NPAO RESPONSE TO LTC STAFFING STUDY

Dear Minister Fullerton:

The Nurse Practitioners’ Association of Ontario (NPAO) congratulates the Ministry of Long Term Care and the Government of Ontario for taking the long overdue steps required to address the needs for Long Term Care (LTC) in this Province.  This is a critical time for the future of long term care in this province.  We need bold decisions and actions to right the long term care ship.

Unfortunately, as the COVID-19 pandemic has accentuated and what the Justice Gillese public inquiry has shown, there are a number of barriers to overcome in the current long term care system to be able to achieve the vision for long term care that provides residents the enjoyment, respect, comfort, safety and the quality care they deserve.  

Recent government announcements to increase LTC capacity and launching the Commission to look into Long Term Care Homes (LTCH) and the COVID-19 pandemic suggests that the government has recognized this need for change. The release of the Long Term Care Staffing Study identifies numerous challenges that are deterrents to achieving the long term care vision for residents.  

It should be obvious that to achieve the vision for long term care, appropriate and adequate staffing for the long term care homes will be a critical success factor.  We need the health care providers and support workers to be an efficient and effective team that sets the tone for this vision.  Recognizing the need for common-sense regulations, staff must be provided the flexibility to render the most appropriate care and support the residents require. 

NPAO has long known and stated that Nurse Practitioners (NPs) are a critical element to increasing the quality of care in long term care homes.  We are pleased that the staffing study recommends expanding the use of NPs.  We would like to provide the following points for consideration by the government in the development of its long term care strategy and expanding the use of NPs.  

Nurse Practitioners (Registered Nurses in the Extended Class)

Nurse practitioners, as autonomous health professionals with advanced education, provide essential health services grounded in professional, ethical and legal standards. Nurse practitioners integrate their in-depth knowledge of advanced nursing practice and theory, health management, health promotion, disease/injury prevention, and other relevant biomedical and psychosocial theories to provide comprehensive health services. Nurse practitioners work in collaboration with their clients and other health-care providers in the provision of high-quality, patient-centred care. They work with diverse client populations in a variety of contexts and practice settings. 

Nurse practitioners have the competence to provide comprehensive health assessment, to diagnose health/ illness conditions, and to treat and manage acute and chronic illness within a holistic model of care. Nurse practitioners order and interpret screening and diagnostic tests, perform procedures and prescribe medications, while integrating the principles of resource allocation and cost-effectiveness, in accordance with federal, provincial and territorial legislation and policy. 

Nurse practitioners are accountable for their own practice and communicate with clients about health assessment findings and diagnoses, further required testing and referral to other health-care professionals; they are also responsible for client follow-up. Nurse practitioners counsel clients on symptom management, health maintenance, pharmacotherapy, alternative therapies, rehabilitation strategies and other health programs. 

Nurse practitioners have the knowledge to assess population health trends and patterns and to design services that promote healthy living. They provide leadership in the development, implementation and evaluation of strategies to promote health and prevent illness and injury, and they work with interprofessional teams, other health-care providers and sectors and community members. Nurse practitioners collaborate in the development of policy to influence health services and healthy public policy.

(Source: Canadian Nurses Association: Canadian Nurse Practitioner – Core Competency Framework. May 2010)

One of the biggest barriers NPs face is a lack of awareness and understanding of NP competencies by policy makers, other health professionals, support personnel, and patients.  This is compounded by changes to the NP scope of practice, which is rapidly expanding. To fully capitalize on this educated and competent health care professional, there must be an understanding and appreciation for what NPs can bring to the table.

What is a Nurse Practitioner?

• Registered Nurses in the Extended Class with the College of Nurses of Ontario (CNO)
• Holds a Master degree & has nursing experience
• Treats the whole person
  • Nursing model of body, mind & spirit
• Brings together the medical knowledge
  • To diagnose & treat illnesses
  • With the values & skills of nursing

What does a Nurse Practitioner do:

• Performs comprehensive and focused physical assessments
• Diagnosis illness and injuries
• Orders and interprets diagnostic tests
• Provides counseling and education
• Provides treatment
• Refers clients to other health care professionals and specialists as necessary
• Prescribes medication
• Manages chronic diseases
• Provides Medical Assistance in Dying (MAiD)
• Collaborates with physicians and other members of the health care team as necessary
• Admits, treats, and discharges patients from hospital

