Though the COVID-19 outbreak has drawn attention to (and amplified) the pressures facing Ontario’s long-term care (LTC) workers, the province’s LTC staffing crisis—and the structural problems contributing to it—existed long before the novel coronavirus emerged. 1 1 Johanna Wolfert, “Long-Term Care Was in Crisis Even Before the Onset of COVID-19,” Ottawa Citizen, March 30, 2020, https://ottawacitizen.com/opinion/wolfert-long-term-care-was-in-crisis-even-before-theonset-of-covid-19/  Workers and employers across the province warned of widespread staffing shortages, low attraction and retention of quality workers, declining wages, worker dissatisfaction, and burnout. The shortage of personal support workers (PSWs), the most numerous group of frontline workers in LTC homes and the group responsible for the majority of hands-on care, is particularly acute.

But why is this happening? What are the long-term structural causes that contributed to the massive challenges facing the system today? In this paper, we provide an overview of the structural challenges to PSW funding that have contributed to the current staffing crisis in Ontario’s LTC homes.

Demand for PSWs in the LTC sector is extremely high: in a survey by the Ontario Long-Term Care Association, nine in ten homes reported challenges recruiting staff—and PSW positions were the hardest ones to fill. 2 2 Ontario Long-Term Care Association, “Long-Term Care that Works. For Seniors. For Ontario. 2019 Budget Submission,” 2019, https://www.oltca.com/OLTCA/Documents/Reports/2019OLTCABudgetSubmission-LTCthatWorks.pdf . This demand will only increase as the 15,000 new LTC beds promised by the Ontario government begin operation. 3 3 CLAC, “2020 Budget Submission,” January 27, 2020, https://www.clac.ca/Your-voice/Article/ArtMID/4829/ArticleID/1391/2020-Ontario-Budget-Submission. . And the COVID-19 crisis has led not just to shortages but to a genuine crisis for PSWs, a crisis so acute that the government has created a staffing strategy to address it. The expected response of a labour market, however, where labour shortages in a competitive environment result in higher wages, is prevented by a combination of the government’s failure to properly account for increased resident acuity in LTC funding, a broken arbitration system, a centralized bargaining pattern, and concentrated market actors.

In 2010, Ontario expanded its Aging at Home Strategy, designed to keep seniors in their homes or communities longer and to lessen the burden on hospitals of patients needing extended care. 4 4 Ministry of Health and Long-Term Care, “Aging at Home Strategy,” August 31, 2010, https://news.ontario.ca/mohltc/en/2010/08/aging-at-home-strategy.html. Since then, stricter admission requirements for entry into LTC homes have been in effect. While LTC facilities have always provided care for residents who needed more support than they could receive at home, now only those with high and very high needs are eligible for admission into LTC. In addition, downloading of responsibilities from hospitals to LTC has meant that high-acuity patients who formerly would have received care in hospitals now receive care in LTC facilities. 5 5 Eileen E. Gillese, Public Inquiry into the Safety and Security of Residents in the Long-Term Care Homes System: Report, vol. 2, A Systematic Inquiry into the Offences (Toronto: Queen’s Printer for Ontario, 2019),86, http://longtermcareinquiry.ca/wp-content/uploads/LTCI_Final_Report_Volume2_e.pdf; Ontario Health Coalition, “Situation Critical: Planning, Access, Levels of Care and Violence in Ontario’s Long-Term Care,” January 2019, http://www.ontariohealthcoalition.ca/wp-content/uploads/FINAL-LTC-REPORT.pdf.  As a result of these transformations in seniors’ care, more residents have been entering LTC at a later stage of their physical and cognitive decline. While there may be sound public-policy reasons for this shift, the requisite changes to staffing that are required to properly handle this increased acuity have not been made.

