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Concerns regarding "Hours of care" in Continuing Care Facilities

"Hours of care" is a central issue of concern in both funding and care quality. Staffing
costs are 70% of the operating costs of facilities, and staffing issues are the basis of
most of the resident and family concerns about quality of care.

Both the Auditor General's 2005 Report on Seniors and the MLA Task Force Achieving
Excellence report acknowledged staffing concerns, and the Minister of Health responded
by announcing "increased hours of care". The increase, we were told, would be from the
1.9 hours in the 1985 Nursing Home Act regulations, to 3.1, 3.4, 3.6, and, by 2008, to
3.81 (or 4.12). The initial increases to 3.1 and 3.4 did not appear to have much effect in
the care facilities, and so we asked what "an hour of care" meant.

The Minister explained that the number was "a measurement of paid hours of care
(which includes) considerations such as vacation time, sick days and training time".3
Since clearly an "hour of care" does not mean 60 minutes during which care is being
provided to residents, we made some further inquiries, and learned that:
"Hours of care" is the primary "quality measure" required by AHW, since 2006.1 Prior
to that, the term "hours of care" was not used to describe services provided in long
term care facilities.4
"Paid hours of care" includes direct care time (during which care is provided to
residents), indirect care time (non-resident specific duties, including training,
meetings, and administrative duties), and time paid but not worked, provided by
care staff (Registered Nurses, Registered Psychiatric Nurses, Licensed Practical
Nurses, and/or Personal Care Aides) assigned to a unit or units.5
In 2004, the Alberta Long Term Care Association reported that funding for 3.1 hours of
care provided an actual 2.5 hours per resident per day.6 Neither the Ministry nor
the Regional Health Authorities have provided a similar description of the actual
care time provided in an "hour of care".
The current "blended jobs" staffing models for care staff include duties previously
designated as "non-care" and not included in the "care services" funding, such as
daily housekeeping and social/recreational activities. This, together with the high
proportion of indirect care duties currently assigned to professional nursing staff,
seriously erodes actual care time.7
A similar ambiguity regarding hours worked/ paid hours exists with respect to "full time
equivalent", used as an alternative workforce measure: AHW has variously

1 Health Authority Accountability in Alberta's Health System (2006),
2 AHW Guide to Health Authority Accountability Documents 2005
3 Personal correspondence, April 26, 2006.
4 Statistics Canada Residential Care Facilities 2003/2004 surveys collect data on care to
residential facilities; the staff data requires number of staff employed and total paid hours,
including holiday and other paid leave time. The survey definition specifically addresses the
"expense" of care; the report distinguishes this from level of care, acknowledging that these two
variables are closely linked. http://www.statcan.ca/english/freepub/83-237-XIE/83-237-
XIE2006001.pdf http://www.statcan.ca/english/sdds/instrument/3210_Q1_V8_E.pdf
5 Interview and correspondence with Capital Care Group and Capital Regional Health Authority,
6 ALTCA Newsletter, Fall 2004 (Issue Two Volume Two)
7 We note that a similar situation does not occur under the Child Care Regulation, where
specifically qualified staff must be on duty to meet the required staff/children standards

Concerns regarding "Hours of care" in Continuing Care Facilities, page 2 of 8
defined an FTE as calculated from "total number of hours worked" 8 and from
"total paid hours" 9.
The cost of benefits, including time paid but not worked, is a significant cost item for
employers, and will change over time as collective agreements define new or
increased benefits, affecting both the average time and the proportion of time for
each employee category which is actually worked.
The 'hours of care' funding model and accountabilities distinguish the proportion of
PCA/LPN/RN staff hours, which are not described by the reported average.
The number is an average for all care staff (for each facility, each RHA, and finally as
a provincial average), and gives no information about unit or facility staffing
numbers or competencies in relation to the number or care needs of the residents.
The facilities are not required to record or report actual time worked for the purpose of
reporting delivery of care services.
The Alberta Employment Standards Code requires employers to record, detailed
information and to provide that in writing to each employee at the end of each pay
period.
There was no information available to us to clearly define the "1.90 paid hours" of care
in the 1985 Nursing Act Regulation. In 1988, A New Vision of Long Term Care
reported that average hours of nursing care worked per resident was "average
1.65 worked hours" in nursing homes, and "3.6 paid hours (may go up to 4.0,
based on specific conditions)" in auxiliary hospitals.10
It is not at all clear that using a gross payroll calculation to define care time is an
industry standard in Canada.11
The Canadian Institute of Health Information, which works to standardize data
recording and reporting, confirms there is no standard definition for care time, and
no requirement to report time spent by staff delivering care services.
The American federal regulations of publicly-funded care facilities are specific that the
reported care time must be recorded by time actually worked by distinct caregiver
classifications providing direct care specific to a resident or residents, and require
daily posting in each unit of resident census, shift schedules and hours worked by
staff classification.12