NPs in LTCHs provide evidenced-based, safe, and high quality resident-centred care within the LTC setting while also avoiding unnecessary emergency department (ED) transfers and the associated increased clinical risks and costs.  Through their work they directly support your government’s mandate of ending hallway healthcare.  NPs seek to avoid transfers to emergency departments, so LTC residents can remain in their familiar surroundings while receiving needed treatment administered by familiar staff. The objective for NPs in LTC, either as attending NP or a Nurse Led Outreach Team (NLOT) NP, is to divert health care services away from costly inpatient acute care facilities to skilled long term care settings.  This is accomplished by:

• Provision of individualized, resident-centred health assessments, diagnosis and treatment plans;
• Provision of care of the older adult including those with geriatric syndromes, mental health and chronic diseases, and palliative and end of life care and support with transitions including repatriation from acute care facilities;
• Order medications, diagnostic testing and other therapeutic interventions;
• Provide monitoring of acute, episodic and chronic disease health conditions; 
• Collaborate with members of the interdisciplinary team members with respect to the resident’s health issues;
• Communicate clinical findings with attending physicians, nursing staff, residents and families;
• Provide education, coaching, and mentoring to LTC staff around management of complex medical conditions and best practices in infection prevention and control; and
• Identify and embrace the opportunity for capacity building in the long term care setting.

Based on current data available, adding an additional 150 on-site NPs in LTC will save the Ministry approximately $20M/year, more than offsetting the cost of funding to support and expand the NP role in LTCH.

• NPs would improve availability, timeliness and quality of care to residents and provide significant dedication to clinical care.
• NPs have shown to reduce ER transfers by greater than 90%.
• Because an advanced clinician (NP) is on site, NPs will increase the acceptance of  complex residents from hospital, thus supporting the reduction of both days in hospital and reducing alternate level of care (ALC) days.
• NPs will increase family satisfaction with quality of care provided to residents.
• NPs would improve the skill set and leadership of nursing staff through on-going educational opportunities, quality initiates and NP leadership.
• NPs would manage and appropriately reduce medications to prevent polypharmacy and side effects.
• As a result of all of the above, NPs will improve family and caregiver comfort and confidence in NP care.

Expanding Roles of NPs in LTC

NPs have a positive impact on the quality of care in LTCHs.  The Ontario Ministry of Long Term Care, as well as other Provinces, has seen this impact through pilot programs and the first two phases of the Attending NP program.  The capabilities of NP leadership is on full display within the 25 Nurse Practitioner Led Clinics that exist in Ontario that provide care to over 100,000 Ontarians, most of them in rural and underserved communities.  The inherent comprehensive, relational, and patient-centered model of care employed by NPs is the type of care perfectly suited to the needs of LTCH residents.

It is not coincidental that, if given the flexibility in the Long Term Care Act (LTCA), Nurse Practitioners could fulfill every role described under staffing requirements for LTCH:

• Administrator: Each home must have an Administrator who is in charge of the home is responsible for its overall management
• Director of nursing and personal care (DONPC): Each home must have a DONPC, who must be a registered nurse (Suggested Change to LTCA – ADD: or Nurse Practitioner). They supervise and direct the nursing staff and personal care staff of the home as well as provide care.
• Medical director: Each home must have a Medical Director to evaluate and address medical practices, clinical procedures and resident care. This position must be filled by a physician (Suggested Change to LTCA – ADD: or Nurse Practitioner), and may not be the licensee, a person having a controlling interest in the license or a member of the board of a corporate licensee.
• Attending physician or registered nurse in the extended class (RNEC): Each home must ensure that either a physician or RNEC (Nurse Practitioner) conducts a physical examination of each resident upon admission and annually thereafter. The RNEC shall supply a written report of their findings.
• Registered nurse: Each home must have at least one registered nurse (Suggested Change to LTCA – ADD: or Nurse Practitioner) on duty and present in the home at all times, except as provided for in the regulation. The registered nurse must be both an employee of the licensee and a member of the regular nursing staff of the home.

The Canadian Nurses Association (CNA) identifies the competencies of NPs as:

1. Professional Role, Responsibility and Accountability
   1. Clinical Practice
   2. Collaboration, Consultation and Referral
   3. Research
   4. Leadership
2. Health Assessment and Diagnosis
3. Therapeutic Management 
4. Health Promotion and Prevention of Illness and Injury

The parallels between the competencies and capabilities of NPs with the needs identified within LTC are obvious.