While LTC residents are responsible for some of their room-and-board costs, LTC homes get most of their funding from the government. This funding is administered through four envelopes: nursing and personal care (which includes funding for PSW wages), program and support services, raw food (ingredients for resident meals), and other accommodation. For-profit homes are only allowed to keep—that is, earn a profit from—any surplus funds from the other accommodation envelope. Not-for-profit and municipal homes, meanwhile, keep nothing and have an incentive to reinvest every extra dollar into improving operations and staffing. Given that for-profit homes have an incentive to put surplus funds toward shareholder dividends rather than resident care—and that “one of the principal mechanisms for generating profit is reducing staffing levels, which results in inferior quality of care” 6 6 Margaret J. McGregor and Lisa A. Ronald, with commentary by Gail Dobell, “Residential Long-Term
Care for Canada’s Seniors,” Institute for Research on Public Policy, January 24, 2011, https://irpp.org/research-studies/residential-long-term-care-for-canadas-seniors/. —it is unsurprising that research has linked for-profit ownership to poorer outcomes for residents in LTC. 7 7 Peter Tanuseputro et al., “Hospitalization and Mortality Rates in Long-Term Care Facilities: Does For-Profit Status Matter?,” Journal of the American Medical Directors Association 16, no. 10 (October 2015): 874–83, McGregor and Ronald, “Residential Long-Term Care”; AdvantAge Ontario, “Not-for-Profit Difference in Services for Seniors,” http://www.advantageontario.ca/AAO/Resources/AAO/Resources_Content/Resources.  Yet the issues we outline in this paper are not unique to for-profit homes. While there are those who are calling for a removal of for-profit homes from Ontario, this will do little to solve the underlying, structural issues with LTC and its labour-market challenges.

The amount of funding each LTC home receives in its nursing and personal care envelope is calculated accorded to the home’s level of acuity, known as its Case Mix Index (CMI). 8 8 District Municipality of Muskoka, “Long-Term Care Home Funding and Case Mix Index (CMI) Overview,” August 22, 2019, 2, https://muskoka.civicweb.net/document/34306; Gillese, A Systematic Inquiry into the Offences, 353.  In theory, this system directs funds where they are most needed, by providing more funding to homes whose residents have more complex health problems and thus higher care needs. In practice, however, total provincial funding for the nursing and personal care envelope has not kept pace with the increased staffing demands created by rising acuity in all Ontario LTC homes. A home’s CMI compares the acuity of its residents only to that of other homes in the province each year. It was originally designed to account for increased acuity over time in the system as a whole, but is re-indexed every year to prevent LTC funding from going over budget. Having the same CMI over time results in receiving inflation-adjusted decreases in many of the funding years since 2004. When coupled with the skyrocketing acuity of LTC residents, insufficient funding increases mean that homes are forced to provide more care with less money every year.

The CMI-adjusted funding system also creates a moral dilemma for PSWs and other care staff: if they do not prioritize paperwork over patient care—even if information on some forms was already entered by other staff—the documented acuity of their facility could decrease and cause their home to lose funding in the care envelope, making it even harder to meet patients’ care needs in the future. 9 9 Hank Beekhuis, “Patients First: A Plan to Combat Pressures in Ontario’s Long Term Care System,” CLAC, February 28, 2017, https://www.clac.ca/Your-voice/Article/ArtMID/4829/ArticleID/130/Patients-First-A-planto-combat-pressures-in-Ontario%e2%80%99s-long-term-care-system. Partial and inconsistent access to technology is a common cause of documentation redundancy: if there aren’t enough tablets to go around, some PSWs have to do mandatory charting using paper at the bedside, leaving the information to be re-entered into the digital system later. Documentation is an important part of care, but every minute that a PSW is forced to spend on redundant or unnecessary paperwork takes away from direct, hands-on resident care. One way to address this in the short term and introduce greater accountability on expanding resident needs would be to pay for charting/documentation costs out of the housing envelope rather than the care envelope. When residents receive less hands-on care, their health and quality of life suffers—a deeply distressing cycle for the many workers who entered LTC to help residents. 10 10 Brian Dijkema and Johanna Wolfert, “People Over Paperwork: Time, Dignity, and Other Labour Market
Challenges for Ontario’s Long-Term Care Workers,” Cardus, November 12, 2019, https://www.cardus.ca/research/work-economics/reports/people-over-paperwork/.

