CITATIONS
1) See, e.g., Ron Grech, “PSW Shortage Poses Crisis in Long-Term Care,” The Timmins Daily Press, April 24,
2019, https://www.timminspress.com/news/local-news/psw-shortage-poses-crisis-in-long-term-care; CBC
News, “Overloaded and Undervalued, a Crisis for Personal Support Workers,” CBC News, May 22, 2019,
https://www.cbc.ca/news/canada/sudbury/personal-support-workers-sudbury-crisis-1.5143707; Ontario
Health Coalition, “Long Term Health Care at Situation Critical,” January 21, 2019, https://www.ontariohealthcoalition.ca/index.php/long-term-health-care-at-situation-critical-baytoday-january-21-2019/.
2) Ontario Treasury Board Secretariat, “Public Accounts of Ontario: Annual Report and Consolidated
Financial Statements 2017–18,” Government of Ontario, 2018, https://www.ontario.ca/page/public-accounts-2017-18-annual-report.
3) Financial Accountability Office of Ontario (FAO), “Ontario Health Sector: 2019 Updated Assessment
of Ontario Health Spending,” March 6, 2019, https://www.fao-on.org/en/Blog/Publications/health-update-2019.
4) Canadian Institute for Health Information (CIHI), “National Health Expenditure Trends, 1975 to 2016,”
2016, https://secure.cihi.ca/free_products/NHEX-Trends-Narrative-Report_2016_EN.pdf.
5) Statistics Canada, “Age and Sex, and Type of Dwelling Data: Key Results from the 2016 Census,” May 3,
2017, https://www150.statcan.gc.ca/n1/daily-quotidien/170503/dq170503a-eng.htm#archived.
6) Statistics Canada, “Census in Brief: A Portrait of the Population Aged 85 and Older in 2016 in Canada,”
May 3, 2017, https://www12.statcan.gc.ca/census-recensement/2016/as-sa/98-200-x/2016004/98-200-
x2016004-eng.cfm.
7) Ontario Ministry of Finance, “Ontario Populations Projections Update, 2017–2041,” modified June 25, 2018,
https://www.fin.gov.on.ca/en/economy/demographics/projections/
8) Alfons Palangkaraya and Jongsay Yong, “Population Ageing and Its Implications on Aggregate Health
Care Demand: Empirical Evidence from 22 OECD Countries,” International Journal of Health Care Finance and Economics 9 (2009): 391; Meena Seshamani and Alastair Gray, “A Longitudinal Study of the Effects of Age and Time to Death on Hospital Costs,” Journal of Health Economics 23, no. 2 (2004): 217–35.
9) Ontario Long-Term Care Association (OLTCA), “More Care. Better Care. 2018 Budget Submission,” 2018, 8.
In 2011, the North East Local Health Integration Network estimated the cost of caring for seniors in a hospital bed to be more than six and a half times that of caring for them in an LTC bed: $934 and $140 (2019
dollars) respectively. North East Local Health Integration Network, “HOME FIRST Shifts Care of Seniors
to HOME,” August 22, 2011, http://www.nelhin.on.ca/~/media/sites/ne/assets/69a65c95-6177-4adc-b6f2-
ccc3e47cec95/bfdd7682635c42db803e3d46b1dcb2a55.pdf.
10) FAO, “Long-Term Care Homes Program: A Review of the Plan to Create 15,000 New Long-Term Care
Beds in Ontario,” October 30, 2019, https://fao-on.org/en/Blog/Publications/ontario-long-term-care-program.
11) OLTCA, “This Is Long-Term Care 2019,” 2019, 13, https://www.oltca.com/OLTCA/Documents/Reports/
TILTC2019web.pdf
12) In 2015, the size of Ontario’s LTC waitlist was 22,601. OLTCA, “Long-Term Care That Works. For Seniors. For
Ontario. 2019 Budget Submission,” 2019, 2, http://betterseniorscare.ca/wp-content/uploads/2018/10/OLTCA_Budget_Submission_FINAL.pdf.
