ONTARIO NURSES ASSOCIATION. Submission on Ontario s Seniors Care Strategy

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1 ONTARIO NURSES ASSOCIATION Submission on Ontario s Seniors Care Strategy Dr. Samir Sinha Expert Lead for Ontario s Seniors Care Strategy July 18, 2012 ONTARIO NURSES ASSOCIATION 85 Grenville Street, Suite 400 Toronto, ON M5S 3A2 Phone: (416) Fax: (416) Web site:

2 INTRODUCTION The Ontario Nurses Association (ONA) is the union representing 59,000 front-line registered nurses (RNs), registered practical nurses (RPNs) and allied health professionals and more than 13,000 nursing student affiliates providing care in Ontario hospitals, long-term care facilities, public health, the community, industry and clinics. We welcome the opportunity to provide frontline nursing input to Dr. Samir Sinha, the expert lead for Ontario s seniors care strategy. ONA member s have a keen interest in the government s seniors care strategy since nurses provide care to seniors in all health sectors and in all stages of the continuum of care acute care, community care, long-term care and in public health. ONA also supports the expressed overall goal of the government s seniors care strategy, as we understand it, to help seniors stay healthy and live at home longer. However, moving toward this goal will require substantial expansion of capacity in the community sector. Dr. Sinha s mandate is to consult on the following strategies identified by the government as making up the seniors care strategy: Expansion of doctor's house calls. Increase in access to home care for seniors in need. Establishing care co-ordinators to work with health care providers so seniors receive the right care, particularly as they recover from a hospital stay. Helping seniors stay healthy by eating well and exercising regularly so they can manage their own care and stay mobile. In our submission, we will not be commenting on a further component of the government s overall seniors care strategy allowing seniors to adapt their home to meet their needs as they age with the assistance of the Healthy Homes Renovation Tax Credit because it is already in process of being implemented through legislation. Finally, our submission will cover enabling factors within three broad areas where the government has indicated that Dr. Sinha is seeking advice from stakeholders: How to support seniors at home; How to reduce hospital readmissions; and How to relieve pressures on long-term care homes. ONA Submission on Ontario s Seniors Care Strategy/July 18,

3 EXPANDING CAPACITY We believe that any discussion of a seniors care strategy must start with looking at the full continuum of care and not simply looking at health sectors in isolation from each other. It is the integration of care across the continuum that is a critical factor for a successful strategy for seniors care. To take funding from one sector at the expense of another health sector seems to frontline nurses as a major mistake and will not integrate care for seniors but will lead to unintended care consequences for seniors. What we will be highlighting in our submission is a philosophy of the right funding and the right provider for the right care in the right place and the right time that is required by the needs of the patient to achieve a desired outcome of quality care. When you predetermine where and when care will be funded and who will provide the care without basing those decisions on evidence and the needs of the patient, then issues of insufficient capacity arise. Funding and care is shifted in advance before capacity is built up to accommodate both people waiting for care on waitlists and new priority clients coming out of hospital with high needs and in higher volumes. We believe it is essential to address the inadequate ratio of RNs to population in order to provide improved access to nursing care, to retain our experienced nurses and to rebuild our aging nursing workforce. Ontario currently has the second lowest ratio of RNs to population in Canada. The ratio of RNs to population is important because numerous research studies performed both in the U.S. and in Canada show that there is a direct correlation between RN staffing levels and patient outcomes. 1 RN staffing, for example, is associated with a range of better patient outcomes: reduced hospital-based mortality, hospital-acquired pneumonia, unplanned extubation, failure to rescue, nosocomial bloodstream infections, and length of stay. We also know that for every patient added to an average nurses workload, morbidity and mortality rates rise 7 per cent. That means adding one patient to a nurse s average caseload in acute care hospitals is associated with the following outcomes: ONA Submission on Ontario s Seniors Care Strategy/July 18,