The legal framework for collective bargaining in the LTC sector limits the tools for unions and employers to respond to labour-market pressures. Like hospitals, police forces, and other essential services, LTC homes are not allowed to use strikes and lockouts, meaning that the only option for settling labour disputes is binding arbitration: the opposing parties hire an arbitrator to review their case and agree to accept the arbitrator’s decision for their collective agreement. 11 11 Hospital Labour Disputes Arbitration Act, R.S.O. 1990, c. H.14, https://www.ontario.ca/laws/statute/90h14. Unlike police forces, however, LTC homes have middle men—facility owners in the role of employers—who act as the actual bargaining partners in labour negotiations, while the payer—the government, which controls funding—is in the background. In other disputes involving essential workers (police officers, firefighters, hospital employees), it is the payer who sits across the table from worker representatives. But in LTC, the employers are simply the administrators of funds, with no direct levers to increase funding. This middle-man system makes it difficult to hold either the payer or the employer accountable for results: employers can (rightly) insist that they don’t control funding, while government is hidden from view throughout the process.

Arbitration is an expensive and time-consuming legal process for all parties. Yet it typically results in only minimal wage increases for workers, given the pattern structure of collective bargaining in LTC. One of the main factors that arbitrators consider when issuing a decision on a collective agreement is the precedent set by similar collective agreements in the sector, which means that the same wage increases negotiated for one LTC home (or group of homes) are followed by many other homes across the province. About four in five LTC homes follow the percentage wage increases of a master collective agreement that is negotiated by employers in a variety of facilities (including for-profit and not-for-profit homes) who voluntarily elect to bargain jointly with the Service Employees International Union (SEIU), the union representing the most LTC workers in Ontario. 12 12 CLAC, “2019 Public Sector Consultations,” May 27, 2019, 3, https://www.clac.ca/Your-voice/Article/ArtMID/4829/ArticleID/1051/2019-Ontario-Public-Sector-Consultations; CBC News, “Ontario Announces $4 an
Hour Pandemic Pay Increase for Front-Line Workers,” April 25, 2020, https://www.cbc.ca/news/canada/toronto/ontario-covid-19-cases-long-term-care-staff-1.5545042. When negotiations fail to bring strong wage increases for PSWs at these homes—as has been the case for more than a decade—PSWs across the province are effectively stuck with the same result, regardless of other unions’ bargaining efforts. This failure may be attributed to three government interventions (from parties of various ideological stripes) to limit or completely prevent wage increases in this sector for a little over a decade in an effort to control skyrocketing health-care costs. Two of these years resulted in zero wage increases, and most recently all non-profit (and non-municipal) homes are limited to 1 percent per year—during the worst shortage the industry has ever seen since Canadians adopted state-funded health care.

Under normal labour-market conditions, a limited supply of and high demand for certain workers should lead to increased wages, as multiple employers compete to attract and retain these workers. Normally, a diverse market would introduce competition for scarce labour, including competition on both wages and working conditions. On the one hand, there is a reasonable amount of competition in the LTC market. As of April 2020, there were 626 licensed LTC homes operating in Ontario: 360 for-profit (58 percent), 101 municipal (16 percent) and 165 charitable or non-profit (26 percent). 13 13 Ontario GeoHub, “Ministry of Health Service Provider Locations,” April 3, 2020, https://geohub.lio.gov.on.ca/datasets/ministry-of-health-service-provider-locations. Almost all non-profit homes are independently owned and operated. The for-profit LTC sector comprises five large players—Revera, Sienna, Extendicare, Southbridge, and Chartwell—which collectively control almost half of Ontario’s for-profit homes (172 homes, 48 percent) and a number of other smaller, for-profit operators.

Yet, despite the limited supply of and high demand for PSWs, this diversity of market actors has not led to competition for workers by raising wages, benefits, or providing more desirable working conditions.

Incentives to provide increased wages, better working conditions, and the other factors related to innovative structural reform of the sector that might attract more workers are absent in Ontario, due to a combination of the following factors: a single source of revenue constrained by rising health and other government costs (only government pays, and there is little price consideration from residents who may be able to pay); employers who are unable to exercise any real agency due to the de facto centralized structure of bargaining and funding arrangements; and the inheritance of an institutional, rather than community, approach to LTC that most closely resembles hospitals.

