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Position Statement on Responsible Care - May 30, 2014

Health care spending is growing in Ontario. In 20 years, the number of our citizens aged 75 and over will be double what it is today, while the number of our citizens aged 90 and over will be triple1.

To meet our growing health needs, Concerned Friends of Ontario Citizens in Care Facilities is calling on the Ontario government, and specifically the Ontario Ministry of Health and Long-term Care, to spend more wisely.

“We can afford quality health care. We can’t afford poor quality health care.”
- Dr. Michael Rachlis, Health Policy Analyst, Toronto, Ontario

In light of the current $290-billion provincial debt, we are not asking the government to spend more at this time. Rather, we are asking that available money be shifted away from administration and toward the direct care of residents living in long-term care homes.

The following are ways to spend more wisely while improving the quality of long-term care.

1. Improve Financial Accountability

a) Establish cost ceilings on total administrative expenses and profits in long-term care homes and require a return payment for expenditures that exceed cost ceilings.

b) Do not encourage municipal and non-profit homes to bring in outside management, leaving communities on the hook for millions of dollars in administrative fees at the expense of direct care. For example, Extendicare now manages five municipal homes in Ontario at costs of approximately $400,000/year over three years. Instead, consider financial penalties for homes that are poorly run. (See #6, below).

c) Reduce salaries of CEOs at Ontario’s 14 Community Care Access Centres (CCACs). Average CEO salaries sit at $234,000 per year and have seen annual raises of 12% over the past three years. Look for cost efficiencies within the CCACs and Local Health Integration Networks.

2. Legislate Minimum Staffing Levels

Research shows that for-profit facilities in Ontario have significantly lower levels of direct-care staff than both nonprofit and public facilities2 and that the for-profit sector now dominates in this province. It is urgent that a minimum ratio of one personal support worker to every 8 residents be legislated. Concerned Friends recommends that homes schedule two 12-hour shifts per day, instead of the current three shifts per day to ensure consistent staffing levels throughout both shifts. We also want to see a ratio of one nurse practitioner for every 125 residents.

Within the Program Support Services envelope, we want to see minimum staffing levels legislated for recreation workers (one for 30 residents) and social workers with geriatric training (one for 75 residents).

3. Create Two New Quality Indicators

* Include the working conditions of staff when doing quality assessments of long-term care homes.

* Have inspectors monitor and report on staffing levels when they visit homes.

4. Legislate Full-Time Staffing Levels

Minimum full-time staffing levels are required in order to provide continuity of care. The predominance of part-time staff, combined with low staffing ratios, has led to significant gaps in the delivery of care plans3.

We concur with the Registered Nurses Association of Ontario that achieving 70% full-time employment for all nurses and unregulated care providers supports continuity of care and continuity of caregiver, improves team work, reduces costs, and facilitates staff satisfaction and retention4

5. Increase Skill Levels, Diversity of Staff

Staff who are well-trained in behavioural problems are needed on a full-time basis because the majority of long-term care residents are mentally ill. As well, residents and workers are more ethnically diverse and more likely to be racialized than 20 years ago, requiring culturally competent services5.

More nursing care is required in long-term care. Research shows that positive outcomes in facilities with high nurse-to-patient staffing levels, especially registered nurse staffing levels, include: lower mortality rates; improved physical function; less antibiotic use; fewer pressure ulcers, catheterizations and urinary tract infections; lower hospitalization rates; and less unplanned weight loss and dehydration6.

Building advanced nursing capacity in every home and creating a long-term care medical specialty in recognition of the skills required to care for an aging population was recommended by the Ontario Long Term Care Innovation Expert Panel in 20127.

6. Penalties for Non-Compliance

Homes that repeatedly ignore inspectors' orders should be penalized by having their accommodation (a.k.a. profit) envelopes diminished.


We are asking the Ontario government to spend less on administration in order to deliver better and more affordable care in long-term care homes for the benefit of residents, their families, and staff.


1. Ontario Ministry of Finance

2. McGregor JM, Ronald LA. Residential Long-Term Care for Canadian Seniors: Nonprofit, For-Profit or Does It Matter? IRPP Study, No 14, January 2011.

3. Data on file. Concerned Friends of Ontario Citizens in Care Facilities.

4. Registered Nurses Association of Ontario Position Statement: Strengthening Client Centred Care in Long Term Care, June 25, 2010.

5. Residential Long-Term Care in Canada: Our Vision for Better Seniors' Care. Canadian Union of Public Employees. October 2009.

6. Jane E. Bostick et al., “Systematic Review of Studies of Staffing and Quality in Nursing Homes,” Journal of American Medical Directors Association 7 (2006):366-376; John R. Bowblis, “Staffing Ratios and Quality: An Analysis of Minimum Direct Care Staffing Requirements for Nursing Homes,” Health Services Research 46, no. 5 (2011):1495-516; Nicholas G. Castle, “Nursing Home Caregiver Staffing Levels and Quality of Care: A Literature Review,” Journal of Applied Gerontology 27 (2008):375-405; Karen Spilsbury et al., “The Relationship Between Nurse Staffing and Quality of Care in Nursing Homes: A Systematic Review,” International Journal Nursing Studies 48, no. 6 (2001):732–750; CMS (prepared by Abt Associates), Appropriateness of Minimum Nurse Staffing Ratios in Nursing Homes Report to Congress: Phase II Final, vol. 1-3 (Baltimore: 2011); John F. Schnelle et al., “Relationship of Nursing Home Staffing to Quality of Care?” Health Services Research 39, no. 2 (2004):225-250.

7. Why not now? A Bold, Five-Year Strategy for Innovating Ontario’s System of Care for Older Adults. Long Term Care Innovation Expert Panel. March 2012.