Position Statement: Strengthening Client Centred Care in Long Term Care
Adopted by the RNAO Board of Directors on June 25, 2010
RNAO strongly supports the development of Long Term Care Homes (LTCHs) utilizing a resident/client-centred care model, where Ontarians have access to continuity of care and continuity of caregiver from a primary nurse. RNAO also strongly endorses strengthening inter-professional care so all health disciplines work closely to support high quality care in all health care settings. Regardless if a home is not-for-profit or for-profit, adhering to the appropriate nursing care delivery model and skill-mix, is paramount to optimize resident, staff and organizational outcomes. Excellence in resident/client centred long term care is supported by four pillars:
Nursing care delivery models that advance continuity of care and continuity of caregiver by assigning each resident one nurse per shift, that nurse being an RN or an RPN working to full scope of practice and accountable for delivering or directing the total nursing care required by that individual resident;
· Assignment of the most appropriate caregiver based on the resident’s complexity and care needs and the degree to which the resident’s outcomes are predictable, with RNs assigned total nursing care for complex and/or unstable residents with unpredictable outcomes, and RPNs assigned total nursing care for stable residents with predictable outcomes. A resident whose condition is or becomes unclear will be cared for by RNs. This prevents shifting a resident back and forth between RNs and RPNs thereby reducing fragmentation of care and reducing multiple risk factors. When Unregulated Care Providers (UCPs) are utilized, they are assigned to assist RNs or RPNs, where appropriate and under their supervision, with attention given to prevent disrupting the continuity of care provided by the assigned nurse;
· Workforce stability, by achieving 70 per cent full-time employment for all nurses and UCPs, supports continuity of care and continuity of caregiver, improves intra and inter-professional team work, reduces costs and facilitates staff satisfaction and retention;
· Not-for-profit funding, that supports a healthy work environment for all staff, enables a resident to experience a higher quality of care, higher quality of life, reduces risk and prevents unnecessary hospitalizations and other health system costs.
As a society, we have a duty to respond to older persons’ needs, promote their health, and care for them when they are ill; this is a sign of a healthy society with a strong social fabric that does not abandon the frail and / or infirm.
Residents in long term care homes (LTCHs) have increasingly complex care needs compared to residents 15 years ago. The average age of residents in LTCHs has climbed from 75 in 1977 to 86 in 2002 as residents seek LTC closer to the end of their lives and “residents with multiple care needs that were previously cared for in chronic care hospitals are now cared for in LTC (long term care) homes.” While complexity is increasing, the number of LTC residents is also expected to rise. One estimate projects between 565,000 to 746,000 LTC beds will be needed across Canada by 2031; up from a supply of 194,000 beds in 2002.
A severe shortage of LTC services is impacting the entire health-care system confirming the interconnected role LTCHs have with hospital and community services. Currently, at least 21, 500 Ontario residents are waiting for a LTC bed in homes that are 98% full. In January 2010, 4,977 Ontario hospital patients were designated as Alternative Level of Care (ALC) residents, costing millions of health-care dollars unnecessarily each year. Those waiting for LTCHs account for 60 per cent of all ALC days and their wait times have tripled since the spring of 2005 to an average wait time of 105 days. Significant variance in wait times is observed within the province, (e.g., Eastern Ontario region’s waiting list has grown considerably with seniors waiting an average of 237 days; dramatically higher than the 169-day average reported in 2009.)
Retirement homes have been used to relieve hospital ALC pressures but with dire consequences. Inappropriate placement of ALC residents in retirement homes led Ontario’s Chief Coroner to recommend retirement homes be required to meet the same standards of care and services as a licensed LTCH if such services are necessary. With the passage of Bill 21, Retirement homes will be regulated to provide similar care and services as a licensed LTCH. This solution introduces a slippery slope towards the privatization of health-care services and requires seniors to pay for their access to health care; a contravention of the Canada Health Act.
Although the Ontario government states that it “is committed to providing homes where our seniors can live in dignity with the highest possible quality of care,” funding for LTC services has failed to keep pace with increasing care needs. A strong positive relationship between nurse staffing levels and the quality of care in LTCHs has been consistently established. A 2002 landmark national study in the United States carried out by the Center for Medicaid and Medicare Services (CMS) found that a minimum staffing level of 4.1 “worked hours” of nursing and personal care hours (not “paid hours”) is required to avoid jeopardizing the health and safety of LTCH residents.Yet in early 2007, the Ontario government released information that LTCHs in the province only averaged 2.86 worked hours of nursing and personal care per resident day. Furthermore, it has been well documented that Ontario’s LTC homes have a resident population with higher care needs than a number of other jurisdictions, while residents have received less nursing, personal care, and rehabilitation therapy than found in the majority of comparator jurisdictions. Additional PSW and RPN funding have since increased hours of care delivery, but the ministry has not produced any guidelines to consider the optimal skill mix required for quality services in LTC.
The Ministry of Health and Long Term Care is currently implementing many LTC quality initiatives to address significant and repeated concerns that Ontario LTCHs inadequately safeguard residents’ safety and dignity. Evidence of poor quality and a media-led public outcry triggered an investigation by the Ontario Ombudsman in 2008. Although many agree quality initiatives are necessary to improve care in LTCHs, many of the quality initiatives have been introduced but have not been funded at the home level and therefore are perceived as an additional burden on already stretched staff.
Access to Registered Nurses
Access to registered nurses (RNs) in all sectors is essential to achieve optimal health outcomes. There is conclusive evidence of a strong linkage between staffing, and particularly RNs, in long term care facilities and resident/client outcomes including: lower death rates, higher rates of discharges to home, improved functional outcomes, fewer pressure ulcers, fewer urinary tract infections, lower urinary catheter use, and less antibiotic use. Increasing access to registered nurses in LTCHs also reduces hospitalizations that incur significant system costs and resident morbidity. Despite the current trend to move complex continuing care beds out of hospitals into LTCHs and the need to reduce hospitalizations from LTC, LTCHs across Ontario chose to reduce rather than increase their inadequate proportion of RNs by 269 FTEs from 2006 to 2007.This reduction has both ethical as well as cost implications. According to one
recently published Ontario-based study, up to 55 per cent of potentially avoidable hospitalizations (PAHs) could be reduced by adjusting human resources and physical resources in LTCHs. Nursing care delivery models that undermine the importance of RNs’ knowledge and reduce direct care hours provided by RNs result in reduced continuity of care and continuity of caregiver, fragmented care, and higher morbidity and mortality. The evidence is clear that in long term care homes RNs are more effective in improving resident outcomes and reducing cost.