8 Health Authority Business Plan and Annual Report Requirements 2001 ­ 2004. The "Health
Workforce Plan Template" on page 44 requires personnel counts as both "total Employee Count"
and "total FTE".
9 Multi-year Performance Agreement, 2003
10 The Committee on Long Term Care for Senior Citizens, report to the Alberta Legislative
Assembly; Table 10-1.
11 The Task Force on Resident/Staff Ratio in Nursing Homes (2001, Nova Scotia) used a survey
that distinguished between hours worked and hours paid; the report concluded that staffing data
from several provinces, including Alberta, was not comparable, and included only data from Nova
Scotia, Manitoba, New Brunswick and Newfoundland.
http://www.gov.ns.ca/heal/downloads/taskforce_report.pdf
12 Federal Register / Vol. 70, No. 208 / Friday, October 28, 2005 / Rules and Regulations
http://www.nursinghome411.org/documents/finalnhstaffpostingrequirements.pdf and
http://a257.g.akamaitech.net/7/257/2422/01jan20051800/edocket.access.gpo.gov/2005/05-
21278.htm
Department of Health and Human Services, Centers for Medicare & Medicaid Services, Form
CMS-671 http://www.cms.hhs.gov/cmsforms/downloads/CMS671.pdf
The staff function definitions specifically separate resident assessment, reporting time, all
housekeeping duties, and medication management oversight from direct care to residents.
See also http://www.cms.hhs.gov/SurveyCertificationGenInfo/downloads/SCLetter03-14.pdf ;
http://www.cms.hhs.gov/CertificationandComplianc/downloads/2005NHActionPlan.pdf
Concerns regarding "Hours of care" in Continuing Care Facilities, page 3 of 8
It is probable that the Alberta Long Term Care Association's recommendation to
increase the hours of care to 4.0 hours of care per day13 influenced the
government's decision. It should be noted that the ALTCA recommendation was
based on staffing recommendations from predominantly American studies14, most
of which used the OSCAR data, and a very different and specific definition of care
hours. (see footnote 12.)
The Alberta Long Term Care Association calculates "hours of care" from confidential
financial information provided by its members.15
There is no information available to report the basic care being provided to facility
residents by family, volunteers, or staff paid privately by families to supplement
the facility care.

There are several accountability issues in this situation:
1. "Hours of care" as defined is measure of staffing costs; it is misleading as a measure
of the care actually being provided, even on average, to residents.
2. The average number of hours worked by total staff, even in a single facility, does not
provide useful information about the care being provided. The context of care quality
requires information about the number and the care levels of the unit residents, the
numbers and competencies of the staff, and a distinction between direct care, indirect
care, and other duties such as administration and supervision. (In contrast, home
care data reports minutes of actual care by type of care provided (assessment,
hands-on, and communication/consultation) and the qualification of the staff providing
the care.)
3. The issue of appropriate and quality care is the central and most significant concern
of the resident and his/her family or representative; any measure used to represent
quality should be accurate, relevant, understandable, readily available, and audited.
4. Where a standard includes a specific detail of measure, such as the ratio of RN/RPN,
LPN, and care aide staffing), the data reported should acknowledge that.16
5. Any changes in a definition of the measure (such as the inclusion of work duties
previously assigned to a different accounting category, or the ratio of professional
staff) should be clearly and publicly identified.

