Health Equity Impact Assessment:

Are Ontario Budget Cuts to Long-Term Care Equitable?

Sarah Kelly
November 2019
Organization: Renfrew County and District Health Unit (RCDHU).
The RCDHU is one of 35 Ontario Public Health Units, and represents the City of Pembroke, the
County of Renfrew, the Township of South Algonquin, as well as the majority of Algonquin Park (known
as Renfrew County and District).1 The district covered by the RCDHU is approximately 15 000 square
kilometers and serves approximately 106 000 individuals.1 The RCDHU is comprised of approximately 60
staff members among two offices; a main office located in Pembroke, and a branch office located in
Renfrew.1 The mission of the RCDHU is to demonstrate leadership and service excellence in order to protect
and promote the health of residents in Renfrew County and District.1
The elderly population of Renfrew County and District is approximately 22 000.1 The RCDHU has
identified falling as the leading cause of injury among the elderly population of Renfrew County and
District.1 Further, the RCDHU has found that the elderly population of Renfrew County and District have
disproportionately high rates of fall-related hospitalizations and emergency room visits, relative to the rest
of Ontario.1 The RCDHU estimates that 40% of long-term care home admissions are a result of an elderly
person losing their independence after sustaining a fall-related injury.1 There are nine long-term care homes
that fall under RCDHU’s jurisdiction, which together have a total of 825 long-term care beds for the entire
Renfrew County and District population (C. Trombley, Personal Communication, November 17, 2019).
*Above information collected from RCDHU’s website, accessible at: https://www.rcdhu.com/about/
Structural Change: Ontario cuts to long-term care budget (scheduled for 2020).
Upon being elected Progressive Conservative (PC) Premier of Ontario in June 2018, Doug Ford
promised to cut millions of dollars of funding to Ontario’s long-term care budget. This entailed cutting $34
million dollars of funding from two long-term care funds, the High Wage Transition Fund and Structural
Compliance Fund,2 that had been intended for programs, services, equipment, as well as upkeep of long-
term care homes in Ontario.3 This means hundreds of thousands of dollars in annual funding will be cut
from several individual long-term care homes located in Renfrew County and District. The High Wage
Transition fund helps long-term care homes pay their staff and maintain equitable care levels, as a result of
staff wages increasing more than long-term care home budgets permit.2 The Structural Compliance Fund
helps to fund long-term care homes who do not have the budget for regular home maintenance or to upgrade
their medical equipment.2 Funding cuts to long-term care homes located in Renfrew County and District
specifically include a $175 000 annual cut to Bonnechere Manor long-term care home and a $366 000 annual
cut to Miramichi Lodge.4 Both of these homes employ more staff than their regular funding permits, and
therefore rely on this money to pay their staff.2 As of September 2019, these funding cuts have been
postponed until 2020 in order to give long-term care homes across Ontario adequate time to adjust.3

Objective for Completing the HEIA: With the impending funding cuts to long-term care home budgets in Renfrew
County and District, it is imperative that the potential health impacts of these cuts on specific sub-populations be
assessed. Once the impacts of these cuts are understood, appropriate mitigation and monitoring strategies must be
put in place to ensure that the health and well-being of the residents of these long-term care homes does not suffer.
HEIA
Step 1. SCOPING

