Hospital admissions are a crucial part of pandemic planning for long term care (LTC) home residents. They are a potential hotspot for COVID-19 transmission, and admitted residents may carry the virus back to their LTC facilities. In May, federal government data indicated that residents of LTC homes accounted for over 80 per cent of all Canadian COVID-19 deaths.

In a recent paper addressing this issue, University of Toronto researchers have suggested that the key to better health care for people in LTC homes might be to diagnose their problems virtually.

Using data from over 200,000 GTA-based hospital admissions over the last nine years, U of T and St. Michael’s College’s Li Ka Shing Institute researcher Dr. Fahad Razak and his colleagues modelled the resources that would be required to achieve a hypothetical elimination of potentially avoidable LTC-to-hospital transfers.

The upshot was not only a reduced risk of viral transmission during the pandemic, but also greater hospital resource availability for those who need it.

Razak spoke to The Varsity about the paper and the team’s findings.

The severity of the LTC home health care problem

While the population of older adults living in LTC homes has developed more complex needs over the last decades, a provincial strategy to keep up with these needs has stuttered, according to a policy briefing by the Royal Society of Canada.

In June, the society tasked an LTC working group with identifying specific problems and proposing solutions to address this.

The briefing described that LTC home workforce standards have not kept up with the growing needs of the population, and have even declined. Restructuring the workforce would require better governance to improve funding and direct it toward hiring, training, benefits, mental health care, and related areas.

The working group explained that the challenges we currently face include resistance to using existing evidence; an absence of data collection that could be used to monitor, compare, and learn from reforms; and a lack of courageous leadership. 

The value of virtual diagnosis

Razak and colleagues have designed one additional potential reform for health care in LTC homes — a method to reduce unnecessary hospitalizations and conserve resources for those who need them more.

Their methodology centred on analyzing existing hospital records for potentially avoidable LTC-hospital transfers. A potentially avoidable hospital transfer was defined as a presentation to the emergency department without admission, or an admission that lasted less than 72 hours — in other words, an almost direct trip from an LTC home to a hospital with no prior hospitalization.

They found that existing outpatient care services and a centralized virtual physician hub could be equipped to handle these potentially avoidable hospital visits. Using queuing models — “mathematical models used to study services such as call centres” — the team was able to “create a distribution of typical times LTC patients would be arriving.”

They found that two to three physicians at a centralized virtual hub could replace the efficiency of seven physicians at seven hospital sites.

Beyond their significance to pandemic planning, these findings are important in light of other hospitalization-associated harms to older adults in Canada, such as increased risk of suffering falls, delirium, and acquiring other respiratory infections.

Implementation with government programs

The study’s findings feed into the Ontario Health program, LTC+, that was designed to avert avoidable hospital transfers by directly connecting physicians at LTC homes with specialists and nurses. According to the researchers, “approximately 40-50% of calls from LTC centres to LTC+ program resulted in the resident not being transferred [to the hospital].”

However, scaling up the program to avert more avoidable hospital transfers will also depend on on-site resource availability, including human resources. Razak explained that personal support workers and nurses provide crucial care for the management of acute medical conditions.

“The program, when used, looks like it does work, but if it were scaled further or more heavily used, it would require more people to implement it,” he said. The current staffing shortage in the province was among the factors not addressed in their model. 

Improved staffing depends on good governance, funding, and the political will to use mounting evidence — all factors that the Royal Society’s LTC working group has identified to be currently absent in LTC home management in Ontario.

Editor’s Note (September 14): This article has been updated to correct the number of hospital admissions studied in the paper.