) and foster a culture of quality to prevent the bad stuff happening? If not, that is fodder for a KPI in itself and needs to be reported as a resourcing issue to senior management. Managers and others in positions of responsibility who feel they need training need to do whatever it takes to get it; if your department is at risk for non-compliance because you are lacking resources then that needs to be reported, repeatedly if necessary.

What do you think? Let's have a discussion.