Populations Determinants of Health

Seniors Income/SES: There have been tens of thousands of seniors on wait lists for publicly funded long-term care since the 1990s.5 This leaves seniors with no choice but to
(age 65+) navigate expensive privatized long-term care homes, although they are entitled to the same publicly funded care, depending on whether or not their level of income
can support it.5
Employment: For the past 5 years, the average age of retirement in Canada was 63 years old.6 Therefore it is reasonable to infer that seniors over the age of 65 seeking
long-term care are likely no longer employed, and therefore do not have an actual income and rely completely or in part on the pension from their previous employment,
permitting they have a pension at all.
Health care services: Living conditions in long-term care homes are often unsafe which results in higher mortality rates for seniors, often due to preventable situations
caused by understaffed homes and thus lack of adequate care.5
Social/familial support networks: Long-term care is often sought when caregivers, usually family or spouses, cannot meet the rigorous care needs of the seniors they
are caring for.5
Ethnicity/culture: Wait lists are much longer for seniors belonging to a racial minority group seeking access to culturally appropriate long-term care, than for seniors
who are not seeking culturally appropriate long-term care.5
Low income/SES Income/SES: The average wait time for the lowest possible priced bed in a long-term care home (~$1900/month) is 8 months longer than for a higher priced private
or semi-private bed (over $2000/month) in the same long-term care home.5 Those who have an income that supports payment of $2000 + per month towards long-
term care receive significantly higher access to care than a low income person who cannot pay $2000+ per month.5
Employment: If a person seeking long-term care or their family can afford it, they may pay to get privatized care, while those who cannot afford it often do not receive
care and are left to suffer.5 A low SES senior or family that does not have the employment pension to support the price of a long-term care home will likely not be
able to afford to seek long-term care.
Education: Lower levels of education are a determinant of low SES,7 which makes it much harder to access long-term care due to financial barriers.
Health care services: Those who are in desperate need of long-term care services but cannot access it due to low SES are often forced into inhumane living conditions.5
Social/familial support networks. Close relatives or spouses who can afford private caregivers may purchase one, while low SES relatives or spouses who cannot
afford to hire private caregivers for the person they support are forced to go without the extra help.5
Ethnicity/culture: Racial minorities are more likely to have a lower SES due to racial discrimination and marginalization,7 increasing financial barriers to accessing
long-term care.
People with Disabilities Income/SES: Long-term care home residents with disabilities must pay monthly for room and board.8 If the person with a disability or their caregivers do not have
(e.g., physical, D/deaf, deafened or hard of the income to pay for long-term care (monthly ~$1900 standard accommodations, ~$2300 semi-private, ~$2700 private)9 it may not be an option altogether.
hearing, visual, intellectual/developmental, Health care services: Long-term care homes are specifically designed to meet the needs of seniors, not for people with disabilities.10 As a result, people with disabilities
learning, mental illness, addictions/substance in long-term care homes often receive a substandard level of care which does not meet their daily requirements.10
use, etc.) Social/familial support networks: One of the eligibility criteria required for long-term care home admission of a person with a disability is that they do not have a
caregiver (often a parent) to support them.8 Therefore, a person with a disability may be denied long-term care based on the fact that they have a stay-at-home
parent/caregiver, although this may not mean that this parent/caregiver provides adequate care.
HEIA
Populations
Unintended Positive Impacts.
Seniors With an increase in privatized
long-term care homes caused by
budget cuts to the public sector,
seniors with a high SES may
have increased access to long-
term care.
Low There are no unintended positive
Income/SES impacts of budget cuts to long-
term care observed for low
income/SES populations.
People with With an increase in privatized
Disabilities long-term care homes caused by
budget cuts to the public sector,
people with disabilities who
have a high SES may have
increased access to long-term
care.
Step 2. POTENTIAL IMPACTS
Unintended More
Negative Information
Impacts. Needed.
The elimination of the Structural Compliance Fund will be affecting programs, equipment, and upkeep of homes in More information is needed on how