There are related questions arising from the increased hours of care and the funding
provided for that purpose:
6. There was an indication in the Minister's statements in the Legislature17 that an
analysis of how the increased staffing was achieved by numbers of additional staff

13 ALTCA Response to the MLA Task Force, September 2005
14 Residential Continuing-Care Facility Staffing: A Systematic Literature Review Donna Wilson
RN, PhD. 2005; commissioned by the ALTCA
15 Personal email correspondence, Dianne Nielsen, June 6, 2006
16 Nursing Home Act Operation Regulation 258/85, 14 (5) and (6); relevant directives from AHW
17 Alberta Hansard, March 1, 2006, Ms Evans: "We will provide an analysis of how many staff
were added, but I want to make clear that I will define it in two ways: the number of staff that we
believe were added not so much as a result of the move to 3.4 hours of care per patient but
equivalents so that we're comparing apples with apples and not just looking at the numbers that
have been inflated because people have moved into long-term or continuing care residence. The
other part, though, I should tell you is that in some cases dollars that were provided for long-term
care were provided to increase the salary levels of people who were advanced either by merit or
by some other agreement with their institution, so it not only provided more dollars for increasing
the number of hours of staff care on that patient ratio but increased the number of dollars that
individual providers received for the work they did interfacing on the front lines."
Concerns regarding "Hours of care" in Continuing Care Facilities, page 4 of 8
and by increased "hours of care" (FTEs); it will also be significant to report how direct
care has been increased. That has not yet been provided.
7. The purpose of the funding and the increased paid hours was to improve the quality
of care; there has been no indication of how achieving that purpose will be measured
or reported. The relationship between funding, staffing and quality of care is
complex, and cannot be measured simply by the cost of staffing.
8. The increase in "hours of care" coincides with an increase in administrative duties in
respect of medications administration and the MDS assessment and reporting
systems, and there has been no indication of how this will affect time available for
actual hands-on care to residents.

Prepared by Carol Wodak for Citizen Watch, May 2007
Inquiries to Carol Wodak at 417-1705 or cwodak@techwcs.com

Attach: What's in an hour of care?
Concerns regarding "Hours of care" in Continuing Care Facilities, page 5 of 8
What's in an hour of care?

In a 2000 newsletter, the Bethany Care Society published a basic care schedule:

24 hour care schedule for a dependent resident (total, 205 minutes, 3.42 hours)
30 minutes ­morning: toilet,
15 minutes ­ help with lunch
5 minutes ­ medication
mouth care, wash, dressing
(again, 3 - 4 people)
administration
5 minutes ­ medications,
15 minutes ­ 2-person
15 minutes ­ lift onto bed, 2-
10 minutes ­ 2-person
continence care or toilet,
person continence care or
transfer into chair
transfer /lift to bed for nap
toilet
15 minutes ­breakfast
10 minutes ­ check on
15 minutes ­ bedtime mouth
(each caregiver assisting at
resident several times;
care, wash, make
least 3 residents)
provide fluids, snacks
comfortable in bed
15 minutes ­ assist with
10 minutes ­ 2-person
10 minutes ­ late evening
toileting (2-person transfer)
transfer/lift to wheelchair
check and care
10 minutes ­ help finish off
15 minutes ­assistance with
10 minutes ­ nighttime care
getting ready for the day
dinner
and comfort

The article noted that a great many every-day needs (portering to a church service,
going outside for a while, talking about family) weren't included; and the 3 hours of
funded care were expected to include: care management ( physicians' medication
orders, care conferences, care assessment and planning, calling family to update them
on changes, charting, organizing appointments and transportation, etc.); clinical care
and therapies (wound care, insulin, swallowing assessment, exercise/rehabilitation,
recreation activity, social work support, pain; control, palliation and address
unpredictable changes in clinical status); staff vacations, sick time, holidays and other
leave.

