Under legislation introduced last weekhospital patients deemed no longer in need of acute care but still in need of an “alternative level of care” could be admitted to an LTC home of their choice without their assistance — potentially away from critical family members and loved ones role in their daily care.

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Long-Term Care Minister Paul Calandra initially said no patient would be forced into a home they didn’t want to live in, but has since said those who refuse placement they will have to pay hospital expenses for their permanent stay. Doctors, lawyers and advocates say the government’s plan will force patients to make an impossible choice: live somewhere they don’t want to or suffer the consequences. Here’s a closer look at what can — and can’t — happen under the Ontario government’s Bill 7, the More Beds, Better Care Act.

What would the legislation actually do, if passed?

When an attending clinician believes that a patient no longer needs hospital care and could have an “alternative level of care,” they will be able to ask a long-term care placement coordinator to begin the process of admission to an LTC home. The placement coordinator must make “reasonable efforts” to obtain consent from a patient or substitute decision maker — which may be a spouse, child or other caregiver — before:

Determining patient eligibility for long-term care. Option of LTC residence. Sharing private medical information with the home licensee. Allowing the license holder to approve the admission and admit the patient on arrival.

The Ontario government’s plan would make it easier for hospitals to turn away eligible patients to long-term care homes. Here, a person is seen outside a long-term care home in Toronto on April 9, 2020. (Evan Mitsui/CBC) The legislation does not specify what these “reasonable efforts” should entail and makes it clear that these measures can be taken without consent. However, consent is required for the physical transfer of the patient to a long-term care home.

Although the law says a patient cannot be physically transported without their consent, they may feel they have few options given the potential consequences of refusal. Advocates and doctors say some hospitals already have policies where patients who refuse to go to a long-term care home are turned over to a shelter or to a family member who may have little ability to care for them. Jane Meadus, an attorney and advocate at the Advocacy Center for the Elderly, has seen clients who were threatened with hospital bills of up to $1,800 a day for ongoing care. Jane Meadus, an attorney and advocate for the Advocacy Center for the Elderly, says she has seen patients who refused to go into a long-term care home threatened with huge hospital bills, among other penalties. (David Common/CBC) Meadus says she believes the government’s plan will force the elderly and other vulnerable people to give their consent. “If people come and threaten you with things, people get scared and they’ll move.” Trudeau Lemens, a professor of law and health policy at the University of Toronto, says the legislation appears to violate patients’ human rights, as well as informed consent requirements, which require consent to be voluntary. “Even if the government can pretend it’s giving people a choice, it’s clear that this is structural coercion,” he said.

How does the LTC process usually work?

Normally, when a patient or their caregiver examines application to LTCthey can choose up to five houses to be put on the waiting list. Key factors in this decision-making may include proximity to family, as well as cultural or community ties. “I often care for people who are racial, people who maybe don’t speak English as a first language,” said Dr. Amit Arya, a palliative care physician and assistant clinical professor at McMaster University in Hamilton. “If you go into a facility where people serve food that you relate to, the staff speaks a language you understand, celebrates the religious and cultural holidays that are important to you, naturally you will do much better during that time. and I feel strongly that it is worth the wait.” Others will look at who owns a LTC home, including whether it is public, nonprofit, or private, the level of care it provides, and other benefits offered. WATCHES | Palliative care doctor warns of risks for patients in Ontario’s LTC plan:

Ontario’s LTC transfer plan is dangerous for elderly and frail patients, doctor warns

Palliative care physician Dr. Amit Arya says patients’ health will suffer more if they are transferred from a hospital to a long-term care facility where they don’t receive the right quality of care.

To which homes will the patients be sent?

The government says it will create “mandatory guidelines … to ensure patients continue to stay close to a partner, spouse, loved ones or friends”. However, he has yet to give details. Arya reiterated that it is important for patients to remain close to family members, who often perform daily tasks at LTCs, such as feeding, bathing and administering medications. “Not having your support network close by can worsen your health outcomes and even lead to premature death on its own,” he said. Given the long wait times for many LTCs, advocates fear that patients will end up being discharged to homes with only available beds because their living conditions are less than desirable. “What people aren’t clamoring to get into are mostly older, for-profit homes; many that have had some of the worst reputations during our pandemic. … How do you force someone into that bed who doesn’t want to go? create legislation like this,” said Dr. Sameer Sinha, director of geriatrics at Sinai Health System in Toronto. Ontario Long-Term Care Minister Paul Calandra says hospitals “must” charge patients who refuse to go to a long-term care home that isn’t one of their preferences. (Chris Young/The Canadian Press) Calandra said patients will be moved temporarily, “while they wait for a bed to become available in their preferred home,” though there is no guarantee of that under the legislation. And experts say that comes with additional risks. “Temporary, at this stage of life, becomes really dangerous. Because what happens, especially with cognitive decline, is that any moves come with an increased risk of death,” said Tamara Daly, director of the Center for Research and Education for York University Aging.

Will this worsen the LTC crisis?

The government did not respond to questions about what additional funding or other resources would accompany its plan. The Ontario Long-Term Care Association (OLTCA), which represents most of the province’s LTC homes, said in a statement that LTC homes urgently need more staff, especially registered nurses and personal support workers. Advocates want to see the government expand access and resources for home care and community-based services, which will allow more patients to remain at home or with their loved ones, while easing pressure on sector.

When will it come into force?

The exact date is unclear, but the government — which holds the majority — is currently rushing the bill through the Ontario legislature. The Ministry of Health and Long-Term Care confirmed to CBC Toronto that 200 people who have been hospitalized for six months, waiting for LTC beds, will be moved over the next three months, with a total of 1,300 to be moved by March 2023.