RCDHU.2,3 The elimination of the High Wage Transition Fund will leave RCDHU long-term care homes with insufficient the new budget will be distributed
funds to pay their staff in order to maintain equitable care levels.2 This is because staff wages are now higher than long-term within specific long-term care
care home staffing budgets.2 Cutting this fund effectively recreates a problem that was previously solved with the homes in RCDHU once the funding
implementation of the fund. This means that long-term care home staff will likely have less time to care for residents, and cuts have been made. It is critical to
less resources to assist them with such care. For seniors residing in long-term care homes, this will decrease quality of care know for example if the number of
and access to care, thus decreasing health outcomes and quality of life. Wait times for long-term care are already extremely long-term care home staff or the
long, and seniors often die while on the wait list.5 Seniors waiting to get into long-term care homes are almost always capacity for residents will decrease,
unemployed, leaving them less likely to be able to afford to pay for privatized care or private/semi-private rooms, both of or if the monthly cost of living for
which decrease wait times.5 Violence in long-term care homes is at an all-time high, with rates of resident on resident residents will increase.
homicide and assault increasing.5 Homicides in Ontario long-term care homes occur at approximately six times the rate of *the above information is also
homicides in the average Ontario town.5 Funding cuts could mean even less staff and increased violence. Seniors who belong needed for low income/SES and
to racial minority groups already experience decreased access to long-term care and under-treatment while in long-term people with disabilities
care, leading to decreased health outcomes.11 The proposed budget cut will disproportionally affect seniors and minority
populations and widen the gap between best and worst health outcomes.
Budget cuts to publicly funded long-term care homes have been justified by the notion that the privatized long-term care More information is needed to
industry will fill the gap in demand for long-term care in the public sector that budget cuts create.5 Privatized care has been indicate whether or not the budget
known to be much more expensive than publicly funded care.5 Low income individuals seeking long-term care are left cuts will increase cost of living in
without access to the publicly funded care they are entitled to, and no means to afford privatized long-term care.5 Moreover, long-term care homes or decrease
privatized homes have a 10% increase in mortality rates and a 25% increase in rates of hospitalization.5 Low income the amount of money allocated
individuals are forced to pay more money for a lower quality of care. If they cannot gather the funds for privatized care, towards government subsidies given
they are left with no access to care. Racial minorities are more likely to have a lower income,7 making them even less likely to low income people seeking long-
to be able to access care. Individuals who are not part of a racial minority and populations with higher incomes/SES are term care.
much more likely to receive the care they need. Therefore, the proposed budget cut will decrease health outcomes for low
income populations and racial minority groups.
Levels of care in RCDHU long-term care homes are already much too low to meet the needs of residents.4 On top of this, As people with disabilities in long-
people with disabilities living in long-term care homes are already receiving care that is not tailored to their specific needs.10 term care homes are receiving care
By decreasing funding to programs, services, and equipment in long-term care homes,3 people with disabilities may begin tailored to seniors rather than their
to experience an even lower level of care than before. This would increase health disparities between the general population specific needs,10 more information
and the population of people with disabilities within long-term care homes. Ontario, let alone RCDHU, does not currently is needed to determine if budget cuts
have any long-term care homes geared towards people with disabilities, and people with disabilities in long-term care often will disproportionally impact
require even more frequent care than seniors.10 Currently, residents in Ontario long-term care homes receive less than three programs and services that they
hours per day of individual care.5 Seniors require a minimum of four hours per day of individualized care,5 while people benefit the most from.
with disabilities require even more. People with disabilities are not receiving the care they need, and budget cuts will only
increase health disparities in disability populations and worsen health outcomes.
HEIA
Step 3. MITIGATION