13) FAO, “Long-Term Care Homes Program,” 3.
14) CIHI, “Definitions and Guidelines to Support ALC Designation in Acute Inpatient Care,” https://www.cihi.
ca/sites/default/files/document/acuteinpatientalc-definitionsandguidelines_en.pdf.
15) FAO, “Long-Term Care Homes Program,” 23–24
16) Ontario Ministry of Health and Long-Term Care (MOHLTC), “Hallway Health Care: A System Under
Strain—First Interim Report from the Premier’s Council on Improving Healthcare and Ending Hallway
Medicine,” January 2019, http://www.health.gov.on.ca/en/public/publications/premiers_council/report.
aspx#exec_summary
17) MOHLTC, “Aging at Home Strategy,” August 31, 2010, https://news.ontario.ca/mohltc/en/2010/08/aging-at-home-strategy.html.
18) 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.
19) Carole Estabrooks et al., “Who Is Looking After Mom and Dad? Unregulated Workers in Canadian LongTerm Care Homes,” Canadian Journal on Aging 34, no. 1 (2015): 48; Health Quality Ontario (HQO), Measuring Up 2018, 2018, 42, https://www.hqontario.ca/Portals/0/Documents/pr/measuring-up-2018-en.pdf;
OLTCA, “This Is Long-Term Care 2019,” 4.
20) HQO, Measuring Up 2018, 47.
21) OLTCA, “More Care. Better Care,” 3.
22) See Janet E. Squires et al., “Job Satisfaction Among Care Aides in Residential Long-Term Care: A Systematic Review of Contributing Factors, Both Individual and Organizational,” Nursing Research and
Practice (2015): 1–24.
23) OLTCA, “This Is Long-Term Care 2019,” 5.
24) OLTCA, “This Is Long-Term Care 2019,” 5.
25) Alzheimer’s Society, “Risk Factors for Dementia,” Factsheet 450LP, 2016, 4, https://www.alzheimers.org.
uk/sites/default/files/pdf/factsheet_risk_factors_for_dementia.pdf.
26) HQO, Measuring Up 2018, 47; OLTCA, “This Is Long-Term Care 2019,” 5.
27) Whitney Berta et al., “Relationships Between Work Outcomes, Work Attitudes and Work Environments
of Health Support Workers in Ontario Long-Term Care and Home and Community Care Settings,” Human Resources for Health 16, no. 15 (2018): 2.
28) CLAC, “2019 Public Sector Consultations: Submission to Peter Bethlenfalvy, Treasury Board President,
and Karen Hughes, Deputy Minister, Treasury Board Secretariat,” May 24, 2019, 3.
29) CLAC, “Patients First: A Plan to Combat Pressures in Ontario’s Long Term Care System,” 2016, 5.
30) Gillese, Public Inquiry Report, 2:87–88.
31) CLAC, “Patients First,” 5
32) OLTCA, “This Is Long-Term Care 2019,” 15.
33) AdvantAge Ontario, “2019 Pre-budget Recommendations: Backgrounders,” 1.
34) Gillese, Public Inquiry Report, 2:87–88
35) Albert Banerjee et al., “Structural Violence in Long-Term, Residential Care for Older People: Comparing
Canada and Scandinavia,” Social Science & Medicine 74 (2012): 395.
36) Veronique M. Boscart et al., “The Associations Between Staffing Hours and Quality of Care Indicators in
Long-Term Care,” BMC Health Services Research 18, no. 750 (2018): 1–7.
37) AdvantAge Ontario, “2019 Pre-budget Recommendations,” 1; Gillese, Public Inquiry Report, 2:253.
38) OLTCA, “About Long-Term Care in Ontario: Facts and
Figures,” https://www.oltca.com/oltca/OLTCA/LongTermCare/OLTCA/Public/LongTermCare/FactsFigures.aspx?hkey=f0b46620-9012-4b9b-b033-2ba6401334b4.
39) OLTCA, “Long-Term Care That Works,” 3–6.
