Home Care nursing is in crisis in Ontario.

This crisis pre-dates the current pandemic and is over a decade old. It was acknowledged by several governments and Ministers of Health over the years yet remains unaddressed. The Covid-19 pandemic is one element in a perfect storm that has exposed the broken state of our Home Care system. There is an increased need for Home Care services with our aging population of “baby boomers” and the advancements in medical technology that has prolonged the lives of our medically complex population.

There are many children and adults in Ontario living with severe disabilities and medical complexity but lack the skilled nursing support to live safely in their homes and engage with their communities, including school. The concept of Home Care is excellent as it is described on HomecareOntario.ca. This is the system we may strive for, but it is not what we have now.¹

We, the families of Home Care recipients, are intimately familiar with this program and are united in stating that we are on the verge of catastrophe. The lack of skilled and experienced nurses is alarming, the number of shifts that are vacant is increasing and family caregivers have reached their breaking points. We need immediate action.

It is important to note that there is a wide range of Home Care recipients, from stable people who require assistance with daily living to medically fragile people dependent on medical technology to survive who require experienced, and well-trained registered nurses to live at home in their communities. This document will try to address the wide range of changes that must occur within the Ontario Home Care mandate.

Key Issues:

The number of unfilled community nursing shifts has skyrocketed forcing many families to assume these positions in addition to their other responsibilities. Filling these ocean size gaps in the Home Care system is devastating families on many levels: financially, emotionally, and physically. The level of care families are forced to assume is not sustainable and lives are at risk. Multiple steps need to be taken to ensure supportive and healthy Home Care across Ontario.

It is not only Home Care recipients at risk. Hospitals, Long-term Care and Home Care are all links in the same chain of health care. When one link is broken it has a ripple effect on the other systems, resulting in patients stuck in expensive hospital beds rather at home living their best lives.

In this brief, parents directly affected by this shortage have provided both short and long-term solutions to address the extreme shortage of skilled RNs or RPNs for children and young adults with medical complexity who require up to ICU level care in the community. We are urging the Ontario Government to take action to address these unfilled Home Care shifts and offer family caregivers ongoing relief and support.

Recommended Solutions:

Immediate To-Do for Provincial Government:

1. Fix the pay disparity between hospital-based / Long Term Care and Home Care nursing jobs. Immediate wage parity is required for Home Care nurses to ensure competitive wages. This is a necessary retention strategy for Home Care nursing. This will also attract new staff to fill the shortage in this important but overlooked sector.
   
2. Increase training spaces in Ontario College and University for another 1200 registered nurses and 800 registered practical nurses over and above the May 2021 announced spots.
   
3. Track and report chronically unfilled community nursing shifts, both at home and school, in a transparent manner. Collect data from Home and Community Care Support Services, nursing agencies and families. This will allow for better accountability and solutions. This has been an issue for decades it is time to measure the problem so it can be addressed.
   
4. Extend the Family Managed Home Care program to cover school nursing. This would expand the number of nurses available to work in the school setting and provide seamless care between home and school. Kids who are currently at home with a nurse hired through family managed home care, would immediately be able to attend school.

5. Create a Caregiver funding Program to provide funding to families, qualified for PSW or nursing care. As families try to fill service gaps themselves, they experience a loss of income, increased expenditures and frequently must stay up all night providing 24-hour care. The burden of the nursing shortage falls directly onto the shoulders of already vulnerable families. Caregiver funding will keep families from being pushed into poverty and will ensure the duty to accommodate is achieved.
   
6. Create Home and Hospital Complex Care teams across Ontario – Establish a nursing team based on patient centred care model that would work in both the hospital and community, caring for medically fragile children and young adults who require the most significant care 24/7. This would ensure hospital level care at home, improve retention of nurses in the community and allow seamless care between home and hospital. Families would have access to skilled and long-term staff across all Complex Care Clinics throughout Ontario.
   
   Immediate To-Do for College of Nurses of Ontario:
   
7. Ensure nursing students are exposed to Home Care placements during school to ensure graduates consider Home Care careers if they are truly a valued and necessary part of the Ontario health system.
   
