Coming to a Crossroad: The Future of Long Term Care in Ontario August, 2009 Association of Municipalities of Ontario 200 University Avenue, Suite 801 Toronto, ON M5H 3C6 Canada Tel: 416-971-9856 Fax: 416-971-6191 email: amo@amo.on.ca website: www.amo.on.ca
Table of Contents Introduction: Coming to a Crossroad... 2 The Municipal Context in Health Service Transformation-Then & Now:... 3 Local Health Integration Service Accountability Agreement and Long Term Care Homes Act... 3 Optimism for the Next Round of Agreements... 5 The Alberta Regional Health Authority Experience: Lessons Learned... 6 Conclusion: Moving Forward, Setting Priorities and Respecting Realities... 7 Recommendations:... 8 Page 1
Introduction: Coming to a Crossroad Long Term Care is at a crossroad in Ontario. It is well known, that the changing demographics in our communities - what the Atkinson Foundation has referred to as Ontario bracing for a grey wave - will require greater resources and dynamic health services to respond to the needs associated with an aging population. And, while shifting demographics are certain to challenge the capacity of Ontario s health services, emerging changes in health care governance and policy are poised to play a central role in determining the success of responsiveness to Ontario s growing health care needs. A commitment to healthy and positive aging requires a partnership between Ontario s municipal and provincial governments that builds on the strengths of each order of government and on the strengths and uniqueness of our local communities and its citizens. The government s shift to an integrated system of health service in Ontario, was recognized in 2004, by the then Minister of Health and Long Term Care, George Smitherman, as a transformation...that must begin with a new way of thinking and behaving and that this transformation would require a cultural change driven by a genuine desire to rise above self interest which would be leveraged through building mature relationships. It is fundamentally understood, that strong partnerships will drive the successful creation of communities that can meet the health care needs of its citizens. Recent events in the shift to greater service integration, however, have not necessarily reflected the vision of health care transformation as originally expressed. AMO is concerned that at a time when our communities are changing and the pressures on our health services are increasing, the provincial government, through the authority of the LHINs service agreements and proposed regulatory changes to the operation of long term care homes, has demonstrated diminished understanding of municipalities as a key partner in the shared objectives of a robust and responsive health care system in our communities. This is the crossroad we face - a time when strong partnerships and transparency are required but instead municipalities are faced with the prospect of deteriorating authority and increased administrative burden without corresponding funding to attain desired results. If this trend continues it is likely that investing in long term care will become economically infeasible for municipalities. This would ultimately impact the quality of long term care for Ontarians. These events have prompted AMO, through this paper, to advocate for a stronger and more transparent partnership between municipalities, the provincial government and the Local Health Integration Networks as we move forward on health service transformation. Page 2
The Municipal Context in Health Service Transformation - Then & Now: Local Health Integration Service Accountability Agreement and Long Term Care Homes Act In 2005, with the introduction of the Local Health Services Integration Act, AMO, in a prescient advocacy statement, expressed concern with the scope of the decisionmaking granted to the LHINs. Specifically, AMO expressed concern with the lack of municipal involvement in the overall decision-making for a service that is funded by municipalities, specifically municipally operated long term care nursing homes and Elderly Persons Centres. At that time, we expressed concern with the sweeping authority granted both to the LHINs and the Minister, to make decisions of service integration and funding that can result in significant exposure to municipalities. Furthermore, we reminded the government that legislation affecting cost-shared health services must reflect municipalities as governments and funders who require a formal mechanism for coordination and decision-making on any matters specific to them. In recent years, the culture of provincial and municipal relationships has changed significantly with the most critical aspect being the recognition of municipalities as responsible and accountable governments with respect to matters within their jurisdiction. Sadly, the fundamental nature of this relationship has not been incorporated into the initial negotiations between municipalities and LHINs. Given the scope and the magnitude of the health transformation and integration of services the need for core oversight mechanisms is recognized and supported by AMO. However, the LHIN boards and senior staff need to be aware of and understand the unique status that municipalities have among the various health service providers; specifically, municipalities are an order of government with a high degree of public accountability and many practices that support this accountability ranging from transparent procurement processes to sophisticated approval processes involving elected municipal councils and public scrutiny in the media. To date, the service agreements that municipalities had presented to them reflect none of this authority and transparency. Rather, municipalities face significant exposure under the terms of the initial Accountability Agreements. Page 3