40) See Zenobia C.Y. Chan et al., “A Systematic Literature
Review of Nurse Shortage and the Intention to Leave,” Journal of Nursing Management 21 (2013): 606; Berta et al., “Relationships between Work Outcomes,
Work Attitudes and Work Environments,” 2.
41) Jennifer A. Knopp-Sihota et al., “Factors Associated with Rushed and Missed Resident Care in Western
Canadian Nursing Homes: A Cross-Sectional Survey of Health Care Aides,” Journal of Clinical Nursing 24
(2015): 2818.
42) Banerjee et al., “Structural Violence in Long-Term, Residential Care,” 393
43) OLTCA, “This Is Long-Term Care 2019,” 7.
44) Alzheimer’s Society Ontario, “What Are Responsive Behaviours,” https://alzheimer.ca/en/on/We-canhelp/Resources/Shifting-Focus/What-are-responsive-behaviours.
45) James Brophy, Margaret Keith, and Michael Hurley, “Breaking Point: Violence against Long-Term Care
Staff,” New Solutions: A Journal of Environmental and Occupational Health Policy 29, no. 1 (2019): 10–35.
46) OLTCA, “More Care. Better Care,” 6.
47) Banerjee et al., “Structural Violence in Long-Term, Residential Care,” 390–91.
48) Adelheid Zeller et al., “Aggressive Behavior of Nursing Home Residents Toward Caregivers: A Systematic Literature Review,” Geriatric Nursing 30, no. 3 (2009): 177; Brophy, Keith, and Hurley, “Breaking Point,”
19–20.
49) Banerjee et al., “Structural Violence in Long-Term, Residential Care,” 395.
50) Sarah J. Hewko et al., “Invisible No More: A Scoping Review of the Health Care Aide Workforce Literature,” BMC Nursing 14, no. 38 (2015): 6.
51) See, e.g., Shereen Hussein, “‘We Don’t Do It for the Money’ . . . The Scale and Reasons of Poverty-Pay
Among Frontline Long-Term Care Workers in England,” Health and Social Care in the Community 25, no.
6 (November 2017): 1817–26; Estabrooks et al., “Unregulated Workers”; Hewko et al., “Invisible No More,”
6; Montague, Burgess, and Connell, “Attracting and Retaining Australia’s Aged Care Workers: Developing Policy and Organisational Responses,” Labour & Industry 25, no. 4 (2015): 293–305; Douglas A. Singh,
Effective Management of Long-Term Care Facilities (Sudbury, MA: Jones and Bartlett, 2010), 430; Morgan,
Dill, and Kalleberg, “The Quality of Healthcare Jobs.”
52) The characteristics of burnout are typically understood to include “emotional exhaustion (depletion of
emotional resources and diminution of energy), depersonalization (negative attitudes and feelings as
well as insensitivity and a lack of compassion towards service recipients) and a lack of personal accomplishment (negative evaluation of one’s work related to feelings of reduced competence).” Natasha
Khamisa, Karl Peltzer, and Brian Oldenburg, “Burnout in Relation to Specific Contributing Factors and
Health Outcomes Among Nurses: A Systematic Review,” International Journal of Environmental Research and Public Health 10, no. 6 (2013): 2214–40.
53) Joanne Laucius, “‘We Are in Crisis’: Personal Support Workers Are the Backbone of Home Care in Ontario—and There Aren’t Enough of Them,” Ottawa Citizen, July 13, 2018, https://ottawacitizen.com/news/
local-news/when-the-backbone-is-broken.
54) Squires et al., “Job Satisfaction Among Care Aides,” 2; Mary Halter et al., “The Determinants and Consequences of Adult Nursing Staff Turnover: A Systematic Review of Systematic Reviews,” BMC Health
Services Research 17, no. 824 (2017): 13–14; Chan et al., “A Systematic Literature Review of Nurse Shortage
and the Intention to Leave,” 609.
55) Yin Li and Cheryl B. Jones, “A Literature Review of Nursing Turnover Costs,” Journal of Nursing Management 21 (2013): 405–18.