On the one hand, of all health-care careers who work directly with patients in Ontario, PSW jobs have the lowest entry requirements. Typically, low levels of entry make attracting workers to an industry easier than jobs that require, for instance, multiple years of education before one can work. And in the world of direct health-care provision, it is relatively easy (compared with, for instance, registered nurses) to become a PSW. To qualify to work in one of the province’s LTC homes, prospective PSWs must complete a certificate program with at least six hundred hours of training; this certificate can be completed in eight months at a publicly funded community college—significantly shorter than the two years (and national exam) required to become a registered practical nurse, for instance. 14 14 Personal Support Network of Ontario, “Frequently Asked Questions,” http://www.psno.ca/faqs.html. This makes PSW jobs attractive to newcomers to Canada and those without higher-education credentials. While data on the labour-force makeup of Ontario PSWs is limited, research indicates that PSWs are almost all female and are more likely than the rest of the province’s working population to be older than forty, visible minorities, and immigrants. 15 15 Jane Aronson, Margaret Denton, and Isik Zeytinoglu, “Market-Modelled Home Care in Ontario: Deteriorating Working Conditions and Dwindling Community Capacity,” Canadian Public Policy / Analyse de
Politiques 30, no. 1 (March 2004): 112; Christine Kelly and Ivy Lynn Bourgeault, “The Personal Support Worker Program Standard in Ontario: An Alternative to Self-Regulation?,” Healthcare Policy 11, no. 2 (Nov. 2015): 20–26; CRNCC, “Ontario Personal Support Workers in Home and Community Care: CRNCC/PSNO Survey Results,” https://www.ryerson.ca/content/dam/crncc/knowledge/infocus/factsheets/InFocus-Ontario%20
PSWs%20in%20Home%20and%20Community%20Care.pdf.

At a macro level, the level of entry is low, and theoretically, this should mean that labour supply is easy to attain. But considered at an individual level, eight months of full-time school is a substantial investment for any given person, especially considering that most new PSWs can get only part-time work paying $16 to $18 an hour. This is especially true when one considers other cost-raising factors that disproportionately affect women, such as the need for child care during the schooling period. This means that the same educational requirements that act as a high barrier to entry for prospective PSWs act as a low barrier when it comes to compensation, keeping new PSWs out of the labour market without keeping current PSWs in. The difficulty of the work compared to other low-barrier jobs (such as retail or food services) also provides an additional hurdle for attracting and retaining workers in a competitive environment.

And as we note below, the feminization of care work—exacerbated by women’s dominance in the profession—and low educational barriers to entry both contribute to the undervaluation of personal support work in LTC as low-skilled labour.

PSWs are disproportionately affected by the gender wage gap: for every dollar earned by the average full-time male worker in Canada in 2016, the average full-time female worker earned 75 cents, a rate that falls to 71 cents for newcomer women and 67 cents for racialized women. 16 16 Canadian Women’s Foundation, “Fact Sheet: The Gender Wage Gap in Canada,” https://www.canadianwomen.org/wp-content/uploads/2018/08/Gender-Wage-Gap-Fact-Sheet_July-2018_FINAL.pdf.

The low entry level for PSWs prevents these women from reaping the wage benefits of increased education, which has helped narrow the wage gap for women in other fields. The limited number of full-time PSW positions in LTC increases the prevalence of part-time work, another factor that contributes to the gender pay gap. 17 17 Rachelle Pelletier, Martha Patterson, and Melissa Moyser, “The Gender Wage Gap in Canada: 1998 to 2018,” Statistics Canada, October 7, 2019, https://www150.statcan.gc.ca/n1/pub/75-004-m/75-004-m2019004-eng.htm. Though a healthy balance of both full-time and part-time positions is important, reliance on part-time, casual, and contract-based hours is high across the LTC sector. 18 18 Katherine Zagrodney and Mike Saks, “Personal Support Workers in Canada: The New Precariat?,” Healthcare Policy 13, no. 2 (2017): 31–39, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5749522/. Since part-time positions have a lower compensation cost, employers have an incentive to hire parttime rather than full-time workers. Many PSWs held part-time positions at multiple homes to make ends meet until the Ontario government issued an emergency order limiting all LTC workers to a single facility to combat the spread of the COVID-19 virus. 19 19 Zagrodney and Saks, “Personal Support Workers in Canada”; Katherine DeClerq, “Ontario Restricts LongTerm Care Home Workers to One Facility amid COVID-19 Pandemic,” CTV News, April 14, 2020, https://toronto.ctvnews.ca/ontario-restricts-long-term-care-home-workers-to-one-facility-amid-covid-19-pandemic-1.4895852.

