Addressing Ontario’s Hospital Crisis: A Critical Analysis of the More Beds, Better Care Act

Vivian Qiang
McGill University, Montréal, Québec, Canada

A Comparative Health Analysis

Abstract

Key Messages

• Approximately 6,000 patients occupying hospital beds in Ontario are designated as requiring “alternative levels of care.”
• Bill 7: the More Beds, Better Care Act permits the transfer of patients who no longer require acute care from hospitals to long-term care homes without informed consent.
• Patients and advocacy groups have voiced concerns that Bill 7 violates fundamental ethical principles upheld in clinical practice.
• Further evaluations must be conducted to monitor Bill 7’s impact in addressing the hospital crisis and quality of care delivered in long-term care homes.

• Environ 6 000 patients occupant des lits d’hôpitaux en Ontario sont désignés comme ayant besoin de « niveaux alternatifs de soins ».
• Le projet de loi 7: Loi sur l’augmentation du nombre de lits et l’amélioration des soins autorise le transfert des patients qui n’ont plus besoin de soins aigus des hôpitaux vers des maisons de soins de longue durée sans consentement éclairé.
• Les patients et les groupes de défense ont exprimé leur inquiétude quant au fait que le projet de loi 7 viole les principes éthiques fondamentaux défendus dans la pratique clinique.
• D’autres évaluations doivent être menées pour contrôler l’impact du projet de loi 7 sur la crise hospitalière et la qualité des soins dispensés dans les établissements de soins de longue durée.

Brief Description of the Health Policy Reform

Patients who are deemed as no longer requiring acute care but remain in hospitals are referred to as “alternative levels of care” (ALC) patients. In response to the significant number of ALC patients, the Government of Ontario passed the More Beds, Better Care Act> (Bill 7) on 31 August 2022, only three weeks after it was first introduced by Doug Ford’s Progressive Conservative (PC) party. This reform amends the Fixing Long-Term Care Act and Health Care Consent Act to streamline the transfer of ALC patients from hospitals to long-term care homes. Bill 7 focuses primarily on granting placement coordinators more decision-making power. Under the reform, a placement coordinator has the authority to:

• Determine the patient’s eligibility for admission to a long-term care (LTC) home;
• Select an LTC home for patients who are assigned to an “alternative level of care” (ALC) within 70 to 150 kilometres of the hospital;
• Provide an LTC home with the regulated assessments and information, which may include the patient’s personal health information;
• Authorize the patient’s admission into a LTC home; and
• Transfer responsibility for the placement of the ALC patient to another coordinator who may carry out these actions (MacRae, Whiteside, and Carlin 2022).

The More Beds, Better Care Act permits placement coordinators to carry out these actions without the consent of the ALC patient or their substitute decision-maker, provided that “reasonable efforts” (Bill 7) have been made to reach consensual agreement with the patients and families. There is no detail in the legislation regarding what “reasonable efforts” entail (Calandra 2022). The main provisions of Bill 7 came into effect on 21 September 2022.

To supplement Bill 7, which does not allow for the forcible physical transfer of patients (e.g., with restraints), a monetary disincentive was introduced. As of 20 November 2022, the amended Hospital Management Regulation under the Public Hospitals Act charges patients $400 for every day that they remain in the hospital 24 hours after their discharge date.

Explicit goals

The stated objective of Bill 7 is to reduce hospital overcrowding and help ease the pressures facing Ontario’s acute care system. The reform encourages patients to relocate to LTC facilities, where “seniors could be cared for in a more home-like setting while acute care beds would be freed up for the anticipated surge in COVID-19 and flu cases,” said Long-Term Care Minister Paul Calandra (Artuso 2022). Bill 7 supports the Ontario government’s broader political platforms related to health care, which aim to increase the health system’s capacity and “ensure hospital beds are there for patients when they need them” (Ontario Ministry of Health 2022).