4 a 7 per cent increase in failure to rescue (complications), a 7 per cent increase in patient mortality, a 23 per cent increase in nurse burnout, and a 15 per cent increase in job dissatisfaction. 2 We also have to address inequalities in working conditions to attract new nurses to community care and to retain experienced nurses as services are shifted out of hospitals as part of the government s plan to transform the delivery of health care in Ontario. In addition, our long-term care facilities must have minimum staffing standards that are funded and regulated to protect the increasing level of care our seniors require. These are not isolated decisions but must be considered together. Addressing challenges sector by sector will not achieve the government s objective of quality care. The Ontario 2012 budget begins the shift in priorities. It allocates 4 per cent annual average growth for the community care sector over the next three years, which is about half of the past growth rate. Though the community sector will gain from spending increases compared to other sectors such as zero per cent growth for hospital base funding, the auditor has identified that 10,000 people are waiting for community care. 3 We are informed from frontline case managers that the current complement of RNs are already hard pressed to manage caseloads and coordinate home care to meet community needs. We are, therefore, concerned that the community sector will be unable to grow at a fast enough pace to keep up with the transfer of patients and services from hospital to the community sector let alone address the needs of people currently waiting for care. In addition, there are concerns about attracting RNs to the home care sector, given current compensation levels and the lack of pension benefits. Similarly, it is becoming clear that the 2.8 per cent increase in funding allocated in the budget for long-term care is insufficient to cover current staffing and to maintain the current level of service, and will certainly not tackle the waiting list of over 25,000 people in need. 4 Only 1 per cent of the funding growth is specifically allocated for direct resident care. As well, wait times for placement into a long-term care home are too high currently close to four months (113 days). 5 ONA Submission on Ontario s Seniors Care Strategy/July 18,

5 In terms of the importance of the right provider to outcomes of quality care, it is important to note that the increasing acuity of clients in community and in long-term care as a result of shortened length of stay in hospital and renewed efforts to shift alternative level of care (ALC) patients out of hospital requires the skills and knowledge of RNs. 6 IMPROVING CARE COORDINATION AND QUALITY OF CARE We believe a key factor to move towards the government s objective, in addition to expanding capacity in the community and long-term care sectors, must be to improve the coordination and quality of care received by clients in the transitions from hospital acute care to community care. Improved coordination and quality of care for seniors, in our view, is contingent on four primary factors: Clarity of roles; Establishing better linkages between health sectors; Geriatric education in nursing education; and Right provider and right skills for client needs. Clarity of Roles At the moment, Ontario is in the process of introducing a number of new roles such as health navigators, discharge navigators, care connectors, rapid response nursing, behavioural supports nursing, nurse-led long-term care outreach teams into a system with existing roles related to case management, long-term care placement, and discharge planning along with direct nursing care in home and in long-term care homes. While we support the addition of nursing resources, what we are recommending is better clarity of roles and less fragmentation of care when care transitions between sectors and even within, for example, the community care sector. We believe that better clarity of roles and consolidation may assist with better overall coordination of client care. The government s objective is to ensure the right care, at the right time and in the right place. We support such an approach but we are not convinced that introducing multiple fragmented roles is the way towards better integration of care. Let s take a look at some of the nursing roles that are being introduced. ONA Submission on Ontario s Seniors Care Strategy/July 18,

6 We have health navigators being introduced in northern Ontario by the Northeast Local Health Integration Network (LHIN) to work directly with the local Red Cross and who will connect seniors discharged from hospital with the potential assistance of 70 community support service providers. We have 4 discharge navigators being introduced in the Toronto Central LHIN who are to support patients at high risk of readmission to hospital by coordinating care after they are discharged. At the same time, we also have 14 Community Care Access Centres (CCACs) with case managers coordinating home care services and responsible for long-term care placement. Other roles being introduced include rapid response nurses that will provide the first in-home nursing visits to patients with high-risk conditions within 24 hours of being discharged from hospital. These nurses are to help patients with the transition from hospital care to home care to reduce the risk of readmission. We also have care connectors in CCACs helping to connect patients with family physicians and nurse practitioners. So, we have 14 LHINs, 14 CCACs, and multiple navigators, connectors and case managers arranging and coordinating care with multiple service providers for home care and multiple community support service providers. We view this as the description of a fragmented system. Establishing Better Linkages As you can see from our discussion of role clarity among multiple related roles, we have seniors and other patients who make transitions across multiple sectors from acute hospital care to home care or to community support services. But, we also have 14 LHINs and 14 CCACs involved in the coordination of care from multiple care providers and involved in various pilots and projects. In addition, we have seniors trying to navigate decisions about placement in longterm care homes, arranging home care services among numerous providers, and accessing public health services and primary care. One of the key factors to address is where does the hand-off or transition of care take place and who has primary responsibility for the coordination of the client s care in the discharge from hospital, in the coordination of home care services in the CCAC, in coordination of community support services, in accessing aging at home services funded by the LHIN, or in some form of primary care coordination. ONA Submission on Ontario s Seniors Care Strategy/July 18,