Populations Identify ways to reduce potential negative impacts and amplify the positive impacts.

Seniors One central issue long-term care homes in RCDHU currently face is understaffing, leading to inadequate levels of care as well as limited access to care for seniors.5 After
the High Wage Transition fund is removed, it is possible that staffing could decrease further, although more information is needed. Staff members hired to long-term care
homes currently include registered nurses, registered practical nurses, and personal support workers.5 One way to mitigate the potential negative impacts previously
identified for seniors, is to refrain from hiring staff members with a higher pay grade, instead hiring “assistants” who can work part time and are compensated with
minimum wage rather than a salary. This would offer clinical experience to many inexperienced individuals, decrease expenditure on staff, while also increasing the
number of staff. Evidence indicates that with an increased number of staff, care levels will increase, and rates of in-home homicide and violence will decrease.5 A higher
capacity of long-term care home staff might also result in more long-term care bed availability, improving access to long-term care for seniors. Stakeholders that should
be involved in planning these changes include: RCDHU long-term care homes, RCDHU long-term care home residents (seniors), as well as research associations,
academics, and networks within the RCDHU’s long-term care sector.12 Additionally, the Ontario Health Coalition recommends that seniors in long-term care homes each
receive a daily minimum of four hours of one-on-one personalized care.5 This mitigation strategy prevents violence and negative health outcomes and improves the overall
level of care.5
Low Income/SES Cuts to funding for RCDHU long-term care homes disproportionally lower access to care for low income/SES populations. One strategy to mitigate this issue is to base
pricing on income/SES. A potential mitigation strategy that could be used in combination with this strategy is to have long-term care homes allocate more standard beds
at a lower price and fewer private beds at a much higher price, in order to make up for the lowered cost of standard accommodations. Currently, monthly rates are: ~$1900
for standard accommodations, ~$2300 for semi-private, and ~$2700 for private accomodations.9 Current regulations also allow for long-term care homes to allocate 60%
of their beds for more expensive semi-private and private rooms, even though 56% of people are on the wait list for standard accommodation pricing.5 If income/SES was
assessed, residents who have a much higher SES could be required to pay extra for private accommodations, while residents who have a much lower SES could be
pardoned of at least some of the $1900 monthly financial burden, similar to how tax brackets work. It would be beneficial to include these stakeholders in the planning
process: RCDHU long-term care homes, RCDHU long-term care home residents (low income/SES populations), as well as research associations, academics, and networks
within the RCDHU’s long-term care sector.12 Another potential mitigation strategy that the Ontario Health Coalition recommends is implementing a comprehensive
strategy to increase the number of long-term care beds in the publicly funded sector.5 Additionally, they recommend that this planning take into account the needs of racial
minority populations of all socioeconomic backgrounds, and to adjust their strategy accordingly to fit the needs of these populations.5
People with Disabilities People with disabilities living in long-term care homes are at a disadvantage because staff are trained to deal with seniors, and equipment, programs, and services are
geared towards seniors.10 One strategy to mitigate this negative impact is to comprehensively train staff on the specific needs of long-term care home residents living with
disabilities. Training staff to fit resident specific needs has been proven to be an effective way of improving care, increasing health outcomes, and decreasing violence.5
Another mitigation strategy would be to allocate specific funds that focus on disability support within long-term care homes. Increased funding is a necessity in improving
levels of care,5 and would therefore be beneficial in improving health outcomes and decreasing health disparities for people with disabilities. These mitigation strategies
would have a higher chance of success if the stakeholders involved in planning these strategies included: RCDHU long-term care homes, RCDHU long-term care home
residents (who have disabilities), as well as research associations, academics, and networks within the RCDHU’s long-term care sector.12
HEIA
Step 4. MONITORING

Populations Identify ways to measure success for each mitigation strategy identified.

Seniors To monitor the success of hiring minimum wage “assistants,” in order to increase staffing while reducing the cost to the long-term care home, detailed client satisfaction
surveys should be given to seniors residing in RCDHU long-term care homes. Residents should be asked about their satisfaction with the level of care they are now
receiving. This would serve as a method of evaluating if this strategy was effective in increasing care levels. To monitor whether or not this strategy was effective in
decreasing levels of violence in RCDHU long term-care homes, program evaluation should be put into place to measure if rates of resident violence in RCDHU long-term
care homes are decreasing. It may also be beneficial to run focus groups with seniors in long-term care homes to ensure all of the shortfalls and highlights of the strategy
are recorded in detail.
In order to monitor the success of Ontario Health Coalition’s suggested mitigation strategy of a daily minimum of four hours of one-on-one personalized care for each
senior,5 client satisfaction surveys should be distributed. The surveys should ask whether or not residents estimate the amount of individual care they receive to be above
or below four hours, and whether or not they are satisfied with the level of care they are receiving. In addition to this, a program evaluation should be implemented to
more accurately estimate the average hours of daily personalized care. RCDHU long-term care home stakeholders should be consulted on their observations throughout
the course of these strategies.
Low Income/SES The combined strategies of basing monthly pricing on income/SES, increased allocation of even lower priced beds, and increased pricing of private and semi-private beds
should be monitored closely by obtaining feedback from low income populations. This feedback can be obtained through program evaluation of the new long-term care
wait times for low income/SES populations (i.e. measuring if access to care for low income/SES populations has actually tangibly improved). Success can also be
monitored through process evaluation to ensure that equity considerations are being made when the new reduced price for low income/SES populations and intersecting
minority groups are being determined.
To monitor the Ontario Health Coalition’s mitigation strategy of increasing the number of long-term care beds in the publicly funded sector,5 process and program
evaluation should be implemented. Process evaluation should be used to ensure that beds are increased in an equitable way, meaning that resident health outcomes and
care times will not suffer as a result of increased bed capacity. Process evaluation should also be used to ensure that the needs of racial minority populations, low
income/SES in particular, are being equitably considered in the process of increasing bed capacity.5 Program evaluation may be used to monitor the success of increasing
bed capacity by calculating the difference in the capacity of long-term care beds before and after the mitigation strategy was implemented. Stakeholders in RCDHU long-
term care homes should be consulted on their observations of equity throughout the course of these strategies.
People with Disabilities To monitor the effectiveness of staff disability training initiatives, focus groups and client satisfaction surveys should be used. This will be the best indication of whether
or not the beneficiaries of the initiative are satisfied. Process evaluation should be used to ensure that staff are being trained to treat people with disabilities equitably and
that this increases positive health outcomes for people with disabilities. To monitor the success of allocating specific funds that focus on disability support within long-
term care homes, focus groups and client satisfaction surveys should also be used. Process evaluation should be used to make sure that funds are being distributed equitably
to increase health outcomes of people with disabilities in long-term care.
HEIA