To reap the advantages of increased utilization of NPs in LTC, NPAO recommends the following:

1. Funding to Increase NP Leadership with LTCH
   • The staffing study suggests that NPs be better utilized to ‘support’ the Medical Director.  This redundancy does not make sense economically nor efficaciously, when NPs should be able to act as the Medical Director.  Utilizing NPs in the Medical Director role improves continuity of care for residents, reduces costs to LTC, and reduces hospital admissions and emergency department visits from LTCH, to name only a few of the advantages.  In order to have leaders in LTCH, all levels of staff need to have opportunity and availability of relevant education that will help them care for this very specialized patient. NPs could assist in the development and execution of inhouse education programs designed to ensure all staff members are able to function effectively and to the full extent of their roles.
2. Increase NP to Resident Ratio
   • Improving staffing to resident ratio is a critical step to improving the quality of care for LTCH residents and will have a direct and positive impact on the culture in LTCH.
   • Unfortunately, simply adding the outstanding 15 NPs as part of phase three of the Attending NP Program will not be sufficient to meet the needs of LTC for considerable reform and the improvements envisioned.
   • It needs to be recognized that NPs can manage several needs within a LTCH including as Medical Directors, Directors of Care, Medication Management, complex resident management,  nursing leadership, and staff education.
   • The presence of NPs in LTCH can increase the ability to address the increasing complexity and acuity of LTC residents.
   • NPAO recommends a minimum ratio of NPs to residents of at least 1 full-time NP for every 100 LTCH residents.  An appropriate ratio of complementary RN, RPN, PSW and support personal expertise are required to effectively achieve the vision for LTC residents.
   • Ideally, for LTCH with 100 residents or more, at least 3 full time NPs would be employed to provide 24 hour coverage with an attending NP present at all times. With 626 licensed LTCH in Ontario this equates to 1,878 NPs (or 8% of the registered workforce in LTCHs (2018=23,701).
   • The current ratio of NPs in LTC (.6%) is woefully inadequate.  NPAO suggests that as a starting point the goal should be to increase involvement of NPs in LTC to at least 5% of the registered workforce.  
   • There is an opportunity to align the NP workforce working with LTCHs through the Nurse-Led Outreach Team (NLOT) to supplement the registered staff in the LTCH.  Leveraging NLOTs facilitates a team-based approach to resident care to realize the LTC vision and improve staff retention.

It should be noted that increased utilization of NPs in LTCH would not realize its true and positive impact if NPs are not able to practice to their full scope-of-practice.  Nonsensical barriers to practice still exist for NPs in regulations such as: 

• the inability for NPs to order hearing aids and other assistive devices; 
• signing death certificates; and 
• initiate legal forms for mental health services.  

The mental health services forms are a critical need as the alternative is to call the police which only escalates the situation and is not in anyone’s best interests.

3. Address Increasing Complexity and Acuity of Residents with Full Time NPs
   • NPs can be utilized more effectively to address the increasingly complex and diverse needs of residents.
   • NPs full time on site at LTCH can stabilize the need for a fluctuating Case Mix Measurement given their advanced knowledge and competencies. 
   • Increased utilization of full time NPs as Directors of Care and Medical Directors goes hand in hand with the increasing levels of resident complexity and acuity.

The Case Mix Index for calculating funding seems to be redundant and not responsive to LTCH needs.  Statistics show that the average age of a resident is 84 years old.  We know that they will come with a myriad of comorbidities and frailty. We also know that 80% of the residents in LTC have some form of dementia/cognitive impairment that will bring responsive behaviours. The homes need to be staffed appropriately to care for these residents.

To expand LTC’s capacity to address the increasingly complex needs of residents, the Ministry of Long-Term Care should ensure the ongoing sustainability of the existing NLOT programs and provide for every LTC home in Ontario to have access to an NLOT team by doubling the numbers of teams from 14 to 28 within the province.

Nurse Practitioners’ Association of Ontario (NPAO) Commitment to Support LTC Vision

NPAO shares the Ministry of Long Term Care and the Government of Ontario’s recognition for urgency in changing the current LTC model to be able to achieve the vision.  NPAO is committed to working with the Ministry of Long Term Care to address the needs and achieve the reforms to advance LTC in this Province.  