7 It appears to us that the current fragmented system cries out for fewer points of coordination of care and of more integrated roles. We will suggest an approach for better integration through improved case management in a later section. Geriatric Education We are offering our support for a much-needed improvement in nursing education the incorporation of specific geriatric education in nursing education, including placement opportunities in community care and in long-term care. While the responsibility for Ontario education funding and curriculum rests outside of the Ministry of Health and Long-Term Care, we are taking an integrated view of building a better foundation and understanding of geriatric care in nursing education leading to better care for seniors. Nursing student clinical placements in long-term care settings, in particular, should be in the later years of the nursing program to ensure the placement is with a RN and covers the breadth of knowledge required in long-term care nursing assessment skills and oversight of other staff and overall resident care. This will assist to support the retention of new nurses, reduce admission rates to hospital, proactively treat illness, and assist long-term care homes in meeting legislated standards for resident care and 24/7 RN staffing. Right Provider and Right Skills for Client Needs Our advice focuses on ensuring the right provider with the right skills is in place to meet client needs, which is the best approach to ensure quality client care outcomes are achieved. In the nursing profession, the right provider is related to the complexity of the client s care needs and whether the client has stable and predictable care outcomes. RNs are the right provider for complex and/or unstable clients with unpredictable outcomes. RN s should also be the first assessor to determine if a client is stable in all situations. Within the context of the competitive bidding system of home care contracts in Ontario, the right provider is often based on price and not client care needs. 7 We will have more to say about moving away from a system of competitive bidding in a later section. ONA Submission on Ontario s Seniors Care Strategy/July 18,

8 In addition, the current approach of using specified pathways for care require the comprehensive skills of RNs to ensure that the appropriate level of nursing skills, knowledge and judgment are available when client conditions change or are outside of the care pathway. This observation applies to both home care nursing and to case management. IMPROVING CASE MANAGEMENT The current case management practice in Ontario CCACs does not provide total care coordination for clients. We believe current practice should be expanded to coordinate the full range of care needs for clients both in home and in community care but also as the need for services crosses into other sectors such as public health or primary care. There is evidence from the literature that shows when case managers are able to coordinate a range of services for the frail elderly based on need, the use of hospital emergency, acute care and long-term care declined. 8 It appears to us that an evolution is required and with it a clear redefinition of case management as total care coordination based on client needs. Recent developments in integrated client care projects address clients within a defined population health perspective. This approach provides nurses the ability to care for the health needs of a specific population, and to specialize the delivery of care by understanding the unique health characteristics and behaviours of clients. It also allows for acute care while ensuring preventive care measures are included. But, clients may require individual care coordination that might not fit the care pathway. One flaw in the existing care delivery system is best practices and care maps may be a practical application for the majority of defined group of clients but may not address all needs as it does not coordinate the total care required by individual clients. The coordination of care of individual clients should be at the centre of care assessment and delivery. Tools should be available to determine care but assessed need must be at the centre of the coordination of care. Evidence-based practice, with an emphasis on effective client outcomes, is sometimes overlooked because of costs and the current funding model. Coordinating members of the ONA Submission on Ontario s Seniors Care Strategy/July 18,

9 health care team to concentrate their efforts with a specific population enhances the quality of care and health care costs can be reduced. To ensure an integrated model works with coordinated care/case management, it is critical to provide guidance on appropriate caseloads and to adjust for the increased workload and time it takes to make an integrated and coordinated model of care work. This needs to include integrating community support services such as meals on wheels, day programs, transportation so that seniors are not just given multiple pamphlets and if something needs to be cancelled or rearranged a senior is not left trying to navigate a confusing system. As a result, it is our opinion that now is the time for CCACs to deliver home care nursing and to bring components of home care assessment and visiting back to RNs in CCACs to provide hands on home care as part of their practice. This should involve additional home care nurses to cover increasing workload concerns, and be incorporated into ongoing in-person client assessment within current case management practice as was done prior to the introduction of the competitive bidding system. This means moving to a practice where case managers and community nurses are able to assess client conditions instead of focusing on the system in need such as, for example, wound care. We believe that an approach focused on coordination of client needs is also conducive to measure and to address client concerns related to the quality of provider and worries about care being curtailed if they complain. Taken together, it is time to start moving away from the restrictive system of competitive bidding given the negative impacts on client care and on nurse staffing in the sector as we will highlight below. HEALTH HUMAN RESOURCES PLANNING A final dimension for a seniors care strategy that we will discuss involves factors related to building and sustaining a quality nursing workforce in home and community care in Ontario. To begin, we note that the sole database on the characteristics of the nursing workforce in Ontario and by sector is the annual nursing statistics gathered and managed by the College of Nurses. For 2011, these statistics highlight that 30 per cent of the RN workforce is now eligible for retirement in the coming years, and show that 501 fewer RNs are employed in nursing in ONA Submission on Ontario s Seniors Care Strategy/July 18,

