Hunter Prize: The prescription to end hallway medicine once and for all

In Ontario, there are currently over 39,000 people on the waitlist for LTC homes
Sheri Levergood spends time with her mother, Janet Levergood at a long-term care residence where Janet now lives in Waterloo, Ont. on Tuesday, April 4, 2023. Peter Power/The Canadian Press.

The Hub’s first annual Hunter Prize for Public Policy, generously supported by the Hunter Family Foundation, focused on solving the problem of long wait times in Canada’s health-care system. A diverse group of ten finalists have been chosen from nearly 200 entries, with the finalists and winners chosen by an esteemed panel of judges, including Robert Asselin, Dr. Adam Kassam, Amanda Lang, Karen Restoule, and Trevor Tombe. The Hub is pleased to run essays from each finalist this week that lay out their plans to help solve this persistent policy problem.

Health and long-term care (LTC) systems across Canada are struggling now more than ever, and it’s negatively affecting the health of every Canadian. There’s simply not enough support available for everyone who needs care at home or in LTC homes. 

In Ontario, there are currently over 14,000 people on the continually expanding waitlist for home care and over 39,000 people on the waitlist for LTC homes. Many of these individuals, who can no longer reside safely in their own homes, have ended up living in hospitals instead. These and others, who no longer require hospital care, are politely labelled as “Alternate Level of Care (ALC) patients”, but are essentially being held hostage by the current lack of LTC services as they wait for appropriate care to become available back in their own homes. 

Currently, there are 4,514 patients ALC patients occupying 13.6 percent of Ontario’s hospital beds, with 48 percent waiting for LTC home placement and 13 percent of them waiting for access to in-home care. In its overcrowded hospitals, Ontarians are now waiting a staggering 17.9 hours on average to be admitted to an inpatient bed from emergency departments. Furthermore, limited beds only serve to additionally delay timely access to elective surgeries. 

While Ontario’s current government was elected on a promise to end hallway medicine in 2018, the truth is that it’s never been further from this goal. Its proposed solution was to build and redevelop 60,000 LTC beds by 2028, but has only managed to open 1,934 new or renovated beds while only another 5,071 are under construction. While the government has further responded to this by more than doubling its construction funding subsidies from an average of $240 to $560K per bed, or $14 to $34B overall, to help further incentivize and accelerate the building of LTC beds to meet its 2028 goal, it remains highly doubtful this can be achieved.    

So how can we actually end hallway medicine? 

We are proposing that Canada significantly reorient from its current preference to provide LTC services in LTC homes to within the actual homes of Canadians, for which we currently only allocate 31 percent of our LTC spending. While LTC homes must remain an option for some, home care services can be ramped up more rapidly. Furthermore, by lessening the need for more institutional forms of care, we can avoid the significant infrastructure costs that are associated with warehousing vulnerable people. 

However, we don’t just need to provide more home care, but also implement more integrated and intensive ways of delivering this care such as through our proposed “Virtual LTC @ Home Program.”  Such an approach would enable integrated teams, comprising local home care, community services providers, primary care providers, and community paramedics to offer a more robust, flexible, and cost-effective mix of home care services to enable LTC home-eligible individuals, including the nearly 52,000 Canadians awaiting LTC home placements, to live in their own homes for as long as possible. This is also what nearly 100 percent of older Canadians have said they actually want. Furthermore, these teams would have to work with the same level of funding it would cost to care for these same individuals in an LTC home.

While our proposed prescription might sound unrealistic, it is both inspired and informed by the United States and Denmark, which have successfully developed more robust home care programs, to improve care outcomes and reduce the strain on hospitals and overreliance on LTC homes. In fact, Denmark, which has been championing its progressive Ageing-in-Place Strategy since 1988, now allocates only 36 percent of its overall LTC spending to care for individuals in LTC homes, compared to 69 percent in Canada. As a result, Denmark has achieved an almost non-existent 1 percent ALC rate—compared to Ontario’s rate of 13.6 percent—through a strong emphasis on providing adequate home care services that enable patients to be appropriately discharged quickly from hospitals when they no longer need care in them. Denmark also avoided building any additional LTC beds over two decades and closed thousands of hospital beds as a result of its strategy.

In the United States, Program for All-Inclusive Care for Elders (PACE) models currently support approximately 51,000 LTC home-eligible individuals 55 years and older across 31 states to live safely at home for as long as possible with the support of one of 260 PACE programs that provide robust home care services—which receives the same amount of funding per enrollee as would have been given to care for them in an LTC home. Finally, one study showed that after three years, 85 percent of PACE enrollees were still able to live in their own homes.  

Our call to action

Given predictions that Canada will need to more than double its current complement of LTC beds by 2035 to meet the needs of its ageing population, our proposed Virtual LTC @ Home Program offers a high-impact, cost-effective, and politically desirable policy alternative to building more LTC homes that can effectively address health-care wait times and other health-care delivery challenges. 

In its 2023 budget, Ontario announced that it would inject an additional $569M this fiscal year for the provision of more home care. Rather than pursuing more of the same approaches with this funding, it’s time to embrace more innovative and robust solutions. We are thus proposing that Ontario use a small proportion of its new investment to launch up to 10 Virtual LTC @ Home Demonstration Programs. These programs could support up to 150 clients per year with up to $67,510 per enrollee per year (the current annual per-resident cost to provide a year of care in an Ontario LTC home), for an initial three-year period of funding. While this would represent an investment of $100M a year, as part of Ontario’s overall $14B LTC services budget, we think we cannot afford not to test our evidence-informed solution that could begin to finally put an end to Ontario’s debilitating hallway medicine and waitlist crisis once and for all and show a way for Canada to better meet the needs of its ageing population.  

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