Implicit goals

Bill 7 serves the political agenda of Ontario’s PC government. Premier Doug Ford faced a deluge of criticisms for his government’s management of the COVID-19 pandemic and is often blamed in media for the province’s overburdened health care system (Callan and D’Mello 2022; Ontario Public Service Employees Union 2022). The reform therefore serves as a response to public critique. Furthermore, acute care in hospitals costs $800 to $1,000 per day for each bed occupied by an ALC patient, compared to around $250 for each LTC bed. Bill 7 also presents a potential “solution” to the long hospital wait list problem while avoiding nurses’ demands for salary raises (Jones 2020). The More Beds, Better Care Act may thus serve economic purposes as a cost-saving policy option.

History and Context

ALC patients in Ontario hospitals

As of 13 January 2021, there were 5,066 patients deemed ALC in Ontario hospitals, which represents approximately 15% of the total hospital beds in the province (OHA [Ontario Hospital Association] 2021). About 80% of Ontario’s ALC patients are older adults (65+). The risk of delayed transitions in care also increases when older adults experience multiple and complex health and social conditions, such as comorbidities, caregiver stress, and experience of adverse events during admission, such as functional decline, delirium, and social isolation (Government of Ontario 2021c).

Process for transfers from hospitals to LTC prior to Bill 7

Before the enactment of the More Beds, Better Care Act, eligible ALC patients could choose which LTC facility they would like to be transferred to. In their application to a placement coordinator, patients could choose up to five LTC homes and rank them by preference. When a bed became available in one of their preferred homes, the patient was discharged from the hospital and transferred to the LTC facility (Ontario Health Coalition 2022).

Prior to the recent amendment, the Long-Term Care Act and Health Care Consent Act mandated that transfers occur only with the informed consent of the patient or a substitute decision-maker (who may be a spouse, child, or another caregiver). The Long-Term Care Act requires the following elements for consent (Phillips 2021):

• The consent must relate to the admission of patients into the LTC facility;
• The consent must be informed;
• The consent must be given voluntarily; and
• The consent must not be obtained through misrepresentation or fraud

These elements align with the general requirements for consent to treatment outlined by The College of Physicians and Surgeons of Ontario and the Health Care Consent Act (College of Physicians and Surgeons of Ontario 2001).

Patients remained eligible for insured in-patient services until a bed became available in their preferred LTC home and they received an offer of admission. However, if a patient or their substitute decision-maker refused a valid offer of admission to the selected LTC facility, the Health Insurance Act allowed hospitals to charge “chronic care co-payment” – an unregulated rate to remain in the hospital (Ontario Health Coalition 2022).

How Bill 7 came onto the government’s agenda: problems, politics, and policies

The problem of overcrowding in Ontario hospitals existed long before the COVID-19 pandemic. In 2017, the OHA released a report stating that the hospital system was “on the brink” of an “imminent capacity crisis” (OHA 2018). The report highlights the alarming pressure facing the hospital sector: hospital occupancy exceeded 100% capacity in about half of Ontario’s hospitals, with some reaching up to 140%. For context, the international standard for safe hospital capacity is around 85% (OHA 2018). As expected, the COVID-19 pandemic worsened the situation due to increased burnout experienced by health care workers and hospital backlogs. A leaked report by Ontario’s Ministry of Health found that for the month of August 2022, “wait times, emergency department length of stay, time for an admitted patient to move to an inpatient bed, and ambulance offload times were the worst they have ever been when compared to every other August since 2008” (DeClerq 2022b).

Due to a shortage of home care, long-term care, and community-based services, many patients have resorted to remaining in hospitals as their only available source of treatment (Howlett 2022). Accordingly, some posit that the extended occupancy of ALC patients in hospitals represents one of the root causes of emergency department backlogs and extended ambulance offload times (Boyle 2017; Howlett 2022). Data released in December 2022 indicates that patients spent on average 22.9 hours waiting in emergency rooms for admission (DeClerq 2022a). As such, Bill 7 serves as a response to demands for solutions to Ontario’s long wait times. Some also argue that ALC patients, who are predominantly elderly and/or have chronic conditions, deplete resources needed by the critically ill, in addition to costing the province about $500 a day per patient (King 2021). However, the association between ALC beds and hospital capacity is complicated by Ontario’s nurse and physician shortages (Giunta 2022). As personal support workers are primarily responsible for providing care to ALC patients, it is unclear whether freeing up ALC beds will relieve the burden on nurses and physicians to an extent that wait times are effectively reduced.

