A wealth of data shows that long-term care (LTC) home residents have been hit the hardest by the pandemic.
Researchers at Ryerson University have been collecting data on the outbreaks in LTC homes. According to them, over the past year, LTC residents have borne the majority of the death count in seven provinces. In Ontario alone, 63 per cent of the 7,056 COVID-19-related deaths were LTC residents. At a national level, that figure rises to 67 per cent.
This terrible loss of life is occurring amidst a growing awareness of the systemic neglect happening in LTC homes. Last spring, a military report found that five of the worst-hit Ontario LTC homes left their residents uncared for in conditions that Prime Minister Justin Trudeau called “deeply disturbing.” Experts have variously described the state of COVID-19 in LTC homes as a “crisis” and as an emergency requiring serious policy changes.
In January, the Science Table of Ontario, a group of experts who evaluate and report on evidence related to the pandemic, released a brief summarizing the LTC situation and made recommendations for new government policies.
We are master’s of public health (MPH) students at the Dalla Lana School of Public Health and members of the Infectious Disease Working Group, a coalition of MPH graduates and students working to explain the research into COVID-19. We want to use our expertise to explain both the timeline of the LTC crisis and the Science Table recommendations, as we believe scientific expertise is essential to the reform of LTC homes.
A timeline of the LTC home outbreaks
Epidemiological studies published by scientists in Wuhan, China as early as March last year identified that older COVID-19 patients in hospital intensive care units are at a higher risk of dying. In Ontario, in the same month, physicians who had served during the 2003 SARS outbreak sounded the alarm, warning the government that LTC homes would need special attention during the pandemic.
Soon after, epidemiologists based at the University of Toronto began to study COVID-19 outbreaks at LTC homes to identify the disease’s risk factors — factors that predispose groups of people to a greater likelihood of unfavourable outcomes, which include the risk of outbreak and, for some individuals, death.
Using data from March and April 2020, U of T epidemiologist David Fisman and colleagues verified that death after a positive test for COVID-19 occurred more frequently among LTC home residents than among community-dwelling older adults over the age of 69 during a similar period.
They found that lagged infections among staff were associated with death among residents — a finding that supported the hypothesis that residents were being infected through staff members. On this basis, they recommended more widespread testing and the provision of personal protective equipment for staff members. They also recommended that staff members be restricted to working at a single facility.
On April 22, the provincial government issued a public order to restrict some LTC home employees to one facility within any two-week period.
How outbreaks differ between private and for-profit LTC homes
A team led by geriatrician and U of T PhD student Dr. Nathan Stall considered whether the for-profit, nonprofit, or municipal — government-run — home status of an LTC home affected the likelihood of an outbreak occurring. Furthermore, the team aimed to find out whether the LTC home status of where an outbreak had already occurred impacted the number of residents who were infected or who passed away from the virus.
After examining 623 Ontario homes, over half of which were for-profit, Stall and his team found that the status of a home was not associated with the likelihood that it would experience a COVID-19 outbreak. However, outbreaks that occurred in for-profit homes were more likely to infect more residents and see more deaths than outbreaks in non-profit and municipal homes.
By controlling for other variables in additional models, they found that the difference was explained by many for-profit homes’ older design standards, which allow for smaller rooms and more crowded common spaces.
Stall and his team also found that outbreak occurrence was associated with the incidence of COVID-19 in the home’s public health unit region. Each additional case per 1,000 individuals in the region nearly doubled the odds of outbreak in the home. This finding and others highlight the need for targeted approaches and funding to help at-risk communities battle high incidence rates.
U of T epidemiologist Kevin Brown led a second study on the correlation between care home crowding and infection, which also found that the incidence of both infection and mortality were significantly higher in more crowded LTC homes as of May 20 last year. The study’s simulation showed that 271 deaths might have been avoided before that date if quadruple-bedded rooms had been replaced with double-bedded rooms.
In the following month, the province prevented new admissions into rooms already occupied by three or more residents. By October 2020, the maximum was reduced to two residents per room.
Recommendations from the Science Table
Given the clear connection between crowding and infection, the Science Table researchers recommended that temporary spaces continue to be built to make homes less crowded, and that Infection Prevention and Control guidelines be further enhanced.
They also recommended that the LTC home sector offer more full-time jobs with fair pay and benefits, including paid sick leave, to counter infectious spread because some employees were unable to afford taking time off when sick.
The researchers highlighted the importance of government commitment to making data available so that research can continue to inform policy.
They also noted that policies should consider a more nuanced approach that accommodates outdoor walks and visitation to support residents’ mental health.
A similar consensus arose last June from a report issued by the Royal Society of Canada, which explained that the current situation was not uniquely caused by COVID-19. According to its report, the pandemic should instead be seen as simply another event that reveals the state of LTC in Canada.
It explains that neglect on a systemic scale — neglect of the consequences of population trends in aging, of staffing and management standards, and of financing and data needs — meant our elders in care have been in crisis, albeit less visibly, for years.
In the last 10 years, researchers have published over 150 reports detailing older Canadians’ negative experiences in LTC homes. Differences in the standards of care maintained by for-profit and nonprofit homes have also been studied for years by health policy researchers. Evidence from epidemiological and other studies in non-crisis times seems not to have averted the current situation.
Solving the workforce crisis is identified as the solution in this report, which also reiterates calls for full-time employment, adequate pay, and sick leave for unregulated workers. Unregulated workers provide over 90 per cent of direct care and are paid the lowest wages in the health care sector.
The federal government is urged to “act on a… data-based assessment of national standards for necessary staffing,” and the provincial and territorial governments are tasked with “[establishing] minimum education standards” and continuing training for the unregulated direct care workforce.
These recommendations all indicate that long-term change will require transparent data collection, the development of further standards, and workforce reform to address some of the root causes of the crisis in LTC homes.