This article originally appeared in the Winter 2021 issue of the Ontario Medical Review magazine.
Role of medical director, IPAC, system co-ordination and palliative care are critical
On Nov. 25, representatives of the Ontario Medical Association were invited to appear before the Standing Committee on the Legislative Assembly, which was tasked with the review of Bill 37, Providing More Care, Protecting Seniors, and Building More Beds Act, 2021. The OMA stressed in its presentation that while Bill 37 is a first step to improving long-term care delivery, many improvements are still required through regulation and policy to resolve long-standing system issues.
The OMA provided recommendations in four key areas:
The role of medical directors
Infection prevention and control
System co-ordination
Palliative philosophy and end-of-life care
On behalf of Ontario’s 43,000 doctors, thank you for the opportunity to appear here today. The OMA applauds the government and Minister of Long-Term Care Rod Phillips for seeking to improve long-term care delivery. Bill 37 is a good first step, however more improvements are needed through regulation and policy.
COVID-19 tragically exposed the weaknesses in our long-term care system, and we can no longer wait to properly understand and address long-standing system-wide issues. However, we must recognize the tremendous work of the majority of long-term care homes to elevate resident dignity and provide the best possible care within the current system restraints.
In lead up to this bill, the OMA was an active participant throughout the Long-Term Care Commission process overseen by Justice Frank N. Marrocco. This included providing two written submissions and appearing before the Commission to discuss where physicians feel improvements can be made.
On Oct. 26, the OMA launched Prescription for Ontario: Doctors’ 5-Point Plan for Better Health Care, a roadmap comprising five key themes and associated recommendations to fix our health-care system. Long-term care featured prominently. Prescription for Ontario was informed by the largest consultation in the OMA’s 140-year history and included input from 8,000 Ontarians representing 600 communities through our survey at betterhealthcare.ca.
When asked “What is your top priority for health care?,” 19 per cent of respondents selected “Improvements to seniors’ health, including long-term care.” This priority ranked second only to “Improve wait times” at 30 per cent and was tied with “We need more doctors.”
The OMA believes that focus is required in four key areas:
The role of physicians
Infection prevention and control
Long-term care capacity
Palliative care approach
The medical director has a critical role to oversee the delivery of medical care, and a clearly defined and consistently understood role description with expectations is needed. Unfortunately, there is limited support currently available for medical directors. While they are motivated by a strong desire to care for those requiring long-term care, factors that promote retention and recruitment must be addressed.
However, this is not just about funding. Medical directors must be enabled through proper training, education and mentoring. Attending physicians also provide vital medical care delivery and leadership. They are available 24/7 to provide care and/or medical guidance to staff but report challenges with remuneration and often being stretched thin as they balance multiple clinical duties.
Therefore, the OMA recommends that Bill 37 maintain the requirement that the medical director role must be held by physicians to ensure all homes have access to the medical leadership needed to positively transform the sector, and that their role, as well as that of attending physicians, should be clarified and adequate supports provided.
Creating a homelike environment is central to the philosophy of long-term care so we must strengthen linkages across the system to deliver as much care on-site as possible.
Infection prevention and control practices and procedures play a critical role in preventing or reducing transmission of infectious diseases. Currently, there is no clear guidance on who is accountable for the leadership role for developing the IPAC program and which authority should oversee IPAC activities.
The OMA recommends that funding be provided by the ministry to develop and implement mandatory IPAC educational programs and opportunities in all homes and that Bill 37 should maintain the requirement designating a role that focuses on IPAC within each home.
Long-term care exists within a broader health-care system however has been overlooked.
Creating a homelike environment is central to the philosophy of long-term care so we must strengthen linkages across the system to deliver as much care on-site as possible. This will be more comfortable for residents, more efficient for the health-care system and decrease the potential for infectious disease spread.
To improve medical care delivery, homes need sufficient equipment and better access to specialized care when needed. This can be accomplished in several ways including:
Better connections with specialists who have long-term care knowledge
Enhanced communication and connections via electronic medical records and the appropriate use of virtual delivery models
Increased understanding of long-term care among other parts of the health-care system
Anecdotally, we have heard that long-term care homes that had existing relationships with hospitals and system partners and/or were embedded in Ontario Health Teams fared better throughout the pandemic.
This was due to immediate access to resources — including specialized health human resources — when the homes’ resources were strained or depleted.
The OMA, therefore, recommends that funding must be made available to ensure homes have the necessary number of trained staff to safely support and keep residents at home.
Where possible, homes should have access to medical equipment to deliver urgent care services such as access to labs, IVs, X-rays and medications to meet resident needs, and the required physical space to provide care.
We are pleased to see the integration of a palliative care approach. Most Ontarians with life-limiting illnesses prefer to be cared for in the home rather than hospital. In this case, the long-term care home is their home.
Given these patients are likely to remain in a long-term care home until end of life, palliative care needs to play an essential role.
When residents receive in-home palliative care they experience better symptom management, have shorter and/or few hospitalizations, and have a better overall experience and quality of life.
Providing high-quality and continuous palliative care in the home requires both dedicated resources, and appropriate training and education, which is currently lacking. The OMA is keen to work with government to define a palliative philosophy in long-term care.
To support this palliative care approach, the OMA recommends that all long-term care homes should have access to 24/7 in-house palliative care and expertise, throughout the trajectory of a patient’s journey.
The OMA also provided a written submission to the committee, which laid out the recommendations in much great detail and will be providing input to the process of developing the regulations.