Given these grave circumstances, Ontario’s PC government was under immense political pressure to alleviate the burden of ALC patients in hospitals and free up beds for patients requiring acute care. Accordingly, the provincial government released its “Plan to Stay Open” as part of their 2022 election platform. The plan outlines strategies to “bolster Ontario’s health care workforce, free up hospital beds, and ease pressures on emergency departments” (Ontario Ministry of Health 2022). A key focal area is to allocate “the right care in the right place,” which involves better connecting seniors with appropriate care and providing more LTC beds. These goals also align with the Ontario government’s $933-million plan to modernize LTC, with aims to build 30,000 new beds and 15,918 upgraded spaces by 2028 (Government of Ontario 2021a). These pre-existing policies and governmental plans set the political foundation for the PC government to introduce the More Beds, Better Care Act.

There have been minimal changes in the PC Party’s perspectives and stance on the issue in recent history, as their 2018 election platform also focused on increasing LTC capacity.

The Policy-making Process: Interests, Ideas, Institutions

Policy options and instruments

The PC government’s Long-Term Care Minister Paul Calandra introduced Bill 7 in response to public demands to increase hospital capacity in Ontario. The Ministry of Long-Term Care’s portfolio does not typically include regulations related to hospital care, as their primary duties pertain to the management of LTC homes and programs to attract and retain LTC workers. With the exception of the Fixing Long-Term Care Act, the Ministry of Long-Term Care shares responsibility with the Ministry of Health for other regulations related to hospitals (i.e., Connecting Care Act, 2019, Health Protection and Promotion Act, s. 78). As such, given that hospitals fall beyond the Ministry of Long-Term Care’s stated jurisdiction, it is unclear why the reform was proposed by Minister Calandra without joint responsibility with The Ministry of Health.

Although Bill 7 addresses concerns related to appropriate care for ALC patients, stakeholders demanded alternative policy actions that the PC government did not undertake. One of the most dominant demands is the call for increased provincial funding for hospitals. In 2020, Ontario’s hospitals and other health sector stakeholders asked for a nearly $1 billion increase in funding to maintain services and ease overcrowding (Jones 2020). When the Ontario PC government announced the installment of 15,000 new LTC beds, the OHA’s President and CEO raised that “[these] projects take time, and [$1 billion] is the level of funding needed to bridge the gap” (Jones 2020). However, Premier Ford did not respond favourably to the request, as he believed funding to be a jurisdictional issue between federal and provincial agencies. Accordingly, the Ontario PC party assigned responsibility to the federal government for financial support, stating that it is unacceptable for provinces to be paying for 78% of their health care spending (Tsekouras 2022).

Table 1. Timeline of PC Party perspectives and stance on LTC capacity

As such, rather than increasing health care spending, the Ontario government opted to introduce a regulation that waives patients’ rights to informed consent to facilitate the transfer of patients from hospitals to LTC facilities. The Ontario government also leveraged co-payments to enforce Bill 7’s regulations – hospitals must charge patients $400 for every day that they remain 24 hours after their discharge date. Given concerns that hospitals may charge patients inordinate uninsured rates, the amendment was enacted to standardize rates of co-payments for patients who refuse LTC placement (Canadian Press 2022). Therefore, despite public calls for increased health care spending, the PC government took a cost-saving regulatory approach, which aligns with their fiscally conservative political agenda.

Stakeholder views and stances on the More Beds, Better Care Act

Many stakeholders expressed strong dissent against Bill 7 after the reform was announced through media outlets. Despite Minister Calandra’s reassurance that “[they] will not move people without their consent” (Ferguson 2022c), there was significant public outcry over the ways in which Bill 7’s provisions violate core ethical values and principles in health care. The OCHU, who carries out advocacy on behalf of their members, patients, and long-term care residents, released a statement calling Bill 7 a “contravention of [elderly patients’] right to consent” (Ontario Health Coalition 2022). The Council serves a variety of purposes, including bargaining a provincial collective agreement with Ontario hospitals and defending against cuts or privatization of community health services.

