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Sudbury medical director has serious concerns about LTC transfers

‘The process for referring patients to long-term care has become significantly less consultative, transparent and collegial in recent years. … I am often asked to make clinical decisions with little or no information,’ says Dr. Maurice St. Martin, the medical director at Pioneer Manor and St. Joseph’s Villa
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Sudbury physician Dr. Maurice St. Martin is the medical director at both the Pioneer Manor and St. Joseph’s Villa nursing homes.

The medical director at two of Sudbury’s long-term care homes says too many patients who get transferred out of hospitals and into long-term care (LTC) homes are so sick they should be going to palliative care or hospice care instead. LTC homes are not equipped to handle those patients.

The comments were part of the testimony of Dr. Maurice St. Martin of Sudbury who gave evidence in the Ontario Superior Court of Justice during the challenge to Ontario Bill 7, also known as the More Beds, Better Care Act; the law that gives Ontario hospitals the power to transfer patients from acute care beds to a long-term care home.

The new law (enacted in 2022) allows hospital placement co-ordinators to send patients to any nearby LTC home (within 75 kilometres in Southern Ontario, 150 kilometres in Northern Ontario) where a bed is available.

In the case where a bed in an appropriate LTC home is found, the patient must either leave the hospital within 24 hours or pay a daily fee of $400 to remain in the hospital. 

The law was challenged by the Ontario Hospital Coalition and the Advocacy Centre for the Elderly. Their arguments were that it was unfair to force patients into a nursing home not of their choosing or face a financial penalty.

The challenge was subsequently dismissed, but the details of the arguments and testimony were just released by the court on Jan. 27, along with the decision and comments of the presiding judge, Justice Robert Centa.  

One of the issues considered in the application was an affidavit from Dr. St. Martin, the medical director at both Sudbury's Pioneer Manor and the St. Joseph's Villa nursing homes.

Although the court found St. Martin’s evidence was of limited value in the legal challenge, St. Martin’s concerns that hospitals are transferring patients to long-term care homes without providing enough information or having consultations about the patient’s medical condition prompted Sudbury.com to reach out to him this week. 

The doctor explained his position in an interview with Sudbury.com, saying he is understands the importance of moving patients out of the hospital if they don’t need acute care, but he disagrees with the idea of just arbitrarily moving a patient into the nearest LTC home because the law – Bill 7 – says it can be done.  

For context, Bill 7 gives hospital “placement co-ordinators” the power, with or without a request from an attending clinician, to:

  • Determine the ALC patient’s eligibility for admission to a long-term care home; and 
  • Select a long-term care home or homes for the ALC patient in accordance with the geographic restrictions that are prescribed by the regulations.

In St. Martin’s opinion, an underfunded provincial system from the province is putting pressure on hospitals and other ALC facilities to move patients out as quickly as possible — meaning, in his view, proper patient care falls by the wayside. 

St. Martin said he remembers a time when most long-term care admissions were the result of consultations with families and physicians who would decide on the best course of action for an elderly family member. There would be interviews, medical reviews and consultations with the family of the patient.

Now, as his evidence to the court contends, this has changed. He said more admissions to nursing homes are coming directly from hospitals.

"In my observation, the process for referring patients to long-term care has become significantly less consultative, transparent and collegial in recent years. Often, information that would allow the LTC facility to make a proper assessment of the individual is not provided and, as a result, I am often asked to make clinical decisions with little or no information," said the affidavit from St. Martin.

"Unfortunately, these examples reflect a broader trend where the communication and documents associated with the process of admitting patients to LTC has become significantly less transparent and consultative." 

St. Martin said this is part of a bigger fundamental problem with the model of care for older patients.

"There is a clear lack of resources for proper care in the community, which would allow older patients to remain in the community, enter LTC facilities when necessary and on the proper terms and/or to be transferred to palliative or hospice care when appropriate," St. Martin wrote.

In its ruling, the court opined, based on St. Martin’s submission, that hospitals are transferring patients to LTC homes who have far greater needs than what the facilities can manage.

"In his view, many of the long-term care admissions are ‘older and frailer’ than in the past and “they should [instead] have been considered for or transferred to palliative care or hospice,” Justice Robert Centa wrote.

He further noted that hospitals and hospices have “much higher staffing levels than now exist” in long-term care homes.

“The under-resourcing of the chronic care and long-term care systems” affects patient care, Dr. St. Martin said, and frustrates and angers family members who “demand and expect the same level of care provided in the acute care setting from the … doctors and staff” in long-term care homes who aren’t equipped to deliver at the same level.

In his evidence to the court, St. Martin said he was also concerned that a greater number of younger, more physically able patients with psychiatric issues are being admitted to long-term care homes. 

St. Martin confirmed that, as medical director of care, he can block any admission that he does not believe is medically appropriate, adding there are times when he and acute care centres (i.e. the hospital) will butt heads. At Pioneer Manor, he rejects approximately 40 applicants each year because, in his medical opinion, the long-term care home cannot provide suitable care to the applicants.

Speaking to Sudbury.com this week. St. Martin said there are many issues still to be resolved in the process of having patients moved from acute care facilities to long-term care. 

He said he fully understands the concern as there are many elderly people who are in hospital, staying in an acute care bed, often described as an ALC bed (Alternate Level of Care). They aren’t well enough to live on their own, but not sick enough to remain in hospital.

At this point, St. Martin said the hospital will decide to move a patient who no longer needs acute care — patients who are sometimes called “a bed blocker” —  to a nearby LTC home. 

The way these transfers happen, though, often show a lack of respect for both the patient and the LTC being asked to accept them.

It’s not uncommon, St. Martin said, for an LTC to receive a transfer notice for a patient to arrive on a given day, but for the hospital to blow the deadline entirely. This throws the entire transfer process into chaos, he said.

For example, say a patient is supposed to arrive at 11 a.m. 

"You want them before 1 p.m., because you've got things to do,” St. Martin said. “You've got to meet the family, you've got to meet the patient, you've got to re-look at all the meds, get approvals for the meds, and you got to get the meds in, because the pharmacy closes at 5 p.m.”

In those instances, St. Martin said he will step in to block the transfer until the patient can be transferred safely.

St. Martin said part of the problem is a lack of communication, lack of collaboration and a lack of respect on the part of hospitals.

St. Martin describes himself as "old school" and said he remembers the days when physicians would meet to discuss patient options or at least pick up a phone.

"Primary care is in crisis. This is another canary in the coal mine,” he said. “You know, in the old days — I go back to 1982 — we used to all work in the hospital. We used to collaborate and meet and have hallway consultations with specialists. We would assist the specialist for our own patients, for surgeries. 

“There was that collaboration. Now everybody's working in silos."

And those siloes aren’t doing a very good job of communication, in Dr. St. Martin’s view.

Len Gillis covers health care as well as the mining industry for Sudbury.com .



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