Step 5. DISSEMINATION

Populations Identify ways to share results and recommendations to address equity.

Seniors Results of client satisfaction surveys on level of care after increase in low wage staffing of RCDHU long-term care homes should be compared across homes and distributed
to all nine long-term care homes across RCDHU. Program evaluation results detailing whether or not rates of resident violence have decreased after mitigation should also
be compared and distributed to the nine homes. Shortfalls and highlights of the low wage staffing initiative obtained from focus groups should be reported and used to make
recommendations for implementation of this strategy in the future. Survey and program evaluation results of the daily minimum four-hour care strategy should be distributed
to stakeholders and to homes in all public health units across Ontario. The distribution of these results should prompt recommendations for future initiatives. These
recommendations should be disseminated through the formation of a community of practice by using the above evidence to recommend ways to reduce health inequities
among seniors, low income populations, and people with disabilities living in long-term care homes.

Process evaluation was completed concerning the equitable implementation of:

Low Income/SES • Increased number of beds (i.e. resident health outcomes and care times will not suffer as a result of increased bed capacity);
• Consideration of racial minority population needs in the process of increasing bed capacity;5
• Determining the revised price for low income/SES populations and intersecting minority groups;
• Staff disability training (i.e. to increase positive health outcomes for people with disabilities);
• Distribution of funds within long-term care homes to increase health outcomes of people with disabilities.
The results on whether or not the above strategies were implemented in an equitable manor should be compiled, synthesized, and used to make recommendations on how
to implement mitigation strategies for long-term care in the future. These results and recommendations should be disseminated through a long-term care equity workshop.

Results of all conducted surveys, focus groups, and program evaluation data should be compiled and synthesized into a long-term care report for RCDHU. This report will
be extremely useful in evaluating which mitigation strategies were most effective and which strategies other long-term care homes should refrain from using in the future.
People with Disabilities This report should be comprehensive and should make recommendations based on evidence obtained through data collection. The RCDHU will be able to use this document
to create new mitigation strategies for future changes to funding in long-term care homes. This report should be given to the Ontario Ministry of Long-Term care and
distributed to other Ontario health units so that they may use these results in the future.
Conclusions:
Current levels of care in Ontario long-term care homes are already too low to meet resident care
needs.4 Ontario long-term care homes are experiencing the highest levels of violence and resident on
resident homicide ever before seen, due to lack of resources and low levels of care.5 The PC government’s
decision to cut two major long-term care funds will result in a significant loss to much needed programs,
services, equipment, and maintenance of long-term care homes in RCDHU.3 The termination of the High
Wage Transition Fund and the Structural Compliance Fund will leave RCDHU long-term care homes with
insufficient funds to pay their staff in order to maintain equitable care levels, limiting access to care and
lowering health outcomes of residents.2 These negative impacts will disproportionately affect seniors, low
income/SES populations, and people with disabilities. Seniors will be subjected to lower levels of care
and increased violence in long-term care homes. Low income populations will experience increased
barriers to accessing long-term care, and racial minorities will experience an amplified version of these
barriers. People with disabilities will experience lower quality of care than seniors, resulting in an increase
in health disparities and lower quality of life. There is a surplus of evidence to indicate that funding cuts
to long-term care are not equitable.

