The provision of appropriate, high quality services that can enhance independence and quality of life for the frail elderly is one of the most important challenges facing health policy makers around the globe. One of the cornerstones of care for the elderly is the provision of appropriate long term care (LTC).

Ontario’s long term care programs provide services and support to individuals in their home and community as well as facility based care for those whose needs can best be met in a long term care facility. Nursing homes and homes for the aged are available for people who are not able to live independently in their own homes and who require a 24-hour nursing service to be available to meet their nursing and personal care needs.

Since 1993 when the current system for identifying funding levels for Ontario LTC was introduced, dramatic changes have occurred and more are proposed for Ontario’s health system. Many of those changes have had, and continue to have, a significant influence on the delivery of long term care services in the province. Some of these influences include:

• Overall reduction in the number of acute care beds with an increasing emphasis on shortened lengths of stay which in turn, puts renewed emphasis on caring for patients in non-acute based settings including LTC facilities,
• Uneven distribution of long term beds across the province,
• A continuing shift to a higher proportion of heavier care residents (based on the Alberta Classification System) and an increase in provincial Case Mix Measure in Ontario LTC facilities,
• Re-organization of a number of chronic care/complex continuing care beds and a shifting role for complex continuing care facilities, and
• Placement Coordination Services and access to long term care beds managed by Community Care Access Centres.

These changes in the system create a number of important questions when reviewing long term care services and when evaluating the underlying policies related to care for the elderly a number of central questions arise such as:

• What are the most appropriate types of care and services to offer a given population?
• Where are these services most appropriately provided?
• How much service should be provided to this population?
• How should scarce resources be distributed to be equitable?
• How can we maximize the impact of the allocation of those scarce resources?
• On what basis can the quality of care be assessed - and what relationship exists between quality of care and levels of services?
• What mix of expertise is required in order to serve the needs of the frail elderly?
• What limits are currently in place in long term care settings that must be addressed?

Given these important questions for facility based long term care, the Ontario Association of Non-Profit Homes and Services for Seniors (OANHSS) and the Ontario Long Term Care Association (OLTCA) embarked on an initiative to review the provision of services in long term care (LTC) facilities. The objectives of the review were to determine:

• The existing complexity (acuity), of a sample of long term care facility residents,
• The current amount of services (direct and indirect for nursing, therapies and accommodation) provided to a sample of residents in long term care facilities in Ontario in minutes/resident/day, and
• How the existing acuity and levels of services in Ontario LTC compare to similar residents/patients in Ontario Complex Continuing Care (CCC) settings as well as long term care facilities in other Canadian provinces, the U.S. and European jurisdictions.

The study used a combination of facility-specific staffing levels, financial and MDS 2.0 data from a sample of Ontario long term care facilities and compared both needs of and services provided to residents in the Ontario LTC setting to the needs of and services provided to individuals in CCC in Ontario and individuals receiving long term care in Manitoba, Saskatchewan, four U.S. states and three European countries.

Evidence about the care of almost 150,000 frail elderly persons in Canada, the U.S. and Europe was used to compare against the experience of a sample of residents in long term care facilities in Ontario.

Throughout this report, "level of care" and "level of service" are used to describe the amount of care provided by a range of caregivers in long term care facilities and Ontario CCC to residents and patients in those facilities. The focus of the report is a quantitative analysis of the amount and type of care (i.e. by type of provider). In referring to the amount of care provided and potential patient outcomes, no comment is being made about the quality of care in these settings. It is hoped that this report will assist in providing a richer understanding of the important issues related to differences in care levels in the study population.

Study limitations considered the following:

1. reliability and validity of data;
2. degree to which the samples used are representative; and
3. relevance of historical period in which observations are made.

• The MDS 2.0 has shown consistently to have good measurement properties in terms of inter-rater agreement, internal consistency, convergent validity and criterion validity.

• MDS 2.0 data is limited to providing information on what services have been received and not on what services should have been received given the need of the resident or patient. Consequently, if a population is under-served then the case mix index of that population may be comparatively lower than the cohort based upon what services were received.

• The need analysis was designed to identify persons in need of specific services and provides an overview of the need for medical, nursing, rehabilitation and psychosocial services but does not control for the acuity of the persons under investigation. This need data was also extracted from the MDS 2.0.

• Several of the jurisdictions are required to submit MDS 2.0 data for funding purposes, which may influence data quality.

• The Canadian, European and U.S comparators were chosen based upon the availability and quality of MDS 2.0 data.

• The Ontario LTC, Manitoba, Sweden and Finland data are all from pilot/research studies in which samples of residents were drawn at the time of assessment.

• The issue of the time of data collection is also another important consideration. The Swedish, Finnish, and some of the U.S. data were gathered from 3-5 years earlier than the Ontario data.

Despite these caveats, this study represents a major step forward in providing new evidence about at least some of the questions posed earlier with respect to long term care in Ontario.

The key question this project is intended to address is "how does the level of services (nursing, aide and therapies) provided to residents of Ontario long term care facilities compare to the services received in other long term care and Ontario CCC settings"?

The approach taken in this report to deal with the issue of measuring and comparing service levels is to consider the extent to which persons with specific needs are able to obtain access to interventions that can address those needs. For this study, indicators of need were developed based on MDS 2.0 data that are independent of the services received data within the MDS. This comparison can be done on a non-monetary basis, i.e. separate from different levels of funding or reimbursement across sectors, and enable comparisons to be made about differences in services received by similar populations with similar needs.