Low PSW wages are inconsistent with increasingly difficult working conditions, making it hard for employers to attract and retain quality workers. Over the past ten years, a PSW job has paid less and less in real terms even while the work has become more demanding and dangerous. After adjusting for inflation, a PSW working full-time-equivalent hours made almost $2,800 less per year in 2018 than she did in 2009. 20 20 Dijkema and Wolfert, “People Over Paperwork.”  Meanwhile, residents are being admitted to LTC homes at older ages and in more fragile health: by almost every measure, today’s LTC residents need more care than they did ten years ago. But staffing levels have not kept up with the increasing demand, which translates to a greater workload for existing staff.

While PSWs have responded to these pressures with admirable perseverance, poor working conditions are driving workers out of the LTC sector. The disparity in working conditions of jobs paying the provincial minimum wage compared to the LTC sector makes PSW jobs unattractive in relation to jobs in sectors such as retail or food service.

Most LTC residents suffer from cognitive impairments, which can lead to aggressive behaviour. As the prevalence of severe dementia among LTC residents rises, so does the risk of resident-to-staff violence—a risk that is particularly high for PSWs, since they are responsible for up to 80 percent of hands-on care. 21 21 Dijkema and Wolfert, “People Over Paperwork.” The threat to workers’ safety is amplified by insufficient training and staffing shortages, both of which are to be expected when resident acuity surges without corresponding increases to staff capacity. 22 22 B.F. Hagen and D. Sayers, “When Caring Leaves Bruises: The Effects of Staff Education on Resident Aggression,” Journal of Gerontological Nursing 21, no. 11 (1995): 7–16, https://www.ncbi.nlm.nih.gov/pubmed/7594259; Adelheid Zeller et al., “Aggressive Behavior of Nursing Home Residents Toward Caregivers: A Systematic Literature Review,” Geriatric Nursing 30, no. 3 (May-June 2009): 180, https://pubmed.
ncbi.nlm.nih.gov/19520228/; James Brophy, Margaret Keith, and Michael Hurley, “Breaking Point: Violence Against Long-Term Care Staff,” New Solutions 29, no. 1 (2019): 10–35, https://journals.sagepub.com/doi/10.1177/1048291118824872; Albert Banerjee et al., “Structural Violence in Long-Term, Residential Care,”Social Science and Medicine 74, no. 3 (February 2012): 395, https://pubmed.ncbi.nlm.nih.gov/22204839/.

Overwhelmed by skyrocketing resident demands, underequipped for the challenges of dementia behaviours, and burdened by excessive paperwork and over-regulation, Ontario’s PSWs have been leaving LTC for less exhausting work. Retirement and home care, for instance, are able to attract PSWs away from LTC despite offering even lower wages, because of less burdensome work demands.

The COVID-19 outbreak now puts Ontario’s long-term care personal support workers—and, by extension, their families—at risk of contracting the coronavirus, adding another level of pressure to a workforce that was already under extreme strain. The wage top-up for low-income essential workers that the federal and provincial governments announced in April 2020 is a good first step toward ensuring that PSWs are fairly compensated for the new level of hazard that the coronavirus outbreak has introduced into their daily work, but its temporary nature will not make up for the losses in purchasing power that PSWs have experienced over the past decade. 23 23 Department of Finance Canada, “Expanding Access to the Canada Emergency Response Benefit and Proposing a New Wage Boost for Essential Workers,” last modified April 17, 2020, https://www.canada.ca/en/department-finance/news/2020/04/expanding-access-to-the-canada-emergency-response-benefitand-proposing-a-new-wage-boost-for-essential-workers.html The emergency order reducing non-essential documentation requirements for LTC staff is also a positive step toward relieving the burden of paperwork and giving PSWs more time for hands-on resident care, and it should be continued even after the pandemic eventually passes. 24 24 O. Reg. 95/20: Order Under Subsection 7.0.2 (4) of the Act—Streamlining Requirements for Long-Term Care Homes, https://www.ontario.ca/laws/regulation/200095.

