Ontario gives overcrowded hospitals power to transfer patients to seniors' homes without their consent

The Ontario government has given hospitals and health-care bureaucracies the power to transfer some patients to long-term care and retirement homes without their consent when those hospitals are experiencing "a major surge event."

Some of the province's hospitals are experiencing severe capacity pressure as the third wave of COVID-19 continues to cause a surge in admissions of patients. According to the province, there are currently 4,288 alternate level of care (ALC) patients in hospitals who are awaiting discharge, of whom 1,854 are waiting for long-term beds. Meanwhile, there are 5,401 vacant LTC beds available for new admissions.

"This would be done in only the most urgent of situations when a hospital is at risk of becoming overwhelmed," said Health Minister Christine Elliott at a press conference Wednesday. "Hospitals may rely upon this order only when absolutely necessary to respond to a major surge event. And when the attending physician is satisfied that the patient will receive the care they require in their new setting."

Ontario Health CEO Matt Anderson said there is some optimism that COVID-19 hospitalizations could be plateauing, but added that the system has to be prepared for any eventuality even if the new power isn't needed.

"It's important to have it — hopefully it'll never be used," Anderson said.

Elliott said granting the order was a difficult decision to make. "However, the consequences of not doing so could be devastating," she said. "If we don't have the hospital beds, we urgently need to care for the growing number of COVID-19 patients across the province."

The change comes after the province tried to transfer ALC patients to long-term care on a voluntary basis: Ontario Health and the provincial government issued a "call to action" on April 11 to transfer 1,500 patients to long-term care to ease the pressure on hospitals. According to the Ontario Hospital Association, from April 11 – 24, 2021 approximately 695 ALC patients were transferred to long-term care and approximately 195 were discharged to supervised or assisted living. As of April 25, 2021, there were still 4,530 ALC patients waiting in Ontario hospitals for a more appropriate level of care, the association said.

Two geriatricians who spoke with QP Briefing Wednesday raised serious concerns about the use of the new power but both said that given the crisis in hospitals, and in limited circumstances, it could be justified, for example, if another patient requiring acute care would be denied a hospital bed otherwise. But both said the situation should never have come to this; the government should have acted sooner to prevent the hospital crisis that has prompted the extraordinary decision.

"It's sad that's it's come to this," said Dr. Samir Sinha, director of geriatrics with the University Health Network.

Sinha said the Ontario government could have avoided the devastation of the third wave by following public health advice and not relaxing public health measures too soon. He likened the decision to override seniors' consent to the province's draft triage protocol — a plan hospitals have been preparing for and will implement if intensive care units reach a breaking point, that would determine who gets life-saving care and who doesn't.

"I look at this no consent order, as a similar situation: we should never have been put in this place," he said.

Dr. Nathan Stall, a geriatrician with the Sinai Health System, called the decision "unfortunately necessary" but also completely foreseeable after the province decided to loosen public health measures despite the warnings of public health experts and another example of the provincial government's failure to adequately plan ahead.

"My fear is, that because this is being done in such a rush, like so many other things have been with Ontario's pandemic management, that there's just going to be this huge rush to push patients out and both the long-term care homes and the residents — and not just the residence being transferred, but all of them — may end up suffering in all this," he said.

While there are many vacant spaces in some long-term care homes, many of them are in homes that suffered high numbers of deaths during the first two waves of the pandemic, Stall said, adding that residents and their families have been rightfully hesitant to embrace them.  At the same time, many homes are suffering severe staffing shortages and an influx of new residents could compromise the care all residents receive, he said.

The staffing concern was also raised by the long-term care sector. Earlier this month, the Ontario Long-Term Care Association (OLTCA) asked the government for additional human resources assistance in order to support the transfer of additional residents from overcrowded hospitals to long-term care homes. On Wednesday, it issued a statement saying the sector was committed to helping hospitals, but also noted that "staff teams are exhausted and traumatized after this past year."

According to the province, the transfers will only be made when the patient's doctors believe it won't compromise their health and long-term care homes can refuse transfers if they don't have adequate facilities or staff. They are being reimbursed for the government funding portion for unfilled beds. If they accept a transfer of a resident under this order, the government will also pay the amount of the resident's co-payment. Private-pay retirement homes that accept the transfers will be paid by the government.

Stall said all transfers should be of fully vaccinated residents. He also stressed there should be a geographic limit to how far from their preferred homes, and family members and caregivers, patients can be transferred.

But the government guaranteed neither of those things, saying only that "every effort" would be made to address both issues.

Both Stall and Sinha stressed the need for the transfers to be for a finite period of time and for plans to be made to ensure residents are moved to where they want to be. Sinha said the decision to transfer patients between hospitals without their consent, which the province made earlier in the third wave, is different than overriding a senior's right to choose what home to live in. Residents and their families choose homes based on factors that are important to them, such as a specific cultural accommodation, proximity to loved ones and the ability to meet their specific care needs.

While Elliott said the transfers are temporary, and residents sent to homes they hadn't chosen will continue to maintain their place in line for their first choice, there is no clear exit plan spelled out.

Patients will be expected to remain where they are transferred unless they need acute care in hospital or are transferred to their home of choice when a spot is available, her ministry said.

The press release the province issued announcing the change included supportive quotes from the Ontario Hospital Association and several hospital CEOs, all stressing the extraordinary pressure that hospitals are under.

"We are grateful for the decision by government today as it provides for the tools to effectively transfer patients waiting for long-term care in hospital to the most appropriate safe setting in LTC, thereby relieving the pressure on hospitals in hot-spot areas who are experiencing the impacts of the wave 3 surge," said Michelle DiEmanuele, president and CEO of Trillium Health Partners.

The Ontario Hospital Association said the announcement will allow patients be transferred to a care setting more appropriate to their health needs.

"The Ontario Hospital Association (OHA) recognizes that great sensitivity to the care needs of residents is required at all times, especially under today’s very challenging conditions. The OHA continues to work closely with Ontario Health (OH) and hospitals across the province to ensure transfers are implemented both safely and effectively. It is essential that hospitals continue to work very closely with patients and families experiencing a transition in care during this difficult period.”

Meanwhile, the Registered Nurses' Association of Ontario echoed the same concerns as the geriatricians.

“I think it’s disastrous, but I think we have no other choice because … their strategy is not to stop the spread, their strategy is let’s open more beds so we don’t need to say we turned anyone away because they don’t want to do the triage, none of us wants do the triage,” said CEO Doris Grinspun, adding that it would be terrible for patients who will be far from their families and unable to see them.

“More serious than that is that these nursing homes don’t have the staffing to look after these people,” she said, adding that she thinks the government is “completely lost” in its response to the pandemic.

“We do not have a functioning government in Ontario at this time."