This kind of routine care schedule is fairly common, based on "time-motion" studies of
routine daily tasks for an "average" resident in actual time worked by a competent care-
giver with no distractions or other responsibilities.18 The discussion of appropriate
"hours of care" is simply an academic exercise without the context of the care needs of
the residents. Caring for impaired and ill people is not comparable to a controlled
assembly-line process, with discrete and predictable manual tasks.19

18 The Task Force on Resident/Staff Ratio in Nursing Homes (2001, Nova Scotia)
http://www.gov.ns.ca/heal/downloads/taskforce_report.pdf
19 Reclaiming Medicare Parkland Institute, 2002
http://www.ualberta.ca/~parkland/research/studies/index.html "Women's health policy expert
Pat Armstrong of York University in Toronto is critical of reducing nursing work to countable
tasks: A bath is reduced to a quick application of water to skin, and the way nurses use the
bath to comfort, support, educate and assess disappear, as do the varied skills involved in
getting the patients to co-operate and in lifting them without injury. Any time not spent directly
on tasks is defined as wasted, not productive... (Armstrong, 2001: 136). She also points out
that rigid formulae for length of hospital stay and maximum home care hours per day leave
no room for professional judgement, a patient's condition, or the preferences of paid or
unpaid caregivers. Colleen Flood of Dalhousie University's Health Law Institute in Halifax
provides other examples of important quality of care indicators that are overlooked with a
narrow administrative focus; for example, how long a patient is left in distress or in pain
without help, how quickly a diagnosis or treatment is given to relieve anxiety, and whether
providers respect the wishes of patients (Flood, 1999)."
Concerns regarding "Hours of care" in Continuing Care Facilities, page 6 of 8

Residents are not only older and more disabled today, but they are sicker. In 2003, over
75% of the residents were in the 3 (of 7) highest care needs categories; in 2004, care
needs were up by 35% from 199020. 75% have a diagnosis of dementia.21 Most
residents have complex medical conditions, and their health is unstable; change,
whether a change in an existing condition or a new or secondary problem, can happen
very quickly; the signs are sometimes subtle. In 1992, residents over the age of 65 had
an average of 4.6 diagnoses of serious illness.22

In 2003, 92% of the residents were over the age of 65; 49% were over 85.23 75% have
a diagnosis of dementia24. (Dementia is a set of disorders that involve declining
intellectual ability, memory, judgment, social skills and control of emotions, caused by
illness, strokes, trauma, and some medications.)

What kind of care do residents need?25
98% need assistance with eating (41% need constant assistance or feeding).
90% need assistance with dressing.
91% need assistance with transfers.
80% need assistance finding their way around the facility.
80% have urinary and bowel incontinence; 43% need 2-person assistance with
toileting.
63% have impaired communications abilities.
40% resist care or treatment; 76% have other "behaviours requiring care".
33% show aggressive or angry behaviours; 35% show agitated behaviours.

Most frequent medical diagnoses in 200526:

20 Report of the Auditor General on Seniors Care and Programs, 2005
http://www.oag.ab.ca/html/2005%20Seniors%20Report.pdf
. Calgary Herald Aug 13, 1993: "On average, Carewest long term care patients have more
than 6 diagnosed problems each, such as heart failure, incontinence and other illnesses. As
many as 50% of the patients have behavioral problems like dementia and other
psychogeriatric problems." (Marlene Raasok, vice-president of operations for Carewest, says
in an interview with the Herald.