Yet more must be done to address the systemic attraction and retention challenges threatening the sustainability of Ontario’s PSW workforce, including factors that prevent this group from responding to obvious (and severe) labour-market pressures. Governments of all sorts, but especially Ontario, will still face the same fiscal pressures related to increased health-care costs, and in the context of having borrowed heavily to weather the COVID-19 storm, those pressures may in fact be worse. The structural challenges we have identified above require deeper, structural, reforms.

It is imperative that Ontario’s Long-Term Care Staffing Study Advisory Group 25 25 Ontario Ministry of Long-Term Care, “Long-Term Care Staffing Study Advisory Group,” February 13, 2020, https://news.ontario.ca/mltc/en/2020/02/long-term-care-staffing-study-advisory-group.html.  consider in its analysis the access barriers, low wages, and working conditions that PSWs face. Unless these underlying factors are addressed, the LTC staffing crisis will only worsen.

Attracting new PSWs to the profession will require making PSW training effective and accessible to prospective workers. One option would be to shift PSW education from classroom-focused learning to an apprenticeship model, which would not only allow new PSWs to “earn while they learn” but also prepare them for the reality of modern LTC work. Moving personal support work in the direction of a skilled trade could strengthen the dignity and political voice of the profession without raising barriers to entry (and thus also increasing labour-supply challenges). As we have noted elsewhere, the possession of a trade certificate is linked to better financial outcomes, especially for women. 26 26 Brian Dijkema, “Advancing Structural Reforms to the Skilled Trades and Apprenticeships in Ontario,” Ontario 360, February 13, 2020, https://on360.ca/policy-papers/advancing-structural-reforms-to-the-skilled-trades-and-apprenticeships-in-ontario/ With more than one million Ontarians put out of work by the COVID-19 crisis, 27 27 Nick Boisvert, “Ontario Has Now Lost More Than 1 Million Jobs During the COVID-19 Pandemic,” CBC News, May 8, 2020, https://www.cbc.ca/news/canada/toronto/ontario-covid19-april-jobs-1.5562034. this may be an opportune moment to attract new applicants to a rewarding career as a PSW.

Keeping PSWs in the LTC workforce will require long-term improvements to wage rates, not just a temporary top-up. It is crucial that government provide increased funding to meet the increasingly complex needs of higher-acuity LTC residents. The independent commission should examine the problems embedded in, and make recommendations to improve, the interest arbitration system, so that collective bargaining can bring desperately needed improvements to PSWs’ compensation. Making total compensation costs equal for full-time and part-time employees would result in a more balanced use of full-time, part-time, and casual staff, which can be adjusted to suit the interests and needs of all labour-market participants. PSWs need continued training to equip them to meet the increasingly complex needs of higher-acuity residents, such as mental-health supports and handling aggressive resident behaviour; this may include embedding more registered staff into the workforce. Making the emergency paperwork reduction permanent would make LTC more attractive to PSWs by freeing them to spend more time caring for residents rather than filling out unnecessary paperwork. Alternative models for LTC homes and funding are worth exploring, particularly approaches that are more embedded in, accountable to, and responsive to the needs of local communities and individuals, including their financial capacity, rather than controlled by Queen’s Park. 28 28 For an example of alternative LTC model proposals, see Michael Rachlis, “This Is the Model for LongTerm Care We Need and Deserve,” Canada 24 News, May 8, 2020, http://www.canada24news.com/opinion/this-is-the-model-for-long-term-care-we-need-and-deserve/804111-news. See also Peter Alders and Frederik T. Schut, “The 2015 Long-Term Care Reform in the Netherlands: Getting the Financial Incentives Right?,” Health Policy 123, no. 3 (March 2019): 312–16, https://www.sciencedirect.com/science/article/pii/S0168851018305980, for an example of significant reforms undertaken in the Netherlands, when faced with similar structural challenges in long-term care. Shifting some of the cost burden of care from the state to individuals and communities with the capacity to bear a portion of these costs would reduce the current opacity surrounding how funds are used in LTC, holding all parties that are involved in the provision of care more accountable for their use of funding—including the wages that they pay care workers.

The province’s LTC problems defy easy solutions; there is no silver bullet that will, overnight, give PSWs the wages and dignity that they deserve. We believe that LTC stakeholders can, however, bring significant improvements to the situation on the front lines, if they come together to develop solutions to the province’s LTC workforce woes.