56) Castle and Engberg, “Nursing Home Staff Turnover: Impact on Nursing Home Compare Quality Measures”; Boscart et al., “Associations Between Staffing Hours and Quality of Care Indicators in Long-Term
Care.”
57) See Stephanie A. Chamberlain et al., “Individual and Organizational Predictors of Health Care Aide Job
Satisfaction in Long Term Care,” BMC Health Services Research 16, no. 577 (2016): 7; Chan et al., “A Systematic Review of Nurse Shortage and the Intention to Leave”; Squires et al., “Job Satisfaction Among
Care Aides.”
58) Squires et al., “Job Satisfaction Among Care Aides,” 17
59) Berta et al., “Relationships Between Work Outcomes, Work Attitudes and Work Environments,” 4; see
also Chamberlain et al., “Individual and Organizational Predictors of Health Care Aide Job Satisfaction,” 2.
60) Estabrook et al., “Unregulated Workers,” 53–54.
61) Rachel Barken et al., “The Influence of Autonomy on Personal Support Workers’ Job Satisfaction, Capacity to Care, and Intention to Stay,” Home Health Care Services Quarterly 37, no. 4 (2018): 294–312.
62) Squires et al., “Job Satisfaction Among Care Aides,” 2. Stephanie Chamberlain et al., “Influence of Organizational Context on Nursing Home Staff Burnout: A Cross-Sectional Survey of Care Aides in Western
Canada,” International Journal of Nursing Studies 71 (2017): 67; Knopp-Sihota et al., “Factors Associated
with Rushed and Missed Resident Care,” 2816; Susan Braedley et al., “We’re Told, ‘Suck It Up’: Long-Term
Care Workers’ Psychological Health and Safety,” Ageing International 43, no. 1 (March 2018): 91–109.
63) See Anastasia A. Mallidou et al., “Health Care Aides Use of Time in a Residential Long-Term Care Unit: A Time and Motion Study,” International Journal of Nursing Studies 50 (2013): 1229–39; Brophy et al., “Breaking Point,” 19–20; Knopp-Sihota et al., “Factors Associated with Rushed and Missed Resident Care.”
64) Knopp-Sihota et al., “Factors Associated with Rushed and Missed Care,” 2816.
65) Banerjee et al., “Structural Violence in Long-Term, Residential Care,” 396.
66) See, e.g., Knopp-Sihota et al., “Factors Associated with Rushed and Missed Resident Care,” 2825; Brophy
et al., “Breaking Point,” 21.
67) See Mallidou et al., “Health Care Aides Use of Time,” 1232–34; Knopp-Sihota et al., “Factors Associated
with Rushed and Missed Resident Care,” 2816; Chamberlain et al., “Influence of Organizational Context
on Nursing Home Staff Burnout,” 65; Margaret P. Calkins, “Evidence-Based Design for Dementia: Findings
from the Past Five Years,” Long-Term Living 60, no. 1 (2011): 42–45; Brophy et al., “Breaking Point.”
68) See, e.g., Gillese, Public Inquiry: Report, 2:88–93; AdvantAge Ontario, “2019 Pre-budget Recommendations: Backgrounders,” 2; CLAC, “Patients First,” 6–8; OLTCA, “Long-Term Care That Works,” 11–13.
69) OLTCA, “Long-Term Care That Works,” 11–13; Gillese, Public Inquiry: Report, 2:88–93.
70) OLTCA, “Long-Term Care That Works,” 12.
71) CLAC, “Patients First,” 6–8.
72) Gillese, Public Inquiry: Report, 1:14
73) See CBC News, “Nursing Home Resident Says Support Workers ‘Being Run Off Their Feet,’ Need More Staffing,” CBC News, February 1, 2019, https://www.cbc.ca/news/canada/windsor/ontario-long-term-care-facility-psw-shortage-1.5003312; Gillese, Public Inquiry: Report, 2:88; OLTCA, “LongTerm Care That Works,” 13
74) Gillese, Public Inquiry: Report, 2:88–92; OLTCA, “Long-Term Care That Works,” 11–13.
