OPINION:

Ageism is Discrimination – Prohibited under Ontario Human Rights Code

Feb 28, 2021

Does Ageism drive many long term care decisions?

~ Vicki Hotte ~

“Ageism is often a cause for individual acts of age discrimination and also discrimination that is more systemic in nature, such as in the design and implementation of services, programs and facilities.  Age discrimination involves treating persons in an unequal fashion due to age in a way that is contrary to human rights law.  The Ontario Human Rights Code prohibits age discrimination in: employment, housing accommodation, goods, services and facilities, contracts and membership in trade and vocational associations.”

~ Ontario Human Rights Code

Highlights:

  • The Ontario Government did not respond quickly to the pandemic crisis in long term care; instead, the focus was on hospitals.
  • Since 2012, medical experts have talked about “aging in place;” and how long term care facilities are an out-dated concept, requiring modernization, and a revolution in thinking, regarding care and support to older citizens.
  • Evidence presented to the Covid-19 Long Term Care Commission by geriatricians and well-known economists, including former TD Bank Chief Economist Don Drummond, reveal the current LTC models of care have become increasingly unaffordable and are not meeting the needs of older citizens.
  • There are better, more cost-effective alternatives to providing care and rehab services to Seniors, as identified by medical practitioners and economists.
  • Given that everyone ages and may require different levels of care during their lifetime, it would serve each of us to understand this issue.

The Evidence:

On 23 June 2020, Ontario introduced Bill 175, but the 25-year-old Ontario Health Coalition, whose members include doctors, nurses, and other care workers said the bill reduced publicly funded oversight for homecare again, while allocating greater power to for-profit private health services.  A review of provincial reports going back to 2013, which overlap the preceding Liberal and Conservative governments, shows a consistent theme of ongoing concerns and alternatives presented by medical specialists.

First, consider the following quote from well-known Toronto geriatrician, Dr. Samir Sinha:

“Ageism seems to be the last acceptable ‘ism’ in our society. We, as a society, don’t value older people as much as we should. And therefore, we don’t tend to value the people who work with older people as much as we should.”

In 1966, Medicare enshrined two types of service: physician services and hospital services, but no real thought was given to normal aging and Homecare, perhaps because aging was, and continues to be viewed, negatively. Now, genuine alternatives have emerged repeatedly in a number of different medical reviews.

The concerns regarding long term care facilities (LTCFs) are not new. The only difference is Covid-19 has shone a spotlight on glaring deficiencies within Ontario’s LTC system, which have been left to fester for a few decades. Out of sight, out of mind.

For 25 years, the Ontario Health Coalition has been working to get Ontario to put cost-effective expanded Homecare programs in place at less than half the costs of a LTCF placement. There are greater economies of scale that could be reaped from expanded Homecare if Ontario and Canada would pay attention. Community Care Access Centres (CCACs) and Community Home Assistance to Seniors (CHATS) are examples of accomplishments within community care. In a political decision, CCACs were transformed into Local Health Initiative Networks (LHIN). In March 2019, Ontario issued an Order-in-Council, declaring the 14 LHIN Boards would be replaced by an appointed 12-person Ontario Health Board. Unlike the LHIN Boards, the new super agency board of directors would not be required to meet in public. As LHINs were being dismantled, Covid-19 struck in 2020, creating dreadful havoc and deaths in LTCFs, while emphasizing growing gaps in the current dysfunctional system.

Since costs preoccupy governments, why not try cost-effective medically-sanctioned and tested solutions?

ALL of us do age, and at some point, we will likely need different levels of assistance. This is not some unexpected tsunami, as politicians pretend. Governments are well aware of the natural age-related dynamics associated with all people, including politicians, citizens, permanent residents, immigrants, plus sponsored parents and grandparents. Governments know the numbers. Now, it is absolutely essential that public and governmental attention focus on the history of care to find new approaches. These care issues cannot be solved by MZOs linked solely to building new LTCFs.

On 24 May 2012, Dr. Samhir Sinha (now Director of Geriatrics, Sinai Health and University Health Network, and Toronto Director of Health Policy Research, National Institute on Ageing) was appointed by the former Liberal Minister of Health and Long-Term Care, and the Minister Responsible for Seniors, to prepare a report on opportunities for ageing well in the community. Dr. Samhir Sinha had already gained considerable experience and recognition after setting up cost-efficient pilot programs that allowed older citizens to “age in place” at home.