For example: Various provisions in the Agreement provided the LHINs opportunity to impose additional obligations upon municipalities - additional obligations would require increased municipal contributions without the benefit of appropriate budget planning; At the same time, the LHINs have the right to terminate the Agreement for no cause while restricting the municipal ability to terminate by imposing a 60 day termination notice period that must be accompanied by an approved transition plan; The LHINs may also adjust, reduce or defer funding in certain circumstances without prior notice, due process or a dispute resolution process; and Director s face potential liability in the event of the termination of an Agreement where insufficient funds exist to cease services. This exposure also exists in subcontracting of services. The cumbersome and prescriptive nature of these agreements does not reflect a respect of true partnership with municipalities. By their nature, municipalities are the order of government most accessible and accountable to individual communities. Each of Ontario s 444 communities has their own unique culture, distinct economy, and specific needs. Municipal governments have the most direct insight as to how service delivery can have a profound impact on the lives of Ontarians, especially when the providers of those services are well-informed of the specific needs of the community. At the same time, municipal governments are the governments closet to the people, held to a high level of transparency and accountability. As a unique order of government which invests large amounts of its resources to long term care it is paramount that agreements with the LHINS and Province reflect the desired partnership between the various orders of government. In the implementation of service agreements with municipalities delivering community support services, the LHINS applied a one size fits all approach on service agreements and other processes and did not demonstrate an understanding of the uniqueness, sophistication and inherent public accountability of municipalities. Page 4
The Long Term Care Homes Act itself poses further challenges which undermine an effective partnership. The Act appears to streamline some dimensions of routine compliance, but raises the bar for accountability in new areas. AMO believes increased accountability is a positive measure that will be beneficial to residents if it increases quality of care; however, the need to introduce additional steps in the operations or the need to produce evidence of compliance with raised standards increases the accountability burden on homes which do not receive any commensurate increase in resources to meet the higher standard or to meet the higher degree of accountability processes. Currently, resources are insufficient to produce the desired outcome and to demonstrate evidence of the desired outcome. Such under-resourcing may lead to pressures on municipalities to add resources (which are already provided in other areas of the long term care operations by most municipalities) at a time of significant budget pressures on municipalities and may lead to further questioning of a municipality s role in operating long term care homes. It may also lead to forced redeployment of resources away from needed resident care to help meet the accountability burden, which ultimately is not a desirable outcome for Ontarians. AMO views communicating these challenges as an important first step in fostering a productive partnership between the municipalities, the LHINs, and the Province. Optimism for the Next Round of Agreements The Long Term Care Accountability Agreement process is currently getting underway. While, some efforts have been made to gain a better understanding of municipal authority and governance, AMO remains deeply concerned about the future of long term care provision in Ontario. Unilateral, inflexible and unresponsive service agreements that expose municipal councils to increased liability will have two certain outcomes: one, municipalities will vacate the sector beyond their legal obligation, and two, Ontario s most vulnerable citizens, requiring the security and comfort of long term care will be less likely to have their health needs met. Municipal governments operate over 16,500 beds in long term care homes in Ontario. That is nearly a quarter of the total beds in the province. In any given year, that is over 6 million days of care. In order to make available and maintain these badly needed beds municipalities go above and beyond their legal obligation for funding and invest a net total of $300 million of property tax revenue. Page 5
Ontario s changing demography requires increased and stable investments in long term care. Ontario s provincial government, the LHINs leadership and municipalities must be working together in a transparent and coordinated manner to prepare to meet the needs of our communities and citizens. To begin with, LHINs and municipal staff and elected officials should establish links for communication on key issues and vehicles for dialogue on key developments in order that an improved mutual understanding of each other s role is achieved and the potential to develop effective working relationships can be realized. AMO is hopeful that a coordinated and respectful approach will lead to some improvements in the LHIN s current expectations of municipalities that are now redundant or unnecessarily intrusive. The Alberta Regional Health Authority Experience: Lessons Learned The province of Alberta was one of the first to move towards regionalized health care planning and delivery. Similar to Ontario s rationale; this move was in an effort to provide greater coordination, efficiency and access to health care services in communities across the province of Alberta. A decade later, Alberta is now in the process of considering once again realigning health care provision. This time, the move is away from regionalized health care to a centralized super board. The reasoning behind the move is said