Many non-profit and charity organizations dedicated to promoting the rights of older adults and seniors have expressed deep concern about Bill 7. They argue that targeting the elderly, persons with disabilities, and individuals with chronic conditions with forcible transfers is a violation of human rights (Care Watch 2022; Au-Yeung 2022; Allatt and Parke 2022). Several other organizations involved in advocating for patient rights – including The Ontario Health Coalition, the Advocacy Centre for the Elderly, and the Canadian Union of Public Employees – called upon the Ontario Human Rights Commission to launch a formal investigation into systemic ageism within the provincial health care system after Ford’s government introduced Bill 7.

Furthermore, advocacy groups representing patients and their families also expressed that Bill 7 places seniors at greater risk of abuse and neglect, thereby causing further harm (Au-Yeung 2022; Care Watch 2022). The previous model for transferring patients from hospitals to LTC homes allowed individuals to select up to five facilities that best suit their lifestyle and cultural needs, including proximity to their families and communities. Indeed, placements to distant, foreign, and isolated LTC centres under Bill 7’s provisions may risk undermining patients’ connections to their support networks. Elder Abuse Prevention Ontario, an organization that provides education and resources on elder abuse, also raised equity-related concerns for “seniors who belong to linguistic minority or historically disadvantaged groups, who particularly rely on close connections with their communities to meet their fundamental needs” (Au-Yeung 2022). Therefore, stakeholders have claimed that Bill 7 violates not only the ethical principle of autonomy but also beneficence, non-maleficence, and justice.

Conversely, Oak Valley Health, a community health care organization, coordinated a letter of support for Bill 7 from the CEOs and Chiefs of Staff of some of the largest hospitals and health centres in Ontario. Signatories included the Centre for Addiction and Mental Health, Baycrest Hospital and Long-Term Care (which has a 472-bed LTC facility), The Hospital for Sick Children, Mount Sinai Hospital, and Sunnybrook Health Sciences Centre – all of whom provide care to over 400 hospital beds. In the open letter, they acknowledged concerns surrounding how Bill 7 would impact patients and families but pledged that all decisions will centre “compassion, collaboration, ethical and equitable considerations, and the patient’s best interests” (Oak Valley Health 2022). However, other stakeholders, including a lawyer for the Advocacy Centre for the Elderly, argued that doctors and other hospital staff may not have the capacity to discern which LTC facilities provide the best services and supports for a particular patient.

While community leaders, health centres and organizations took on this work, they initially did so without financial recognition or support. As a result of more advocacy, funding was made available to participating service providers several weeks after the initial approval of the clinic to cover its costs. Funds were made available for community clinics and leaders to apply for the financial resources needed to cover the costs of their labour, programming, and services. Many applications were not fully funded, leaving much of the work without recognition of its significance, or financially supported in a way that acknowledged that work was done. Community leadership advocated for equitable pay for nurses working in the clinic, and action was taken by community leaders running the clinic to ensure fair pay was in practice throughout its operation.

How the reform was achieved

The main public proponents of Bill 7 were Premier Doug Ford and Long-Term Care Minister Paul Calandra. In defending the bill, Calandra stated that “the status quo is not an option. There are close to 2,000 seniors in hospital, waiting to be in a long-term care home...this bill facilitates that to happen and allows our acute system to recover” (Ferguson 2022b). Ford also expressed support for the bill, emphasizing that LTC facilities would provide more suitable and comfortable environments than hospitals for patients.

In June 2022, Ontario’s PC government won a second consecutive majority government, with PC candidates occupying seats in 83 ridings. This political positioning allowed them to push the More Beds, Better Care Act through the legislature in just thirteen days with minimal debate (Calandra 2022). A motion was passed to advance Bill 7 directly from second to third reading, thereby bypassing the committee stage where the bill would have been subjected to public feedback. In the legislative process, most bills must pass the committee stage, which involves conducting a more detailed study of the bill (i.e., clause by clause review) than is possible during other stages (Legislative Assembly of Ontario n.d.). Committees are composed of a small working group of members of provincial Parliament (MPPs), but Ontario citizens may also participate as committee witnesses, submitting written material for the committee’s review, or attending committee hearings (Legislative Assembly of Ontario n.d.). In bypassing the committee stage, the government evaded scrutiny from opposing stakeholders, including the Advocacy Centre for the Elderly, who had planned to speak on their concerns regarding Bill 7 (Canadian Press 2022). The New Democratic Party (NDP) of Ontario claimed that the PC government “silenced” opposing views by moving directly to the final legislative stage before MPPs casted their votes (Canadian Press 2022).

