Bringing long-term care home

This commentary is drawn from the Executive Summary of a new paper from the National Institute on Ageing at Ryerson University. To read the full paper, click here.

The provision of long-term care is at crossroads in Ontario. The current COVID-19 pandemic has brought to light not only some of the system’s pre-existing systemic vulnerabilities, but has also exacerbated its capability to serve more people in need of long-term care services. Indeed, Ontario’s current long-term care system is faced with unprecedented capacity pressures that are creating additional strain on the province’s health care system as a whole. Ontario also lacks capacity to meet its current demands for home and community care alongside residential long-term care services. Additionally, the province is experiencing a rapidly growing and aging population with increasingly complex and diverse long-term care needs that will only result in greater demand for these services over time.

The current and previous governments in Ontario have struggled to build more long-term care (LTC) homes. Building and maintaining more LTC beds is an expensive proposition. Additionally, the need to find more frontline staff will be difficult given that recruitment and retention of staff has already been one of the sector’s greatest ongoing challenges.

The prior government’s inaugural Seniors Strategy in 2012 changed its overall approach to the provision of long-term care, recognizing the overwhelming preference of Ontarians to age in their homes and communities for as long as possible. This led to significant increases in home-care funding that allowed it to increase its LTC home equivalent clients 75 years of age and older from 60,000 to over 90,000 each year, while continuing to serve approximately 78,000 LTC home residents 75 years of age and older each year in these settings. Despite this accomplishment of enabling more older Ontarians to age in place, the rising demand for home and community care still left many Ontarians and their families reporting that they had unmet home-care needs and increased family caregiver distress. Meanwhile, LTC home waitlists continued to climb by over 13,000 individuals from 19,615 individuals in 2011-12 to 32,773 individuals in 2017-18. While the current government has continued to increase its home-care budgets, it has been doing so at a much lower rate and seen a subsequent further increase in its LTC home waitlists by 6,000 individuals in less than two years – climbing to over 38,000 individuals in 2019-20.

The Canadian Institutes of Health Information (CIHI) recently noted that 1 in 12 (8 per cent) individuals being admitted to Ontario’s LTC homes could likely have remained in the community with existing home care and community supports. While many individuals note that the current provision of home care and community supports remains fragmented, inflexible and not well integrated with the local provision of primary care and community paramedicine services, we propose an opportunity to provide a new cost-effective alternative model of LTC in Ontario that could:

1. Let more people stay at home for longer;
2. Better address the currently growing LTC home waitlists; and
3. Save considerable costs and create a more sustainable LTC system for Ontario.

We propose that the Government of Ontario’s Ministries of Health and Long-Term Care collaborate to enable the creation of a Virtual Long-Term Care @ Home Program. This program would allow emerging Ontario Health Teams and other health-care organizations and providers to voluntarily come together to identify individuals currently eligible for LTC and on existing LTC waitlists. Furthermore, they would be given access to a dedicated amount of predictable funding that they can use flexibly to provide the right mix and types of care involving local primary care, home care, community paramedicine and community support services providers to enable individuals at high risk of needing to enter a LTC home the opportunity to now preferentially stay at home longer and perhaps never need a LTC home.

Currently, over 30,000 LTC beds in over 300 homes across Ontario require redevelopment. In 2018, the current government pledged to build 30,000 new LTC beds within the next 10 years, and 15,000 new LTC beds within the next five years. Furthermore, $1.75 billion was committed in the 2019 budget to build 15,000 new LTC beds and redevelop 15,000 existing LTC beds over five years. More recently, in July 2020, the government revised its 2019 pledge to one which would build 8,000 new LTC beds and redevelop 12,000 existing LTC beds over five years for $1.75 billion. All told the projected cost of building 30,000 new LTC beds and redeveloping 30,000 existing LTC beds will likely cost Ontario’s Ministry of Long-Term Care between $12.74 – 16.1 billion (in 2020 dollars) in related capital infrastructure costs to accomplish these goals. This does not include the additional operational costs needed to care for Ontarians in the additionally planned 30,000 LTC beds.

Furthermore, with respect to operational costs, the Ontario Government’s recent announcement that it will move towards providing at least four hours of direct care per resident per day by 2024-25 from its current level of 2 hours and 45 minutes will likely add another $1.52 billion (in 2020 dollars) in increased staffing in order to meet the new standard across the 79,000 LTC beds in current operation across Ontario’s 626 LTC homes.

We propose that the Government of Ontario could more cost-effectively care for and support people eligible for a LTC home bed through a Virtual Long-Term Care @ Home Program. Such a program would promote shorter lengths of stays in LTC homes, thereby optimizing the utilization of current LTC home beds for the people who need them most, and reducing current and future pressures on the system as a whole. Implementing such a model of care would provide the Ontario Government with an opportunity to improve care to vulnerable Ontarians, while reducing its overall health care costs and future capital infrastructure costs. Indeed, our proposed Virtual Long Term Care @ Home Program for LTC home-eligible clients in Ontario could save Ontario’s Ministry of Long-Term Care significant construction and development-related costs of between $212,259 and $268,369 for every LTC bed it may no longer need to build or redevelop to better meet the needs of its aging population to age-in-place. By providing individuals and their families with a more flexible alternative model of home and community care that could allow them to receive the care they need to remain in their own homes for longer rather than in a LTC home, the overall cost savings that such an approach could achieve could be significant.

The Virtual Long Term Care @ Home Program we are proposing is fully aligned with Ontario’s Seniors Strategy core underlying principles of access, equity, value, quality and choice. While this proposed model is not designed to eliminate the need for more the building of more LTC homes and beds, which undoubtedly will be needed across Ontario in the coming decades, it could greatly diminish Ontario’s future need for care in institutional settings especially when 78 per cent of Ontarians recently surveyed said that if they had a preference, they would rather receive care in their own homes rather than in a LTC home setting.