A major plank in Dr. Sinha’s approach was the promotion of Ontario’s Ageing At Home Strategy, part of the larger Senior Strategy. He recommended Ontario increase its funding by 4% for three years and commit to the recommended efficiencies which could be garnered by enhancements to the home and community care sectors.

He recognized the need for LTCFs, but not as a “one-way destination”, instead providing a variety of short-term care services that allow a greater number of older Ontarians to eventually return to their homes and communities, as occurs in Europe.

His thoughtful compassionate 21-paged report, Living Longer, Living Well, captured some support from the Liberal government at the time, but more attention came from the City of Toronto which undertook its own municipal strategy, called A City For The Ages with funding from Canada Mortgage and Housing Corporation (CMHC).

Toronto decided the concept of aging should be addressed through new programs and a change in how the city is designed, or as Dr, Bernard Isaacs, a geriatrician, said:

“Design for the young and you exclude the old. Design for the old and you include everyone.”

Even minor changes in home design were recommended for housing, such that hallways should be wide enough to accommodate a wheelchair while light switches could be placed lower on walls in new homes … because personal circumstances can change suddenly through accidents or illness, but each home could be built to accommodate access for people with changing levels of mobility. Recovery at home may involve temporary use of aids, such as wheelchairs, so build that eventuality right into housing.

The National Institute on Ageing (NIA) presented its November 2020 52-paged report, entitled Bringing Long Term Care Home: A Proposal to Create a Virtual Long-Term Care @ Home Program to Support a More Cost-Effective and Sustainable Way to Provide Long-Term Care Across Ontario.  This report outlines the burdensome new costs associated with current LTCFs, such as $1.52-billion to provide 4 hours of care/day/resident for Ontario’s existing 79,000 beds across the current 626 LTCFs. This doesn’t even include the costs of building new facilities and beds. NIH recommended LTCFs should be used more often for short-term care, optimizing the use of existing LTCFs while preparing to support care and rehab for patients at home.

If implemented, “NIA’s model would save Ontario’s Ministry of Long Term Care significant construction and development related costs between $212,259 and $268,369 for each LTC bed it may no longer need to build or redevelop to better meet the needs of its ageing population to age-in-place. By providing individuals and their families with a more flexible alternative model of home and community care that could allow them to receive the care they need to remain in their own homes for longer rather than in a LTC home, the overall cost savings that such an approach could achieve could be significant.”

NIA is using the best current available data relating to medical care needs. If governments can save on LTCFs where many residents prefer NOT to live, why not listen to medical experts?

Toronto’s first efforts involved Toronto Paramedic Services and the housing agency, while Dr. Sinha and other involved specialists, received provincial funding to launch their Independence at Home Initiative. By focusing attention on the care needs of older citizens at home through regular visits, unnecessary 911 calls were halved within six months. Fine-tuning will see further declines. Toronto is now in Phase 2.0 of this strategy.

In 2018, CMHC reviewed the economic contributions of older citizens to their communities and local economies in a report, entitled Housing a Senior Population: The Economic and Social Benefits: Why municipal governments should attract and support older residents. This report viewed older citizens as the “backbone of their communities” and noted they control key financial resources, tend to have less debt, and they spend more in their local communities. They are also described as more likely to support arts, cultural and service organizations.

Dr. Sinha bluntly observed Canada’s system currently focuses on “warehousing older people” in LTCFs, before stating that older citizens want to age at home:

“They actually have their own bed. They want to go home. The hospital believes they can go home. Home care believes they can go home. But it takes two weeks before we actually can get home-care services in place, because that’s an example of how short we are on providing home care in certain regions.”

In May 2020, Ontario decided to appoint a Commission into Long Term Care, rather than hold a full Public Inquiry, and economist, Don Drummond, was invited to address the Commission.

In November 2020, Don Drummond, former chief economist at TD Bank, now Stauffer-Dunning Fellow at Queen’s University and co-author of Ageing Well, echoed Dr. Sinha’s sentiments, saying, “There are very few people, waving their hands and asking to go to long term care.” And, he particularly noted how Covid-19 has changed perceptions around LTC.