Demographic Characteristics of the Study Population

• Ontario LTC residents were among the oldest (82.1 years). The youngest population is in Ontario CCC beds with an average age of 74.1 years.

The number of residents with dementia and Alzheimer’s disease in Ontario long term care facilities has significant implications for the care and treatment of these individuals. Clearly, there needs to be adequate numbers and types of caregivers with specific training, as well as evaluation and monitoring programs in place to deal with health problems exhibited by these residents.

Arthritis, stroke, congestive heart failure (CHF) and diabetes followed dementia and Alzheimer’s disease as the most common diagnoses in the studied long term care facilities. Compared to Saskatchewan and Manitoba, there is a slightly higher proportion of residents in Ontario long term care facilities with stroke (22%) than Saskatchewan (18%) and Manitoba (16%).

Arthritis was the most common diagnosis of a physical problem in North American long term care facilities with between 26% to 39% of all residents having this diagnosis.

The prevalence of these physical problems contribute to the increase in acuity levels seen in long term care and have a major impact on the efficacy of long term care and specifically nursing care. With appropriately trained long term care staff, morbidity arising from conditions such as CHF, diabetes, arthritis, etc., can be decreased by refocusing the objective of nursing care to the prevention of complications and the promotion of mental and physical health. Long term care staff can learn to recognize and avoid potentially problematic situations or conditions, thereby minimizing the need for transfers to acute care centres for more costly treatments and care.

Several scales which measure degree of impairment with cognitive ability (Cognitive Performance Scale), ability to accomplish activities of daily living (ADL Hierarchy Scale), health instability (Health Instability Profile), and levels of depression (Depression Rating Scale) were reviewed. The results indicate that:

• On the Cognitive Performance Scale, 44.8% of residents of Ontario LTC facilities and 43% of patients in Ontario CCC were in the highest levels of impairment. These results are in comparison to Saskatchewan (35.2%) and Manitoba (39.2%). Only Sweden (48.3%) and Finland (51%) had higher levels of cognitive impairment,

• The ADL Hierarchy Scale, which is a measure of ability to perform everyday tasks such as eating and dressing, indicates that 47.9% of Ontario LTC residents have high impairment scores which is greater than Saskatchewan (46.5%) and Manitoba (38.3%),
• The distributions of the HIP scores are reasonably comparable for Ontario, Saskatchewan and Manitoba LTC, but there is a clear shift in the distribution to higher instability among Ontario CCC patients. This is a likely a reflection of the higher rate of persons receiving post acute care in complex continuing care, and
• The rates for depression in Ontario LTC facilities are higher than any of the comparator groups other than the Netherlands. The following graph presents the findings from the Depression Rating Scale.

Case-Mix Characteristics

Case Mix Indexes (CMI) were used in the study as a broad measure of acuity. Each of the 44 RUG-III groups (Resource Utilization Groups) is associated with a CMI that is comparable across the study settings.

MDS 2.0 data can be categorized using a "grouping methodology", RUG-III (Resource Utilization Groups). The RUG-III case-mix algorithm was developed to provide a patient-specific means of describing the resources used by individuals with different needs. Version 5.12 of RUG-III uses 108 variables from the MDS 2.0 to create 44 categories of patients with homogeneous resource use patterns.

It is important to note that RUG-III classifications are based on a combination of services received and resident characteristics. Thus, residents who may need specific interventions that are not available in certain care settings cannot score based on need alone but score only if those services are received. In this way, Ontario long term care facilities are at a distinct disadvantage as, where there is limited access to therapy staff and other specialized care providers, the RUG-III classification would understate the score compared to jurisdictions where these resources were more readily available. Results of the review of CMI indicate that:

• Residents of LTC facilities in Ontario have comparable RUG–III scores to Saskatchewan and Manitoba (0.75, 0.85 and 0.80 respectively), and
• All LTC facilities had lower RUG-III scores than Ontario CCC (1.35). However, Ontario LTC scores were closest to the mean of small community hospital chronic care units (0.99).

The following graph reports on services received.

The findings clearly indicate that differences exists between Ontario LTC resident/patient needs and the level of service provided, compared to all jurisdictions in the study population. In general, there is a greater gap between needed service and service provided in Ontario LTC facilities than in other jurisdictions for both nursing and other therapy services. It has also been demonstrated that Ontario LTC residents have similar, and in some cases, higher "need" characteristics compared to residents in other jurisdictions. The following table summarizes the key characteristics of the study populations in relation to levels of service.

What the data does not show (because no standardised outcome measures are available nor has data been collected on quality of life) is whether there is any substantial difference in outcome or quality of life between residents of Ontario LTC facilities and LTC residents in other jurisdictions. However, even without quantitative data the impact of nursing and therapy services on quality of life and resident outcomes should not be underestimated.

The literature demonstrates that with appropriate nursing and therapy interventions, improvements in the functional and self care abilities of long term care patients can be improved and thus enhance quality of resident life. Furthermore, costly complications can be prevented that can also reduce the overall costs to the health system and the strain on caregivers and families.

Central to this position is to have a suitable quantity of nursing and therapy care available to intervene appropriately that is based on the needs of the resident population.