Over the past two days, TVO.org has continued to explore the challenges facing Ontario’s health-care system. In July, a three-part look at delays and overcrowding in emergency rooms set the stage for this series. My interviews last month with staff working in (or with) emergency rooms made it clear that many of the problems affecting ERs across the province actually begin elsewhere in the system. Overcrowding anywhere can cause bottlenecks everywhere.
In November 2018, there were approximately 4,600 patients in Ontario who needed an “alternate level of care,” or ALC — that is, they were occupying hospital beds but would’ve been better served elsewhere in the system. On any given day, about 15 per cent of the beds in Ontario hospitals are occupied by ALC patients, approximately half of whom are awaiting transfer to a long-term-care facility. And while the province’s 4,600 ALC patients await more appropriate beds, roughly 1,000 Ontarians a day are admitted to hospital but remain stuck on stretchers in hallways because our hospitals routinely operate beyond 100 per cent of their occupancy.
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The Progressive Conservative government has signalled that this issue is a priority. Premier Doug Ford said just a few weeks ago that he wants “hallway health care” eliminated within a year (Health Minister and Deputy Premier Christine Elliott politely walked the premier’s rather aggressive promise back a few days later). The Ford government has even proposed a solution: open 15,000 new long-term-care beds.
This is a good proposal, and an achievable one. As noted in the second part of this series, the long-term-care system is publicly funded, but much of it has been privatized — the government pays companies to operate many of the province’s facilities, and patients also pay room and board. The system can be expanded if the government chooses to spend more money on it.
But will Ford’s plan actually work?
It will help. No one disputes that. In fact, a bit of quick math suggests that it would totally solve the problem: If roughly half of Ontario’s 4,600 ALC patients are awaiting long-term-care beds, that’s 2,300 people. And if those 2,300 people were moved from hospitals to long-term-care facilities, that would create more than enough room for the thousand or so patients waiting in hallways. Right?
Yes — but also no.
You’ve heard the saying about lies, damned lies, and statistics. In this case, it’s lies, damned lies, and quick math — the numbers check out, but the assumptions are off.
Consider: If all 15,000 of the proposed new long-term-care beds were suddenly open and available, who would fill them? Not necessarily the patients waiting in hospitals.
In late 2018, the average wait time for a long-term-care bed, according to figures presented to the government in January, was 146 days. The Ontario Long-Term Care Association reported that the situation was slightly worse in February 2019: 161 days. That month, 34,834 Ontarians were on a waiting list for a bed in a long-term-care facility. Placement in such facilities is on a priority basis, and clearing a hospital bed is not necessarily a top priority.
According to the province’s published criteria, patients who are the top priority for placement in long-term-care facilities are those who “need immediate admission to long-term care and cannot have their needs met at home,” who are already in a long-term-care facility that is imminently closing, or who are currently waiting in a hospital “that is in crisis.” (Of course, with the entire system operating beyond 100 per cent capacity on a regular basis, you have to wonder what would constitute a crisis.) Patients who need to be reunified with a spouse who is already in the long-term-care system, but at a different facility, are the second priority. Only at the third level of prioritization do we see any real emphasis on clearing out the hospital beds — the same level at which “religion, ethnic origin or culture” factors are considered.
Adding 15,000 new beds would, in theory, make a big difference. It would cut the wait-list almost in half. This would no doubt move some ALC patients out of hospital, but not as many as the quick math above would suggest. There is also the problem of making sure that the new beds are created where they are needed — an empty bed in Kitchener doesn’t do someone in Kingston much good.
This is not intended as a criticism of the Ford plan. Opening 15,000 new long-term-care beds is a good plan, one that should be expedited. Our population is aging, and that means we’re going to need more and more such beds. The sooner we begin providing them, the better. But Ford’s plan is not a complete solution to the problem of overcrowded hospitals.
So what else can be done?
There is one important but complicated element to all this that I haven’t touched on yet, and I regret that I won’t be able to do it proper justice here. So, in appallingly brief terms: another issue at play involves the widely recognized challenges that Ontario faces in providing adequate mental-health care. Though the bulk of Ontario’s backlog of ALC patients are those awaiting a long-term-care bed, roughly 9 per cent of long-term ALC patients are awaiting transfer to supportive housing. Supportive-housing programs are designed to help people with mental illnesses and/or addictions live as independently as possible. There is not nearly enough room left in this final instalment of the series to give this issue the weight it deserves; I merely flag it here as a known issue. If there were enough supportive-housing beds available to absorb all the patients waiting for one, that would ease some of the strain that our hospitals are dealing with.
And there are other ways to move patients out of hospital beds. Not every patient requires full-time housing in a long-term-care facility. In recent years, Ontario has been shifting the focus of its long-term-care resources so as to house only those patients who have need of the most advanced forms of care. Because patients who are able to stay in their own residences often prefer to, the government has been redirecting resources toward in-home and in-community supports that allow them to receive the assistance they need at home. Roughly one-tenth of ALC patients in Ontario hospitals are no longer in need of hospital care and will return to their homes and communities once local supports are in place. Delays in arranging those supports also cause bottlenecks in our hospitals.
Rehabilitation hospitals have a part to play in this, too. Rehab facilities (which are sometimes but not always co-located with primary-care hospitals) are for patients whose injuries and illnesses are no longer threatening their lives but have left them weakened or in need of physiotherapy to regain their independence. According to up-to-date figures provided to TVO.org by the Ministry of Health and Long-Term Care, there are 71 facilities with rehabilitation beds, capable of accommodating 2,562 patients. Every one of those patients frees up a hospital bed they would otherwise end up occupying until they were ready to go home.
A 2013 report by the provincial auditor general found that the rehabilitation system’s lack of capacity was responsible for roughly 25 per cent of ALC patients in primary-care hospitals. It further noted that the rehab facilities themselves had difficulty discharging patients into home- or community-based programs due to delays in putting those supports in place. Some of the capacity problems are being addressed already in ad hoc ways: some mothballed hospitals are being recommissioned to serve as additional rehab facilities, particularly during flu season, when demand for beds is at its peak.
Clearing out the backlog in our hospitals isn’t just essential to preserving our health-care system. It also makes good financial sense. Keeping a patient in a hospital bed is very expensive. Figures provided to me by ministry officials last year indicated an approximate cost of $750 per patient per day for a hospital bed. The cost of a rehab bed was an average of $500 per patient per day. Long-term-care beds were considerably less expensive, at an average cost to the province of $150 a day (recall that patients contribute financially via “room and board” charges). Home-based community supports cost even less. Keeping patients in hospitals for a day longer than needed does nothing but drive up costs.
The problem is complicated, and it will only get worse as our population ages and places increased strain on all facets of the health-care system. Opening 15,000 new long-term-care beds is an excellent first step toward meeting this growing crisis. In the long run, though, it’s clear that only a larger system offering more of everything will be able to keep up with the demand for health care in Ontario. How to fund that system will surely be one of the major political questions in the decades to come.