Implementation and Evaluation

The More Beds, Better Care Act only recently came into effect on 21 September 2022, and therefore no formal evaluations have been conducted on its impact. However, based on the most recent data regarding hospital capacity in Ontario, the situation has only worsened. As of late October 2022, Ontario’s health system remains overburdened, with several of the largest hospitals issuing alerts that they were at full capacity (Cheese 2022). Hospitals were unequipped and without sufficient beds to manage the rise in influenza, respiratory syncytial virus (RSV), and COVID-19 cases observed in the months following Bill 7’s implementation.

However, Bill 7 may provide opportunity for long-term cost savings, as suggested by The Conference Board of Canada’s economic analysis (Gibbard 2017). The report outlines an optimistic cost-benefit analysis of investing in the construction and operation of 199,000 new LTC beds by 2035. They estimate the capital cost (i.e., the initial one-time cost of construction) and operating cost of each new LTC bed to be approximately $395,000 per year. These costs are offset by several benefits, including increased economic activity associated with the construction and operation of the facilities, as well as the costs saved due to the reduction of in-hospital ALC demand. The report presents two long-term projections based on assumptions regarding the program’s success – a naïve (maximum benefit) and a conservative (low benefit) scenario, which predict a net benefit of $293 billion and $1 billion, respectively (Table 2) (Gibbard 2017). The naïve scenario is not plausible, as it assumes that every patient who is not in LTC would remain in ALC beds, while a more reasonable assumption would be that patients would resort to at-home or caregiver services. As such, the naïve model over-estimates the cost savings of LTC beds.

Table 2. Comparative summary of the Conference Board of Canada's economic analysis calculated in 2017 ($ in billions)

Although The Conference Board of Canada’s analysis presents promising findings for the cost-saving potential of LTC expansion, it fails to consider that hospitals may not ultimately save costs. The relocation of ALC patients to LTC homes does not leave hospital beds empty and unattended; rather, the previously designated ALC hospital beds will be occupied by patients requiring acute care, who are approximately six times more expensive than care to ALC patients. (Archer 2016; Canadian Institute for Health Information [CIHI] 2023). Therefore, policy-makers should consider not only solutions that “cut costs,” but how to best allocate funds for the highest quality of care.

Nevertheless, related evidence suggests that Bill 7 is ineffective in addressing Ontario’s hospital crisis and improving patients’ quality of life. Firstly, Bill 7 focuses exclusively on individuals designated as needing LTC, which make up only 2,400 of the 6,000 total ALCpatients (Badone 2022). This legislation therefore omits the majority of ALC patients who are awaiting other forms of care, such as mental health support, rehabilitation, hospice, or palliative services. Additionally, Bill 7 fails to address the interconnected systemic gaps that contribute to the current hospital crisis in Ontario. For instance, staffing shortages have been highlighted as the major contributor to emergency room closures in the province (Badone 2022; Giunta 2022). Finally, LTC homes simply do not have the capacity to host more patients. As of May 2021, 38,000 people were on the waitlist to access a LTC bed in Ontario, with a median wait time of almost 200 days (Government of Ontario 2021b; Health Quality Ontario 2023). Moreover, a slew of media reports documents cases of elder abuse in Ontario’s LTC facilities, with severe violations involving abuse, inadequate infection control, and poor skin and wound care. As such, poor care in LTC facilities could lead to worse health outcomes and feed patients back into the acute care system.

Released on 21 November 2022, the most recent statement from the Ontario government indicates that the number of ALC patients has decreased by almost 20% (Ferguson 2022a). Moving forward, clear and measurable evaluations with standardized tools need to be employed to monitor Bill 7’s impact. For instance, policy-makers and researchers may use CIHI’s indicators for wait times and the safety and quality of care in hospitals and LTC homes (CIHI n.d.).

Strengths, Weaknesses, Opportunities, Threats

Table 3 summarizes the strengths, weaknesses, opportunities, and threats presented by Bill 7 from the perspectives of key stakeholders discussed in this analysis. Stakeholders are indicated in parentheses below.

