Drugs vs. Direct Care: Is a minimum care standard a solution to the current woes facing long term care?

When I walked in to the office this morning I stood face to face with this article on the front page of the Toronto Star – an intimate portrayal of the medicating culture that has taken over long-term care (LTC) homes.

The article brings to light the use of antipsychotic drugs on elderly patients, and questions the alarming rate at which these medications are being administered. According to The Star, “At more than 40 homes across the province, roughly half the residents are on the drugs.” Half! On antipsychotic drugs: medication, The Star claims, that is being used to treat a condition or age group that it’s not approved for. In the article, they cite these drugs as “extremely powerful”, “not proven to work for seniors” and as having “horrible side effects” such as violence, confusion, and [some might suggest] death.

Though much of the article focuses on whether it is even appropriate to prescribe such medications, it also raises the questions around staffing, resources and patient care. Why are seemingly harmless residents being prescribed life-threatening medication, when staff members are unable to “cope” with their behaviour?

According to Statistics Canada, total paid hours of care (including non-direct care) per resident, per day in residential care facilities in Ontario was 3.3 in 1997/98 with a small increase to 3.8 in 2005/06. According to this data, Ontario is second last across the country for total hours per resident/day. The Ministry of Health and Long-Term Care says that paid hours of care in 2012 were 3.43 per resident per day.

The number of paid hours takes into account hours paid for vacation, sick days and personal time. Therefore, “worked hours of care per resident per day” better reflects how many hours of care a resident actually received. According to the Ministry of Health and Long-Term Care, average worked hours of direct care per resident, per day was 2.375 in 2004 and 2.573 in 2006. We estimate that this number corresponds to no more than 2.9 hours of direct care per resident per day in 2012. For reference, in 2008, the government of Ontario commissioned a report on the long term sector, ‘People Caring for People’, authored by Shirley Sharkee. The report recommended 4 hours of direct care per person per day.

An obvious reality is that staff members are unable to respond to the needs of the residents, because of the shortages in caring staff and because of the increasingly complex needs of the residents. For example, 83% of residents in 2011 had “high” or “very high” care needs compared to 72% in 2007. That’s an 11% increase in residents of high need within a period of four years.

Research shows that incidents of violence occur most often when residents are not receiving direct care. And so it seems that some nursing homes that have shortage in staff, are regularly giving seniors these risky drugs to calm and “restrain” wandering, agitated and aggressive seniors. Medicating them with these strong medications seems to be an attempt to control their natural response to the neglect they face in a long-term care home.

The Star article goes on to write that “after a 2011 Star investigation into widespread abuse and neglect in Ontario nursing homes, the government spent $59 million to hire more than 600 employees and train 34,000. The efforts appear to have done little to ease most nursing homes’ reliance on these powerful drugs…”

In spite of successive years of funding increases to the LTC home sector, there has not been a similar increase in daily hands-on care provision. The vast majority of funding increases has gone towards building institutional capacity (either building more institutions or renovating older ones) rather than improving the amount of daily care for existing residents and addressing the urgent quality of care issues.

In January of this year, SEIU Healthcare made the following proposal at the 2014 Pre-Budget submission to the Standing Committee on Finance and Economic Affairs:

A five-year implementation schedule that would begin in 2014 with an immediate establishment of a minimum care standard of 3.5 hours of direct care per resident, per day, with the target of a 4.0 hours of direct care per resident by 2019. The standard should cover direct care staff including RPNs and PSWs, excluding administrative staff. It should be attached to the Nursing and Personal Care funding envelope – excluding incontinence supplies. It should reflect worked hours as opposed to paid hours and should be subject to compliance and enforcement mechanisms.

Staffing levels are crucial to providing sound care, preventing abuse and neglect, ensuring the safety of residents and care workers, and improving the quality of life of residents. A minimum staffing standard will ensure accountability and compliance for all LTC homes in Ontario to deliver a specific amount of daily care for which they are funded.

S.R.S and A.B.

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