NPAO is offering, with Ministry support, to undertake the development of a practical continuing education course, for all health care providers, that can lead to a Long Term Care Resident Care certification.  This could be a series of courses that speak to the practical realities of long term care and how to effectively achieve the vision for long term care.  Collaborative Care, Quality Care in LTCH, Medication Management, Mental Health Challenges in LTCH, High Performing Cultures in LTC, LTCH Health Care Leadership are examples of courses that can be developed leading to a certification.  Courses can be easily modified to address emergent challenges within LTC.

A critical mass of health care providers certified in LTC Resident Care, would raise awareness of the practical challenges health care workers can expect in a long term care environment and equip them with the skills to be successful as well as improve retention. 

Summary of Recommendations

1. Funding to Increase NP Leadership with LTCH
   • NPs should be able to hold the Medical Director position in LTCH.
   • Adjust wording within the LTCA to include Nurse Practitioners in the mandatory roles for LTCH (i.e. Director of Nursing and Personal Care, Medical Director, Registered Nurse) 
2. Increase NP to Resident Ratio
   • At least 1 full-time NP for every 100 LTCH residents.
   • For LTCH with 100 residents or more, 3 full time NPs should be employed to provide 24 hour coverage with an attending NP present.
   • Increase involvement of NPs in LTC to at least 5% of the registered workforce (currently less than 1%)
3. Address Increasing Complexity and Acuity of Residents with Full Time NPs
   • Increased utilization of full time NPs as Directors of Care and Medical Directors 
   • Ensure the ongoing sustainability of the existing NLOT programs and provide for every LTC home in Ontario to have access to an NLOT team by doubling the numbers of teams from 14 to 28 within the province.
4. Support NPAO in the development of a practical continuing education course that can lead to a Long Term Care Resident Care certification.

During the COVID-19 pandemic, LTC residents are experiencing the highest rates of morbidity and mortality in the country. According to the National Institute of Aging, 82% of all Canadian COVID-19 deaths occurred in LTC and residential nursing home settings, with Quebec and Ontario most negatively impacted. Homes were unprepared for this pandemic and remain in a state of crisis, unable to plan for the inevitable second wave of COVID-19. Our preliminary data collection suggests that those LTCHs that had an NP providing care to residents were able to weather the pandemic more robustly, and were more likely to experience either no COVID19 outbreaks or very small and contained outbreaks which were quickly resolved. This is the type of response which should be the standard of care for all LTCH residents, not just those fortunate enough to be in a LTCH with an NP.

Over and above the current pandemic crisis, LTC residents are becoming increasingly complex, unstable and unpredictable. Many are extremely frail, living with multiple complex chronic health and mental health conditions. Once this pandemic is over, LTC must prepare for even more frail residents as our population ages. The time for leveraging our best nursing resources and building a better LTC system is now.

The Ministry of Long Term Care and the Government of Ontario need to be willing to make bold changes to the current LTCA to facilitate the pursuit and attainment of the vision for LTC.  NPAO wants to be recognized as a partner with the Ministry of Long Term Care to help advance LTC in the Province.

Our bias is in our position that increased utilization of Nurse Practitioners is a key element to achieving the LTC vision.  There is considerable alignment between the recognized needs of LTC and the knowledge, skills, competencies and philosophies of Nurse Practitioners.  

There is a way forward.  We have a great deal of evidence and information to develop the strategy to improve LTC in the Province.  It is long overdue and the time to act is now.  

Sincerely,

Dana Cooper, Executive Director

Nurse Practitioners’ Association of Ontario

613-316-3833 

dcooper@npao.org

cc.  

Christine Elliott, Minister of Health

Dr. Michelle Acorn, Provincial Chief Nursing Officer 

Richard Steele, Deputy Minister of Long Term Care 

Sheila Bristo, Assistant Deputy Minister, Long-Term Care Operations

Janet Hope, Assistant Deputy Minister, Long-Term Care Policy

Sean Court, Assistant Deputy Minister, Strategic Policy, Planning and French Language Services

Michael Hillmer, Assistant Deputy Minister, Capacity Planning and Analytics 

Helen Angus, Deputy Minister of Health