Table 3: SWOT analysis

Strengths	Weaknesses
Frees up hospital beds for patients in need of acute care (PC government, hospital management). ALC patients who require LTC services are placed in appropriate care settings more efficiently (PC government, hospital management). More evenly distributes patients across LTC facilities in Ontario (PC government).	Fails to address the root causes of hospital overcrowding (advocacy groups, researchers). Violates patients’ fundamental right to informed consent (patients, families, advocacy groups, unions, public, nurses). As ALC patients require other forms of care aside from LTC (e.g., rehabilitation, mental health services, etc.), does not address other complex needs (advocacy groups, unions). Fails to consider the long wait-times for LTC homes (advocacy groups, researchers, health care providers). Places patients in undesired LTC facilities, which may isolate them from their communities and support networks (advocacy groups, health care providers).
Opportunities	Threats
Could save health care spending costs by up to 400% (PC government). May increase hospital capacity and lead to better treatment of acute conditions, such as COVID-19 and RSV (PC government, hospital management).	By relocating patients from hospitals, LTC facilities may also become overcrowded, exacerbating abusive conditions (advocacy groups, researchers, nurses). Could introduce a slippery slope in terms of removing informed consent from patients “for the greater good” (researchers). The policy may be perceived as ageist, as it disproportionately impacts the elderly population (advocacy groups, media).

The More Beds, Better Care Act aims to address the crisis of overcrowded hospitals in Ontario by facilitating the transfer of ALC patients from hospitals to LTC facilities. However, by waiving the right to informed consent, Bill 7 enacts an unprecedented regulatory shift concerning a core ethical value – patient autonomy. This has resulted in significant backlash from patients, their families, and health professionals, particularly given the lack of opportunity for public engagement during the legislative process. Bill 7 raises key concerns regarding how policymakers navigate value trade-offs between optimizing hospital capacity and preserving patient autonomy.

References

Allatt P, Parke B. 2022. A public policy dead end: the More Beds, Better Care Act. Healthy Debate. https://healthydebate.ca/2022/09/topic/more-beds-better-care-act/.

Archer S. 2016. Ontario’s alternate level of care (ALC) problem is killing acute care hospitals: time to cut the Gordian knot. Dr. Archer’s blog, School of Medicine, Queen’s University.https://deptmed.queensu.ca/dept-blog/ontarios-alternate-level-care-alc-problem-killing-acute-care-hospitals-time-cut-gordian.

Artuso A. 2022. Bill would make it easier for hospitals to move seniors to LTC homes: minister. Toronto Sun. https://torontosun.com/news/provincial/bill-would-make-it-easier-for-hospitals-to-move-seniors-to-ltc-homes-minister.

Au-Yeung G. 2022. Public statement: More Beds, Better Care Act 2022 (Bill 7) - EAPO. Elder Abuse Prevention Ontario. https://eapon.ca/more-beds-better-care-act-2022/.

Badone E. 2022. Opinion: new ‘more beds’ legislation adds up to worse care. The Hamilton Spectator. https://www.thespec.com/opinion/contributors/2022/09/09/new-more-beds-legislation-adds-up-to-worse-care.html.

Boyle T. 2017. Far too many hospital beds occupied by patients who don’t need to be there: report. The Toronto Star. https://www.thestar.com/news/gta/2017/10/19/far-too-many-hospital-beds-occupied-by-patients-who-dont-need-to-be-there-report.html, as of 25 November 2022.

Calandra Hon P. 2022. More Beds, Better Care Act, 2022, S.O. 2022, c. 16 - Bill 7. https://www.ola.org/en/legislative-business/bills/parliament-43/session-1/bill-7.

Callan I, D’Mello C. 2022. Ontario hospital wait times continue to worsen as health-care crisis grows. Global News. https://globalnews.ca/news/9262922/ontario-hospital-wait-times-september-leaked-report/.

Canadian Press. 2022. Ford government passes motion to skip public hearings on long-term care legislation. CBC News.https://www.cbc.ca/news/canada/toronto/bil-7-long-term-care-public-hearings-1.6565577.