10 Ontario. These are troubling trends given the rising acuity and multiple chronic conditions of our clients. 9 It is our recommendation that now is the time to take a further step forward to formalize a role for LHINs to establish base hours of nursing care by nursing classification in each and all sectors, and to track base nursing hours of care by nursing classification through accountability agreements with health service providers in each and all sectors. This intentional planning for the nursing workforce is necessary given the increasing complexity and instability of client conditions within Ontario s aging population. Research is underway in Ontario to consider retention and recruitment strategies for home care nursing that incorporate the unique professional and personal needs associated with different stages in nursing careers whether early career, mid career or late career. 10 Overall the initial conclusion is that it is a challenge to retain and stabilize the nursing workforce in home care because of changing contracts, funding based on a blended client case mix while the complexity of the client population is increasing, and fluctuations in referral volumes within the system of managed competition. As well, early career nurses were more likely to leave home care nursing. A further consideration is improving the working and care environment by improving the ratio of full-time to part-time nursing positions in the community and long-term care sectors. While progress has been made overall towards a RN target of 70 per cent full time employment (67.9% in 2011), differences remain between sectors and for nursing classifications within the community sector. Based on the latest available data (2010), the percentage of full-time RNs varies from 67.3 per cent in hospitals, to 63.6 per cent in long-term care and 61.4 per cent in community care. Within community care, 79.1 per cent of case managers are employed in fulltime positions compared to 49.3 per cent of visiting nurses. A final factor impacting recruitment and retention of the nursing workforce is the disparity in compensation levels between the home care and long-term care sectors compared to the hospital sector. This disparity is also a significant barrier for nurses whose work may be shifting from the hospital sector into the community sector. ONA Submission on Ontario s Seniors Care Strategy/July 18,

11 CONCLUSION We have outlined our support for improved geriatric education within nursing programs and improved placement opportunities for home care nursing and long-term care nursing in the later part of the nursing program. We have discussed a number of additional factors role clarity, sector linkages, and the right provider for client needs to improve care coordination and the quality of client care. We have recommended expanding capacity in the community and longterm care sectors to address rising demands and increasing complexity of client conditions. Further, we have made recommendations to expand the current case management practice to coordinate the total care needs for the client. Finally we have outlined the need for intentional planning and initial steps to take to build and sustain the nursing workforce in the community and long-term care sectors to address the care needs of our aging population. We thank you for the opportunity to provide our frontline input and we look forward to reviewing the recommendations for Ontario s seniors care strategy when they are developed. 1 See, for example, Needleman, et al. Nurse-staffing levels and the quality of care in hospital. New England Journal of Medicine 346(22): , See Linda H. Aiken et al. Hospital Nurse Staffing and Patient Mortality, Nurse Burnout, and Job Dissatisfaction. Journal of the American Medical Association 288(16): , Annual Report of the Office of the Auditor General of Ontario, 2010, p Ontario Association of Non-Profit Homes and Services for Seniors, Long Term Care Waitlists Growing Homes Challenged to Respond, Media Release, June 3, Health Quality Ontario, Quality Monitor, 2012, p Health Quality Ontario, Quality Monitor, 2012, pp Doran, Diane. Home Care Nursing Health Human Resources: Building and Sustaining a quality Nursing Workforce in Home and Community Care, Interim Progress Report, MOHLTC Grant #06508A, March 31, Williams, A.P. et al. Reducing Institutional and Community-Based Care, Healthcare Quarterly 12(2): College of Nurses of Ontario. Membership Statistics Report See note 5 above. ONA Submission on Ontario s Seniors Care Strategy/July 18,

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