Recent staffing and quality indicator trends in Canadian long-term care

Gregory Feng ^a, Andrew McCabe ^a, Margaret Mousseau ^a, Lauren Clow ^a, Norma Hall ^a, Cathy Hyunh ^a, Laura Salter ^a, Chantal Couris ^a

Introduction
Nearly 190,000 people are living in a Canadian long-term care (LTC) home, a number that continues to increase. As older adults (85+) are one of the fastest growing age groups in Canada, it is projected that LTC capacity must double within the next decade to meet the increasing demand. Already facing staffing constraints prior to the COVID-19 pandemic, the LTC sector is under pressure to adjust to the changing environment. Knowing that working conditions strongly influence the conditions of care for residents, this analysis describes recent trends in (1) staffing, (2) staffing hours, and (3) quality indicators to explore the current state of Canadian LTC at a macro level.

Methods
Counts and proportions of healthcare providers working in LTC was obtained from CIHI's Health Workforce Database (HWDB, 2014-2023). Totals and median per organization for worked hours (i.e., regular, overtime), purchased hours (i.e., from private agencies), and benefit hours (i.e., sick leave) were obtained from the CIHI's Canadian Management Information System Database (CMDB, 2018-2023). Risk-adjusted quality indicator rates (worsened physical functioning, potentially inappropriate use of antipsychotics, falls in the past 30 days, worsened behavioural symptoms, unexplained weight loss, restraint use) were obtained from CIHI's Continuing Care Reporting System and Integrated interRAI Reporting System (CCRS and IRRS, 2014-2023). Trends were examined using visual inspection.

Results
In 2023, an estimated 13.6% (50,216 healthcare providers) of the health workforce in the HWDB was employed primarily in LTC. Nevertheless, in many professions the number and proportion working in LTC is declining (e.g., among licensed practical nurses, a 6.1% decline from 35,622 in 2021 to 33,459 in 2023 was observed). Data on staffing hours in 2023 suggests that the number of regular worked hours has surpassed pre-pandemic levels for the first time (43.3M or 22,208 full-time equivalents [FTEs]), while overtime (3.8M or 1,967 FTEs), purchased (2.9M or 1,408 FTEs), and sick hours (2.7M or 1,408 FTEs) have remained elevated. Although most quality indicators have remained stable or changed slightly, risk-adjusted rates of potentially inappropriate use of antipsychotic medications have increased in recent years (i.e., from 20.2% in 2019 to 24.3% in 2023).

Discussion/Conclusions
As the demand for LTC increases, declining numbers of providers working in LTC underscores the importance of recruitment and retention efforts. Particularly considering heightened reliance on overtime and purchased hours in place of full-time positions and regular worked hours, which can be costly and unsustainable. Continued efforts to prevent and address potentially inappropriate use of antipsychotic medications in long-term care is warranted. Further data, particularly among the LTC workforce (e.g., personal support workers), is needed to better understand the impacts of staffing on LTC quality.


^a Canadian Institute for Health Information, Canada

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