Care Watch. 2022. More Beds, Better Care Act, 2022: an open letter from Care Watch Ontario. Ontario Society of Senior Citizens Organizations. https://www.ossco.org/more-beds-better-care-act-2022-an-open-letter-from-care-watch-ontario/.

Cheese T. 2022. Amid fears health system is buckling, Toronto hospitals to issue alerts about overcrowded ERs. CBC News. https://www.cbc.ca/news/canada/toronto/emergency-rooms-at-capacity-1.6633704.

CIHI (Canadian Institute for Health Information). 2023. Ontario: cost of a standard hospital stay. https://yourhealthsystem.cihi.ca/hsp/endetail?lang=en&_ga=2.177082918.2070990861.1689779664-809987764.1689779654#/indicator/015/2/C5001/.

College of Physicians and Surgeons of Ontario. 2001. Consent to treatment. https://www.cpso.on.ca/Physicians/Policies-Guidance/Policies/Consent-to-Treatment.

DeClerq K. 2022a. Average ER wait times in Ontario reaches new high, data shows. CTV News. https://toronto.ctvnews.ca/average-er-wait-times-in-ontario-reaches-new-high-data-shows-1.6185804.

DeClerq K. 2022b. Leaked report shows Ontario hospital wait times increased about 54 per cent in a year. CTV News. https://toronto.ctvnews.ca/leaked-report-shows-ontario-hospital-wait-times-increased-about-54-per-cent-in-a-year-1.6106256.

Ferguson R. 2022a. 2,400 elderly patients had rights violated in moves from Ontario hospitals, critics charge. The Toronto Star. https://www.thestar.com/politics/provincial/2022/11/21/2400-elderly-patients-had-rights-violated-in-moves-from-ontario-hospitals-critics-charge.html.

Ferguson R. 2022b. Doug Ford’s government is ignoring the rights of elderly patients, MPPs charge. The Toronto Star. https://www.thestar.com/politics/provincial/2022/08/29/doug-fords-government-is-ignoring-the-rights-of-elderly-patients-mpps-charge.html.

Ferguson R. 2022c. Ford government will charge $400 a day for long-term-care patients who won’t leave hospital. The Toronto Star. https://www.thestar.com/politics/provincial/2022/09/14/ford-government-will-charge-400-a-day-for-long-term-care-patients-who-wont-leave-hospital.html.

Gibbard R. 2017. Sizing up the challenge: meeting the demand for long-term care in Canada. The Conference Board of Canada. https://www.cma.ca/sites/default/files/2018-11/9228_Meeting%20the%20Demand%20for%20Long-Term%20Care%20Beds_RPT.pdf.

Giunta M. 2022. Ontario hospitals continue to deal with significant staffing shortages. Global News. https://globalnews.ca/news/9216828/ontario-hospitals-significant-staffing-shortages-october-2022/.

Government of Ontario. 1996a. Health Care Consent Act. https://www.ontario.ca/laws/statute/96h02.

Government of Ontario. 1996b. Health Insurance Act. https://www.ontario.ca/laws/statute/90h06.

Government of Ontario. 2008. Ontario tackles ER waits with $109 million investment. News release. https://news.ontario.ca/en/release/984/ontario-tackles-er-waits-with-109-million-investment.

Government of Ontario. 2021a. Ontario making historic investment to modernize long-term care. News release. https://news.ontario.ca/en/release/60796/ontario-making-historic-investment-to-modernize-long-term-care.

Government of Ontario. 2021b. Ontario welcomes new long-term care development proposals. News release. https://news.ontario.ca/en/release/1001009/ontario-welcomes-new-long-term-care-development-proposals.

Government of Ontario. 2021c. The alternate level of care (ALC) leading practices guide: preventing hospitalization and extended stays for older adults. https://quorum.hqontario.ca/Portals/0/Indicators-and-change-ideas/ALC%20Leading%20Practices%20Guide%20v1%202021%20(2).pdf?ver=2022-03-30-133617-273.

Government of Ontario. 2022. Plan to stay open: health system stability and recovery. Ministry of Health. http://www.ontario.ca/page/plan-stay-open-health-system-stability-and-recovery.

