How to end hallway medicine, Part 2: Solving the long-term-care crunch

ANALYSIS: Every day, thousands of Ontarians occupy beds they don’t need because the beds they do need are already occupied by other patients — and the problem is most acute when it comes to long-term care
By Matt Gurney - Published on Aug 22, 2019
an elderly woman with a walker in a care home
A report released in January found that the average wait time for a patient needing a long-term-care bed was 146 days. (iStock.com/SolStock)

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This is the second instalment in a three-part TVO.org series on hallway medicine in Ontario. Click here to read Part 1. Watch for Part 3 on Friday.

In February 2018, the provincial election was still a few months away. The campaign hadn’t officially begun yet. The Progressive Conservatives didn’t even have a leader — the vote that would see Doug Ford defeat Christine Elliott wouldn’t happen until March 10. Another Ontario story was getting a lot of attention: the sad death of Stuart Cline.

Cline, a 71-year-old London man, had been vacationing in Mexico when he fell and struck his head, resulting in a brain injury. In critical condition, Cline was taken to an intensive-care unit at a Mexican hospital. His family was understandably eager to have him treated closer to home, and Cline had private health insurance, which covered the cost of an air ambulance back to Canada. His condition was stable enough for the flight, but Ontario couldn’t take him. There apparently wasn’t a hospital bed available — at least not one close to his home.

For days, Cline’s family spoke openly with the media about their struggle to get their elderly and injured loved one home. Liberal MPP Helena Jaczek, the health minister at the time, told the legislature that “there was capacity here in Ontario” and that it was up to Cline’s insurer to coordinate with the health-care system to find him a bed. After a week in Mexico, Cline was flown back to Ontario and admitted to a hospital in St. Catharines — almost 200 kilometres from London. Several days after he arrived, Cline died.

The government quickly went on the defensive and released figures showing that a series of suitable beds had been available in Ontario. Perhaps there had been a miscommunication between the insurer and the health-care system? Cline’s story faded from the headlines shortly thereafter, bumped by coverage of Ford’s leadership win and, soon enough, the election campaign itself.

But the topic of jammed hospitals stayed in the news. The NDP pledged to significantly boost health-care spending to get more hospital beds open and staffed. The Liberals, in their last days in office, also pledged to spend hundreds of millions more a year to ease overcrowding in hospitals. The Tories’ “Plan for the People” made a slightly different promise: to cut back on so-called hallway medicine, which sees patients languish on stretchers in corridors and in other hospital spaces such as chapels and breakrooms due to the lack of available beds. The PCs said they would create 15,000 new beds — specifically, long-term care beds.

In the first part of this series, I explained how emergency-room bottlenecks may actually be caused by another part of the health-care system — for example, a long-term-care home — reaching capacity. Our hospitals are not just centres of healing; they’re also logistics hubs that manage the movement of patients. Some moves are internal: a patient arrives in the emergency room and, after triage and stabilization, is transferred to a specialized ward that’s better able to meet their needs; or a patient who has spent days recuperating from surgery in an intensive-care unit becomes stable enough to be relocated to a lower-intensity ward. Sometimes, patients are healthy enough to go home. Other times, they need a bed in a rehabilitation hospital or a long-term-care facility.

But chronic overcrowding across the system prevents the smooth movement of patients. It’s a known problem. “Alternate level of care” is the agreed-upon term used to describe a situation in which a patient is occupying a bed that they don’t need to be in because they’re awaiting transfer to a more appropriate bed that is itself occupied.

The numbers tell the tale. In January, the government received a report that it had commissioned, titled “Hallway Health Care: A System Under Strain.” It examined the capacity issues facing Ontario’s health-care system and included some fascinating, and current, stats. Years ago, as a journalist with an interest in health care in Ontario, I’d been told by a doctor to assume that approximately 15 per cent of patients needed an alternate level of care on any given day. He stressed that this ballpark figure would vary by institution, time of year (flu season is a particular challenge), and region. But 15 per cent, he said, was a good guess.

He was right. In October 2018, according to the report, 16 per cent of patients in Ontario hospitals needed an alternate level of care. The following month, in raw numbers, slightly more than 4,600 patients were occupying beds they didn’t need because the bed they did need was already full (perhaps with someone who didn’t need to be in that one). On any given day in Ontario, roughly 1,000 patients would receive health care on beds in hallways or break rooms.

The problem is system-wide. As noted in my TVO.org series on emergency-room crowding, though the international best-practice standard for hospital occupancy is 85 per cent — enough to get good value from the facility and staff while maintaining some reserve capacity — Ontario hospitals routinely operate at beyond 100 per cent capacity.

But the problem is particularly acute in our long-term-care facilities. The January report noted that Ontario’s long-term-care system was at 98 per cent of capacity, with just under 79,000 beds occupied. The average wait time for a patient needing a bed was 146 days. And this is the key point: the report found that by far the biggest contributor to the “alternate level of care” problem was delays in transferring patients to long-term-care homes.

Long-term care is a publicly funded program in Ontario, although residents pay for room and board. The costs for individual patients are capped but can still add up: a year of “standard” accommodation in a long-term-care home will cost a resident $22,000 annually (there are programs in place that assist residents who are unable to afford these fees). A private room is considerably more expensive, at upwards of $32,000 a year. Families with sufficient means can, of course, arrange for a bed in a so-called retirement home, where necessary medical care and personal supports can be arranged privately. The costs of such care can easily add up to many thousands of dollars per month — well out of reach for most. Publicly funded long-term care is where many elderly Ontarians will spend their final years.

I should take a moment here to clear up a common misconception: long-term care is not synonymous with elder care. It is available to anyone over 18 who has a valid OHIP card and requires, to quote the health ministry’s website, “24-hours nursing care and personal care, frequent assistance with activities of daily living [and] on-site supervision or monitoring to ensure your safety or well-being.”) My late grandfather, for instance, spent his last days in a long-term-care home, mostly with other people his age, but also with a middle-aged woman who’d suffered neurological damage after an illness and a much younger man who’d been in an accident and had sustained catastrophic injuries.)

Still, elderly people make up the preponderance of those who need long-term care — and Ontario’s aging population is putting enormous pressure on the system. It’s been an issue for years: the previous Liberal government, looking to ease the pressure but also to meet the evolving desires of an aging population, invested in programs designed to keep seniors safe and comfortable in their own homes for as long as possible, and thus to keep them out of the long-term-care system. It’s a good plan, and the efforts continue today. But, eventually, many seniors will require the kind of support that only long-term-care facilities can provide.

That’s why Ford’s promise to create 15,000 new long-term-care beds was a very good idea. Adding capacity to the system would ease the backlog of patients and start to address the problem of hallway health care in Ontario. With 4,600 patients requiring alternate levels of care on any given day — and more than half of those awaiting long-term care — a bit of quick math suggests that those 15,000 long-term-care beds would free up 2,000 hospital beds. That’s more than enough to handle the 1,000 patients waiting in hallways every day.

But the reality is a little more complicated than that. And we’ll explore why in Part 3.

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