OP-ED: A perspective on quality within LTC homes

(Panmure resident Marilyn Colton, nurse administrator, retired from Almonte Country Haven in 2016.  Previously, she was the community director, Waterside Retirement Community in Carleton Place, ON, and executive director, Central Park Lodge, Ottawa, ON.  Marilyn is currently the chair of the Family Council at the Grove Long Term Care Home in Arnprior, ON)

This article details my personal views on quality within long-term care (LTC) homes in Ontario and is based on my experiences working within the LTC and Retirement sectors.                                                                                                          

In Ontario, there are more than 78,000 people living in LTC homes and more than 32,000 people on waiting lists for admission. 

So, what about the quality of care/service being provided to the more than 78,000 people currently living in these homes?  We only need to review the recent reports on LTC homes across Canada, since the start of the COVID-19 pandemic, to learn of incidents of abuse and neglect of their residents.  As well, we have learned of the incompetence of some administrative staff in effectively managing their resources to control the outbreak and prevent deaths. F

or example, how many administrators established procedures, such as taking staff temperatures on entry and exit from the home, at the very outset of this pandemic? How many administrators ensured that personal protection equipment donning and doffing was reviewed with all staff with testing and reinforcement at the very outset of COVID-19? How many administrators established communication processes with their residents, families and the community at large early in the pandemic and, in fact, have maintained those open lines of communication even now?

From a quality perspective, administrators need to encourage subversive ideas, also known as fresh thinking, across their entire team within the LTC home.  Administrators must provide the leadership required to ensure the quality of processes and outcomes for all residents during these challenging times and beyond.

In Ontario, the legislation to protect our residents includes the Quality of Care Information Protection Act (2016).  This act is intended to increase transparency and maintain quality within our health care system.

In addition, the Long-term Care Homes Act (LTCHA) and O. Reg. 79/10 is in place and intended to safeguard residents’ rights, improve the quality of care and improve the accountability of LTC homes for the care, treatment and well-being of their residents.

So, does this legislation result in optimal quality care within our LTC Homes?

I believe this issue needs consideration at an even more basic level. My experiences within our health care system have led me to believe our society at large does not value elders. How many times have you heard about the ‘tsunami of an aging society’ rather than celebration of the fact that people are living longer and still contributing to society, many still in the workforce or volunteering within all sectors of our health care system? This population built our country, served our country in wartimes, and endured many hardships while raising their families through the depression years and beyond. Our parents instilled in their children the goal of making a contribution to society at large while supporting their immediate family and their local community. A strong work ethic was never an option; it was a firm expectation. The seniors of today have a wealth of knowledge and experience to share if only society would listen. In LTC homes, the value must be on a resident’s life ‘to be lived’ rather than a ‘life lived.’  People do not move into LTC homes to die, but rather to live their lives as fully and independently as possible within their physical/mental/social limitations.

So, what needs to happen to enhance the focus on quality within an LTC home?

I believe we need to see a paradigm shift from an institutional (hospital) model, that provides for custodial care, ie., assistance with the tasks of daily living, to a social model of care. At the heart of the social model is compassion, respect, dignity and self-determination. We need to perceive health as more than the absence of disease. It is sadly narrow to define quality as the absence of negative outcomes.  The absence of bedsores or the absence of depression are hardly evidence of a good quality of life. I believe health refers to the wholeness of a person as that person interacts with their environment. Banal as it sounds, relationships make life worth living, whether they be relationships of love, friendship or even rivalry. I once heard a resident tell her friend to visit often “so I will know I am alive.”

Are staffing levels in LTC homes a concern relative to a discussion of quality? Yes, I believe so. At this time, Ontario’s minimum care hours/resident/day is the second lowest in Canada with B.C. being the lowest. There needs to be a minimum standard of care and such has been recommended through coroner’s inquests as well as the various provincial health care associations and coalitions.  An important note regarding the minimum four hours of care/resident/day is that it must refer to ‘worked hours,’ not ‘paid hours’ since the latter includes vacation and sick leave and does not translate into direct care.  I would like to see mandatory reporting of staffing levels per shift at each LTC home with this report provided to residents, families, Family Council and Residents’ Council.

But staffing levels are far from being the only issue. Work organization and lack of autonomy for front-line workers are also critical factors. So often, managers schedule irregular shifts which take away from continuity of care and reduce reasonable home life for the workers. As well, many LTC home managers are too rigid, do not provide for autonomy at the front line and do not adequately involve workers in decision-making or collaborate with them in making changes to resident protocols, etc. Too many managers are office-bound rather than being visible on care units to monitor care, determine and act upon the need for additional resources, supervise staff, provide just-in-time training, and, of course, converse with the residents and their family members regarding resident’s specific needs/expectations, their essential family caregivers and their level of satisfaction with care/service. 

Lastly, I would like to see more LTC homes providing a more ‘social environment’ for the residents. The cultural associations we all have with ‘home’ include autonomy, familiarity, history, relationships, privacy and dignity. These are the same expectations every resident would have when moving in to a LTC home. In doing this, the LTC home needs to better integrate its residents with the local community with initiatives such as invitations to afternoon teas, card games, intergenerational activities, varied entertainment by local musicians, special event activities, spiritual services, veteran’s services, etc. Such is consistent with the neighbourly approach and social interactions the residents would experience if still in their own private home. LTC home staff must accept the one-size-fits-all is not appropriate within this sector. There is always a care plan developed for each resident; similarly, each resident needs a recreation/social plan unique to his/her needs and interests. Both the care plan and the recreation plan must be accessible to the resident within their living space. As well, those residents suffering from dementia require special interventions such as, the Music for Memories initiative and the Montessori approach to resident care. One resident with dementia was heard to say, “the problem here is that they treat us as though we were children.”

LTC is ordinary life and people with dementia live among us as part of family units or communities.  I clearly recall when one of our residents celebrated a 60th wedding anniversary party, several members of the original wedding party with visible dementia were guests and were involved in the event to the best of their abilities. All residents need to perceive their lives are replete with interesting and meaningful things to do and see. Some will participate actively, some will be spectators, and still others will continue to make a contribution to the operations of their new home, to their families, or even to the community at large. It is essential this needs to be addressed through complete and comprehensive assessments of each resident prior to and during the move-in process as well as when changes occur.

When it comes to quality within LTC, let’s remember we must keep our eye on the quality-of-life ball or the game is lost.

In my next article, I will share information on the concept from hallways to households”in LTC.  This refers to the transformation in culture within the LTC sector that is long overdue.

Please feel free to forward your comments or queries to mcolton@xplornet.com.