75) OLTCA, “Long-Term Care That Works,” 11–13.
76) OLTCA, “Long-Term Care That Works,” 13.
77) See CLAC, “Patients First,” 6
78) AdvantAge Ontario, “The Challenge of a Generation: Meeting the Needs of Ontario’s Seniors,” 2019
Provincial Budget Submission, http://www.advantageontario.ca/AAO/Content/Resources/Advantage_Ontario/2019-PB-Advocacy-Pub.aspx.
79) See Jerry Muller, The Tyranny of Metrics (Princeton, NJ: Princeton University Press, 2018); Cathy O’Neil,
Weapons of Math Destruction: How Big Data Increases Inequality and Threatens Democracy (Largo, MD:
Crown, 2016).
80) See, e.g., Seth Freedman, Haizen Lin, and Jeffrey Prince, “Information Technology and Patient Health: An Expanded Analysis of Outcomes, Populations, and Mechanisms,” Social Science Research Network,
paper no. 2445431 (2014): 1-35; Jeffrey S. McCullough, Stephen T. Parente, and Robert Town, “Health Information Technology and Patient Outcomes: The Role of Information and Labor Coordination,” The RAND Journal of Economics 47, no. 1 (2016): 207–36; Jeffrey S. McCullough, Michelle Casey, Ira Moscovice, and Shailendra Prasad, “The Effect of Health Information Technology on Quality in U.S. Hospitals,” Health Affairs 29, no. 4 (April 2010): 647–54; Goldzweig et al., “Electronic Patient Portals: Evidence on Health Outcomes, Satisfaction, Efficiency, and Attitudes: A Systematic Review,” Annals of Internal Medicine 159, no.
10 (2013): 677–87; Leila Agha, “The Effects of Health Information Technology on the Costs and Quality of Medical Care,” Journal of Health Economics 34 (2014): 19–30.
81) See CLAC, “Patients First,” 9.
82) Gillese, Public Inquiry: Report, 3:157–65.
83) John F. Schnelle et al., “Relationship of Nursing Home Staffing to Quality of Care,” Health Services Research 39, no. 2 (2004): 225–50; Margaret J. McGregor and Lisa A. Ronald, “Residential Long-Term Care for
Canadian Seniors: Nonprofit, For-Profit or Does It Matter?” IRPP Study 14 (January 2011): https://irpp.org/
wp-content/uploads/2011/01/study-no14.pdf; Knopp-Sihota et al., “Factors Associated with Rushed and
Missed Care,” 2816; AdvantAge Ontario, “2019 Pre-budget Recommendations: Backgrounders,” 3; Kathryn Hyer et al., “The Influence of Nurse Staffing Levels on Quality of Care in Nursing Homes,” The Gerontologist 51, no. 5 (2011): 610–16; Nicholas G. Castle, “Nursing Home Caregiver Staffing Levels and Quality
of Care: A Literature Review,” Journal of Applied Gerontology 27, no. 4 (2008): 375–405; Karen Spilsbury
et al., “The Relationship Between Nurse Staffing and Quality of Care in Nursing Homes: A Systematic
Review,” International Journal of Nursing Studies 48, no. 6 (2011): 732–50; Haizhen Lin, “Revisiting the
Relationship Between Nurse Staffing and Quality of Care in Nursing Homes: An Instrumental Variables
Approach,” Journal of Health Economics 37 (2014): 13–24; Boscart et al., “Associations Between Staffing
Hours and Quality of Care Indicators.”
84) After factoring in breaks.
85) Jackie Dunham, “Six Minute Challenge: Can You Get Ready as Fast as Nursing Home Residents?” CTV
News, January 10, 2018, https://www.ctvnews.ca/canada/six-minute-challenge-can-you-get-ready-as-fastas-nursing-home-residents-1.3753212.
86) Infrastructure Health and Safety Association, https://www.ihsa.ca/.