8. Create an efficient program for licencing and training foreign nurses currently living within Canada.
   Create an Ontario Nursing Assessment and Training Centre to leverage untapped workforce of existing foreign nurses.²  Individually assess foreign trained nurses to determine level of skill, instead of relying on difficult to obtain documentation from foreign accreditation bodies.  Provide required training for skills gaps to ensure they meet all the of entry to practise competences. Send only those with significant skills gaps back to attend Canadian Nursing schools. Provide financial aid to ensure they can complete their studies in the nursing field. To access accelerated licensing, nurses could commit to 2 years of working in an underserviced sector or location. This will also provide opportunities for indigenous and other Northern Ontario Communities to gain essential health care resources.
   
   Immediate To-Do for a Federal and Provincial partnership:
   
9. Increase the number of nurses in Canada with a Skilled Nurse Fast Entry Immigration Program for rapid entry of foreign trained and experienced nurses with five to ten years of experience to immigrate to Canada by providing them with a permanent resident pathway after two years working in Home Care in geographical areas most in need. Provide concurrent processing of permanent residence application for spouse and dependants to ensure family reunification.
   

Conclusion

Investing in a robust Home Care system is vital to support healthy families. It is cost effective, as children, adults and seniors with disabilities are not utilizing costly hospital beds. We need a functioning Home Care system for medically fragile children to return to school, for disabled adults to continue living in the community and for family caregivers to re-enter the workforce. This allows them to be at home, living their best lives in the community. Home Care is an important link in the chain and worthy of investment in a proactive and cost-effective way to invest in Ontario’s Health Care system.

Solutions gathered and prepared by the following Parents:

Sherry Caldwell, BA, Resident Richmond Hill, Ontario, Co-Founder Ontario Disability Coalition.
Nicole Payette-Kyryluk, BSc, Resident Toronto, Ontario
Marcy White, BSc, MSW, MBA, Resident Toronto, Ontario
Tonya Martin, MSc, Resident Toronto, Ontario
Joanne Witt, BA LLB, Resident Dundas Valley, Ontario
Ipek Wellington, Resident Toronto, Ontario, Director, Ontario Disability Coalition

Insights:
• New Zealand Caregiver Support
• Lessons on Public-Private Collaboration from Four Countries with Universal Health Care
• HealthCare workers warn of national nursing shortage
• Ontario nurses call for action to address hospital staffing shortages
• Burnout in Hospital-Based Healthcare Workers during COVID-19
• Amidst Nationwide Nursing Shortage, Foreign-Trained Nurses Unable to Practice
• Quebec.ca – Exceptional measures to attract and retain health and social services staff
• Facing shortage, Quebec to headhunt health staff in France, Brazil, Lebanon, elsewhere

Shortage’s and concerns pre-pandemic:

• Children with medical complexity in Canada
• Complex care for kids Ontario: protocol for a mixed-methods randomized controlled trial of a population-level care coordination initiative for children with medical complexity
• Ontario mom says home nursing has never been worse
• “Do we have a nurse coming?” Families worry shortage puts kids at risk

2020 Home Care Nursing shortage:
• People with severe disabilities-feel-especially vulnerable in covid19-shutdown
• Disabled Canadians face uphill struggle for regular care as COVID-19 drains resources
• https://ici.radio-canada.ca/info/videos/media-8310840/un-choix-dechirant

2021 Home Care Nursing Shortage
• ‘Heartbreaking’: Medically fragile children yearn to go back to school but a nursing shortage means some are being turned away
• Nursing shortage means some medically fragile children won’t be going to school, parents told
• Parents still fighting to ensure their medically fragile children receive an education
• Sawyer can’t get a nurse, so he can’t go to school
• Ontario Nurse Shortage keeps some kids home from school
• ‘A crisis for home care’: Droves of workers leave for hospitals, nursing homes
• Systemic barriers keeping foreign nurses from filling shortages
• Nursing Shortages in Ontario on AMI with Dave Brown