to be driven by the desire to make more fundamental changes to health care in Alberta, namely efficiency. The Government of Alberta saw that many elements of care from human resources, to information technology, to the degree of care varied from region to region. The government believes change can come about more easily when governance is centralized and when authority is more spread out across communities. The Alberta government espoused that seamless service for all Albertans will best be achieved by employing a centralized structure. It is early days for health service integration in Ontario; AMO believes that the opportunity for positive change is great. But, it is important to revisit the founding principles that were to drive this transformation: a cultural shift built on transparency and a mature relationship driven by strong partnerships. In all change, missteps will occur; the LHINs have an opportunity to engage municipalities as partners that support the health care of Ontario s communities. Page 6
Barriers between the LHINs and municipalities related to the provincial government s objectives and municipal authority and governance will certainly result in barriers between Ontario s citizens and access to quality health services. AMO is hopeful that future agreements will reflect this and that a future needless and potentially expensive realignment of health care provision can be avoided. Ontario has an opportunity to build on lessons learned and to get it right. Conclusion: Moving Forward, Setting Priorities and Respecting Realities Provincial and municipal governments in Ontario share objectives regarding the quality of care and the overall living experience of those in our long term care homes. In fact, municipalities have long been touted as leaders in care and quality in the long term care sector. Historically, municipal homes have led the way in innovations and best practices in long term care. Providing health care, especially long term care, with a large aging population has emerged as one of the most complex social and economic challenges facing Ontario. As discussed earlier, quality and efficiency are the main priorities for all partners in Ontario s health care system. Moving forward, municipal experience and insight are essential to rolling out comprehensive and effective measures to ensure Ontario meets the long term health care needs of its citizens. Currently, the provincial government is undergoing a review of the regulations under the Long Term Care Homes Act. AMO is concerned that the government s desire to improve the quality of care and safety may in fact result in increasing the cost burden to municipalities that will undermine the ability to achieve the care objectives. We ask that the government be mindful that each administrative initiative adds up, even if the requirement in and of itself is a marginal one, to an overburdened system. In an already under resourced system, each incremental requirement has the potential to result in the withdrawal of municipal funding in other areas. In 2007, municipalities injected Ontario s health care system with over $680,000,000. Municipalities go above and beyond just enhancing provincial health care services. In addition to supporting the long term care sector, municipalities subsidize public health, hospitals, ambulance services, cemeteries and various other health care services. Page 7
The government must be reminded that municipalities share its objectives in improving health care for Ontarians. There are important caveats however. To begin with, the first principles of the government s health transformation must be revisited. In the absence of moving forward in a manner that recognizes municipalities as both key investors and accountable providers of health care in Ontario, meeting the objectives will be challenging. At the same time, the government must also recognize that municipalities face considerable fiscal challenges in subsidizing provincial health care programs. The crossroad Ontario faces in health care is complex. But, as outlined in this paper, there are changes that can be made now that will lessen the challenges we all will face in the future. Acknowledgement and broad understanding of the role municipal governments have in ensuring quality health care for Ontarians is essential as the partnership between municipalities, the provincial government and the Local Health Integration Networks moves forward to address the coming impact of the changing demographics on Ontario s health care system. This consideration, as supported by the first principles of the government s health transformation efforts, is at the core of the following recommendations: Recommendations: 1) Future agreements between municipalities, the LHINs, and the Province must reflect the municipal order of government as both a key investor and accountable provider of health care in Ontario. 2) The authority and accountability that municipal governments have within their scope is an important part of service delivery in Ontario. The Province must communicate to all partners greater understanding and articulation of the specific roles all orders of government play in health care needs. This includes communication across all partners in health care. 3) In recognition of the fact that long term care is a provincial program, and municipalities are legislated to subsidize this provincial responsibility, the Province must recognize the financial pressures on municipalities and must provide appropriate commensurate financial resources with any increased expectations in long term care standards or in demonstrated accountability for care and service outcomes under the Long Term Care Homes Act. 4) The Province must reinforce consistent communication patterns/processes between the LHINs and municipalities to ensure a relationship based on respect for the municipal order of government, mutual trust, and shared goals. Page 8