Health Quality Ontario. 2023. Long-term care home wait times in Ontario. https://www.hqontario.ca/system-performance/Long-Term-Care-Home-Performance/Wait-Times.

Howlett K. 2022. Elderly patients with nowhere else to go are crowding hospitals. How Ontario aims to solve the crisis. The Globe and Mail. https://www.theglobeandmail.com/canada/article-ontario-hospital-crisis-elderly/.

Jones A. 2020. Ontario hospitals ask Ford government for nearly $1b funding increase. Global News. https://globalnews.ca/news/6452164/ontario-hospitals-funding-overcrowding/.

King A. 2021. How a new program frees up beds by helping patients stuck in hospital find care elsewhere. CBC News. https://www.cbc.ca/news/canada/toronto/program-helps-hospital-capacity-vulnerable-alc-patients-1.6067639.

Legislative Assembly of Ontario. n.d. Participate in committees. https://www.ola.org/en/get-involved/participate-committees.

Legislative Assembly of Ontario. n.d. Stages of a bill. https://www.ola.org/en/visit-learn/parliament-government/legislative-process/stages-a-bill.

MacRae S, Whiteside H, Carlin M. 2022. Transitioning patients from hospitals to long-term care: Ontario’s More Beds, Better Care Act. https://www.fasken.com/en/knowledge/2022/09/transitioning-patients-from-hospitals-to-long-term-care.

Oak Valley Health. 2022. An open letter on Bill 7 – the More Beds, Better Care Act. https://www.oakvalleyhealth.ca/about-us/news/open-letter-bill-7-more-beds-better-care-act-2022.

OCHU (Ontario Council of Hospital Unions). 2019. Protecting what matters most: Conserative cuts on track to wreck havoc on our hospitals. https://ochu.on.ca/wp-content/uploads/2019/08/Brief_Hospital_cuts_forecast_Ontario_2019_06_19.pdf.

OHA (Ontario Hospital Association). 2014. Alternate level of care and emergency room. https://www.oha.com/health-system-transformation/alternate-level-of-care-and-emergency-room.

OHA (Ontario Hospital Association). 2018. A sector on the brink: the case for a significant investment in Ontario’s hospitals. https://www.oha.com/Bulletins/2558_OHA_A%20Sector%20on%20the%20Brink_rev.pdf.

OHA (Ontario Hospital Association). 2021. Fact sheet on hospital capacity. https://www.oha.com/Bulletins/OHA%20Fact%20Sheet%20on%20Hospital%20Capacity%20and%20Projections%20Jan%2015%202021.pdf.

Ontario Health Coalition. 2016. Hospital overload: backgrounder on Ontario’s hospital shortage. https://www.ontariohealthcoalition.ca/wp-content/uploads/backgrounder-on-hospital-bed-shortage.pdf.

Ontario Health Coalition. 2022. Fact checker: Ford government’s claims re. forcing elderly patients into long-term care in contravention of their right to consent. https://www.globenewswire.com/en/news-release/2022/08/25/2505021/0/en/Ontario-Health-Coalition-Fact-Checker-Ford-Government-s-Claims-Re-Forcing-Elderly-Patients-into-Long-Term-Care-in-Contravention-of-their-Right-to-Consent.html.

Ontario Public Service Employees Union. 2022. Premier Ford “pushing public system to collapse”: five largest health care unions join forces, make SOS appeal to save our public hospitals. https://www.newswire.ca/news-releases/premier-ford-pushing-public-system-to-collapse-five-largest-health-care-unions-join-forces-make-sos-appeal-to-save-our-public-hospitals-840120821.html.

Phillips R. 2021. Fixing Long-Term Care Act, S.O. 2021, c. 39, Sched. 1. https://www.ontario.ca/laws/statute/21f39.

Tsekouras P. 2022. Doug Ford says feds need to “step up” to help fix Ontario’s hospital staffing crisis. CTV News. https://toronto.ctvnews.ca/doug-ford-says-feds-need-to-step-up-to-help-fix-ontario-s-hospital-staffing-crisis-1.6012409.

Health Reform Observer - Observatoire des Réformes de Santé, Volume 11 | Issue 2 | Article 2. https://doi.org/10.13162/hro-ors.v11i2.5441.