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Follow-up 1/2

Transitions of patients waiting for alternate levels of care

Health care workers assist an elderly woman as they move her in a wheeled hospital bed, with a family member standing nearby.

Background

In September 2022, the Ontario government amended sections of the Fixing Long-Term Care Act, 2021 to expedite the transition of hospital patients deemed to be “alternate level of care” (ALC) to long-term care homes. Under the new provisions, placement coordinators can determine eligibility for and authorize admission to a long-term care home without a patient’s consent. Related changes to the regulations place ALC patients waiting for long-term care home placement in the “crisis” category, in some circumstances giving them priority over many others waiting for placement in the community or for transfers between homes. They also enabled people to be placed up to 70 kilometres from their preferred location in southern Ontario and up to 150 kilometres in the north.

Related amendments to the regulations under the Public Hospitals Act require hospitals to discharge ALC patients who have been authorized for admission to a long-term care home and to charge them $400 per day for every day they remain in hospital after discharge.

Caregiver experience

A caregiver contacted Patient Ombudsman to express concern about the impact of the More Beds, Better Care Act, 2022 on people waiting in the community for long-term care home placement. The caregiver’s elderly mother had been waiting for placement for five years, and after a medical setback, was escalated to the crisis wait list two months prior to coming to Patient Ombudsman. The caregiver reported exhaustion and frustration as her mother has repeated been bumped down the list so that placements could be offered to ALC patients in hospitals.

What we did

Patient Ombudsman provided the caregiver with referral information to Ontario Health atHome, the organization that manages placement to long-term care homes to discuss their concerns about the placement process.

Public reporting was not available on the number of people that have been placed in long-term care homes they did not choose, or the number of people charged the $400 per diem for refusing to accept a placement.

Nor is there public data about the impact on the wait times for people seeking placement from the community. It’s also not known if the amended legislation has had the desired result in decreasing the number of ALC patients in hospital or the wait times in hospital for long-term care home placement. In June 2024, the Canadian Press reported¹ on Ministry of Long-Term Care data that showed since the legislation change, 424 patients had been discharged to a nursing home not of their choosing out of 20,261 patients who were moved to long-term care homes since the legislative and regulatory provisions came into force.

In 2023/24, Patient Ombudsman received 111 complaints about long-term care home placements from hospitals. Many complainants reported feeling pressured or coerced to consent to placements that were a considerable distance from the patient’s family and friends or homes they were not confident could meet the patient’s needs. Patient Ombudsman also received 73 complaints about placements from the community or about residents waiting for transfers between long-term care homes, many describing extensive wait times.

Caregiver experience

The complainant called Patient Ombudsman and reported feeling pressured to accept a bed in a long-term care home for her father that could not accommodate his care needs. The complainant reported being given 24 hours to choose five homes, so it was not possible to visit or obtain adequate information about the homes prior to making the selections. The complainant was advised that their father would be charged $400 a day if they did not comply. The complainant expressed serious concerns about the quality of care in the long-term care home their father was placed in. The complainant reported that their father was currently back in hospital with a serious infection, bed sores, and dehydration.

What we did

The Early Resolution Specialist advised the complainant to continue working with the hospital’s patient relations to plan for their father’s discharge and provided information about returning to Patient Ombudsman if not satisfied that the resolution was fair. The Early Resolution Specialist also made a mandatory report to the Ministry of Long-term Care about the reported neglectful care at the long-term care home.

In recognition of the significant impact of these changes and patients and families, Patient Ombudsman released a guidance document, Fairness by Design: Placement Process Without Consent in November 2022. This document was developed to help hospitals and Home and Community Care Support Services (HCCSS) (the province’s placement coordinator now known as Ontario Health atHome) ensure that the new provisions were implemented with procedural safeguards that were fair and reasonable.

Two years into the implementation of these provisions, Patient Ombudsman encourages hospitals and HCCSS to revisit our guidance document, in particular the elements of procedural fairness, to ensure that their processes continue to help patients and their families make the best possible decisions for themselves and their families. These elements include:

Patients and their substitute decision-makers (SDMs) are able to express their views and preferences and their views and preferences are documented.
If they choose, the patient can involve family members in discussions related to long-term care placement and key decisions.
Patients/SDMs have a reasonable time frame to make decisions.
Patients/SDMs are given clear information (including in writing) when decisions are being made without their consent at any stage in the process, as well as reasons for the decisions.
Patients/SDMs are given information about their options if they disagree with decisions or actions.
There is a process to review decisions when there is a disagreement.
The roles of everyone participating in the placement process are clearly defined and communicated.