Calgary Herald Feb 17, 2000: "Too often," John Murphy, a professor at Brown University
said recently, "illnesses in older people are misdiagnosed, overlooked or dismissed as the
normal process of aging, simply because health care professionals are not trained to
recognize how diseases and drugs affect older people."
21 Alberta Long Term Care Association Response to MLA Task Force Seniors Report, 2005. On
file with author.
22 Health Services Utilization in the Population Aged 65 and Older: Review of the Literature 1999
http://www.health.gov.ab.ca/key/01_report.pdf
23 Alberta Health and Wellness, Alberta Resident Classification System for Long Term Care
Facilities, Table E-2 for 2002/2003, http://www.health.gov.ab.ca/regions/e2-03.htm
Total residents assessed, 14, 449; this number does not coincide with the number reported
above.
24 Alberta Long Term Care Association Response to MLA Task Force Seniors Report, 2005 On
file with author.
25 Ontario Ministry of Health and Long-Term Care, 2005 Levels of Care Classification On file with
author. Both the Alberta and Ontario governments use the Alberta resident information system,
but the Alberta government does not report similar information from the data collected (Email,
response to request for information, from Alberta Health and Wellness, February 2007)
Concerns regarding "Hours of care" in Continuing Care Facilities, page 7 of 8
Mental problems (dementias, brain damage);
66%
Circulatory diseases (heart, stroke, blood pressure)
62%
Musculoskeletal problems (arthritis, bone degeneration, osteoporosis,
52%
contractures, fractures)
Endocrine & metabolic disorders (including diabetes)
36%
Neurological motor dysfunction (cerebral vascular accidents, MS)
35%
Sensory disorders (vision, hearing)
21%
Digestive disorders
18%
Pulmonary diseases
15%
Genitourinary disorders
10%

Most residents need treatment of existing illness, monitoring for illness progression and
new or secondary illnesses; mitigation of the effects of illness that cannot be cured and
disabilities that limit function; and personal care to ensure safety, comfort and dignity.
This requires skilled nursing services; rehabilitation therapies; attention to physical
needs such as vision, hearing, oral hygiene and dental care, podiatry services, and
exercise; competent and kind assistance with personal care needs ­ nutrition and
hydration, dressing, toileting, maintenance exercise, bathing, emotional and social
support.

It's very easy to underestimate potential improvements in health, functioning, and well-
being. Curative treatments are not always possible for underlying illness or damage;
but, with adequate and appropriately skilled staffing, complications and secondary illness
can often be prevented, and distress and dysfunction can be improved to attain or
maintain the highest practicable level of health and well being27.

There has been no assessment in Alberta of whether either the clinical or personal care
being provided in the continuing care system or in the care facilities is adequate. Any

26 Ontario Ministry of Health and Long-Term Care, 2005 Levels of Care Classification On file with
author. Comparable data is not available from Alberta Health and Wellness.
27 Analysis of Interfaces Along the Continuum of Care Final Report: The Third Way: A Framework
for Organizing Health Related Services for Individuals with Ongoing Care Needs and Their
Families, Hollander Analytical Services Ltd. for Health Canada 2002
http://www.hollanderanalytical.com/downloads/continuum-final.pdf ". . . the goal of care is
generally not to cure a disease or other medical condition, but rather to provide supports and
services that reduce the rate at which individuals deteriorate (lose independence), optimize
functioning, and provide them with the best possible quality of life ."
Alberta Medical Association, Brief to the Long Term Care Review Policy Advisory Committee
1999
http://www.albertadoctors.org/ "the primary objectives of our health care system, and all those
who serve through it, should be quality patient care and a quality of life deemed acceptable by
the patient."
The effectiveness of quality systems in nursing homes: a review Quality in Health Care
2001;10: 211-217 C Wagner et al; http://qshc.bmj.com/cgi/reprint/10/4/211 "A long term care
facility or a nursing home is an institution which provides nursing care 24 hours a day,
assistance with the activities of daily living and mobility, psychosocial and personal care,
paramedical care, and also a room and board for people whose health has deteriorated to
such an extent that they need constant nursing care. The aim of nursing home care is to
maintain the limited physical, mental, and social capabilities of residents for as long as
possible. . . The ultimate goal of healthcare organisations is optimisation of the health status
of individuals and populations . . . The quality of care is the degree to which (a) nursing homes
increase the likelihood of desired health outcomes for residents, and (b) the care process is
consistent with current professional knowledge."
Concerns regarding "Hours of care" in Continuing Care Facilities, page 8 of 8
discussion or assessment of appropriate "hours of care" needs to be considered in the
context of the care needs of the residents and the desired outcomes of the care; until
these assessments are done, any "hours of care" standard or measure is simply an
arbitrary and meaningless number.

Prepared by Carol Wodak for Citizen Watch, June 2007
Inquiries to Carol Wodak at 417-1705 or cwodak@techwcs.com

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