Recommendations:
1. Seniors living in long-term care homes should each receive a daily minimum of four
hours of personalized care by a staff member.5 This strategy has been proven to
prevent negative health outcomes and violence among residents and improve the
overall level of care for long-term care home residents.5
2. A comprehensive strategy to increase the number of long-term care beds in the
publicly funded sector must be developed and implemented using process
evaluation to ensure equitable implementation.5 Additionally, racial minority
populations should be included in the planning process of increased long-term care
bed capacity in order to ensure that there is a significant increase in culturally
appropriate long-term care.5
3. Develop and implement thorough staff training programs centred around the
specific needs of long-term care home residents living with disabilities. Training
staff to fit resident specific needs has been proven to be an effective way of
improving care, increasing health outcomes, and decreasing violence for residents
with disabilities.5
References:

1. Renfrew County and District Health Unit. (2019). Optimal Health for all in Renfrew County and
District. Retrieved from https://www.rcdhu.com/about/
2. Pembroke Observer. (2019). Province announces extension of the high wage transition fund,
structural compliance fund. Retrieved from https://www.pembrokeobserver.com/news/local-
news/province-announces-extension-of-the-high-wage-transition-fund-structural-compliance-fund
3. Ontario Health Coalition. (2019). List of the Ford Government Health Care Cuts to Date.
Retrieved from https://www.ontariohealthcoalition.ca/index.php/update-mounting-health-care-
cuts/
4. Ontario Health Coalition. (2019). Ford Government Cuts to Long-Term Care Funding Risk
Already Over-Stressed Care Levels. Retrieved from
https://www.ontariohealthcoalition.ca/index.php/releaseford-government-cuts-to-long-term-care-
funding-risks-already-over-stressed-care-levels/
5. Ontario Health Coalition. (2019). Situation Critical: Planning, Access, Levels of Care and
Violence in Ontario’s Long-Term Care. Retrieved from http://www.ontariohealthcoalition.ca/wp-
content/uploads/FINAL-LTC-REPORT.pdf
6. Statistics Canada. (2019). Retirement age by class of worker, annual: Table: 14-10-0060-01.
Retrieved from https://www150.statcan.gc.ca/t1/tbl1/en/tv.action?pid=1410006001
7. American Psychological Association. (2019). Ethnic and Racial Minorities & Socioeconomic
Status. Retrieved from https://www.apa.org/pi/ses/resources/publications/minorities
8. Ontario Ministry of Children, Community and Social Services. (2017). Guidelines for Supporting
Adults with a Developmental Disability when Applying to, Moving into and Residing in a Long-
Term Care Home. Retrieved from
https://www.mcss.gov.on.ca/en/mcss/publications/developmentalServices/ltc_home_guidelines.as
px
9. Ontario.ca (2019). Long-term care accommodation costs and subsidy. Retrieved from
https://www.ontario.ca/page/get-help-paying-long-term-care
10. Goffin, P. (2017). Thousands of under-65 adults with physical disabilities are being forced into
Ontario nursing homes: Ministry data. Retrieved from
https://www.thestar.com/news/gta/2017/07/09/thousands-of-under-65-adults-with-physical-
disabilities-are-being-forced-into-ontario-nursing-homes-ministry-data.html
11. Sue Cragg Consulting & CLRI Program. (2017). Supporting Cultural Diversity in Long-Term
Care Needs Assessment and Work Plan for 2017-18. Retrieved from https://clri-
ltc.ca/files/2018/04/CLRI-on-Supporting-Cultural-Diversity-Long-Term-Care.pdf
12. Centres for Learning, Research, & Innovation in Long-Term Care. (2016). Ontario CLRI:
Stakeholder Engagement (Sector Feedback). Retrieved from https://clri-ltc.ca/2016/10/ontario-
centres-for-learning-research-and-innovation-in-long-term-care-stakeholder-engagement-sector-
feedback/?print=print