Drummond explained there was an urgent need for immediate changes to LTC, requiring a much broader context. He figured Canada would need another 250,000 to 300,000 long term care beds by 2041 to eliminate anticipated wait lists, but associated costs would be absolutely daunting. It just won’t happen, he conjectured, because it is unaffordable. Based upon projected costs and need, he said it was necessary to focus on alternatives now.

Ontario also received an interim report, dated 4 December 2020, from its own appointed Long Term Care Covid-19 Commission, chaired by the Honourable Frank N. Marrocco, and Commissioners Angela Coke, and Dr. Jack Kitts.  Bearing in mind this is not an official Public Inquiry, the government’s own appointed Commissioners criticized the government for reducing LTCF inspections so drastically, blaming, “the decision in fall 2018 to discontinue Resident Quality Inspections (RQIs) in all long-term care homes, the apparent lack of consistency in enforcement and the siloed approach to inspections by the MLTC, Ministry of Labour, Training and Skills Development (MLTSD) and Public Health inspectors.”

Noting a backlog of 3,000 complaints, the Commission’s report wrote, “Importantly, we have found no indications that proactive RQIs were initiated by the MLTC when COVID-19 outbreaks began globally. From March 1 to October 15, 2020, only 11 LTC homes received a proactive inspection.”

Imagine if this Commission had been a full Public Inquiry, involving the Ontario Health Coalition, National Institute on Ageing, and other professional groups who provide care and assistance to older Ontarians. Nonetheless, many reports on Ageing in Place are available, and none recommend LTCFs as the primary solution to elder care. When do politicians start to listen to those with medical experience in geriatrics?

In his own evaluation, Dr. Sinha noted that each new LTC bed in Ontario would cost between $212,000 and $268,000 to build.  Then, daily LTC costs per resident would average $200/day, while daily homecare/person would be half (or less than) that amount. If the costs for building new LTCFs were re-directed to Homecare and some home modifications for seniors, the Province (and federal government) would save a lot of money. In fact, the federal government already provides a tax deduction for renovations related to making one’s home amenable to aging in place. It is included under Line 31285, Home Accessibility Expenses with a 2020 cap of $10,000, and people ages 65 or older are eligible, as are individuals of any age who receive the Disability Tax Credit. Ontario took the first tentative steps on 9 February 2021, by investing $4.5 million through its new Senior Community Grant Program to support over 180 community projects (averaging $25,000 per group). That is a baby step compared to what health groups say will be needed to transform LTC, but it is a step in the right direction.

Dr. Sinha said existing funding could be better spent and coordinated across Ontario Health Teams, before stating: “I actually think we could support far more people to age in their own homes, where they want to be. And frankly, we would actually take a huge amount of pressure off the need to build a number of beds that we may not even need in the first place.”

So, the question remains: “Are new LTCFs really needed?” when less costly alternatives have been so starkly outlined, and as Don Drummond observed, “Now is the time to start to prepare for the alternatives … and yet, we’re not.”

Why does Ottawa, the Province, the Region, or Municipalities, continue to jump aboard the old costly LCTF bandwagon when groups of medical professionals, including Dr. Sinha, and a respected economist, like Don Drummond, insist this is not the direction to take? What do politicians and developers know that these professionals do not?

King Township could start by recognizing that it has been the tradition of monasteries to provide continuing accommodation and care to Friars as they work and age normally throughout their lives.  The Friars are a family, and the monastery is their home.  In fact, they are practising the very strategy advocated by Dr. Sinha in his “Ageing at Home” Strategy.  I suspect the Friars do not view themselves as being confined to a rigidly-scheduled and defined LTCF, nor is the monastery certified as a LTCF. Yes, it has an infirmary and care-related beds, but the Friars have the comfort of their own familiar home surroundings and Brothers.  The Friars are living at home. 

While we understand the need for ‘herd immunity’ through vaccination programs to address the current scourge of Covid-19, we also need protection from the type of ‘herd mentality’, or ‘group think’, that seems to imbue every level of government with the same blinkered myopic ‘vision’ consistently over time. Are our politicians working with the best available recent data, or are they following the same old, same old?


Additional Resources:

The Case for Age-Friendly Communities

World Health Organization – Ageing: Ageism

Photo credit: V. Hotte