Canada: Socialized medicine. Hockey. Snow. More hockey. Maple syrup. Stable. Wealthy. Caring. The polite people who live next door.
When the world thinks of Canada, these might be the images that come to mind. However, these images were vastly changed when COVID-19 ravaged nursing homes in two of Canada’s most populous provinces, Ontario and Quebec, and the Canadian military was called in to provide care services to 29 long-term care facilities. What the Canadian military found in those LTC homes – residents who hadn’t been fed for days, filthy and crying out for help -- horrified even seasoned veterans, who in some cases said it was worse than what they had seen on battlefields.
COVID-19 hit Canada in mid-March and it has taken four months to significantly flatten the curve across the country. As a nation, we are looking with great worry at a second wave expected in the fall. As seniors’ advocates, we are trying to understand an oft-quoted “new normal,” which means living with COVID19, rather than trying to avoid or defeat it.
LTC is part of Canada’s socialized health care system, but not in a straightforward way. When the original governing legislation for the publicly funded health insurance, the Canada Health Act[1] was passed in 1984, LTC did not substantively exist in the format we think of now.[2] With the average age of death at 76 years, much of the end-of-life “nursing” care was provided at home, or if necessary in an extended-care hospitalized setting.[3] Simply put, the founders of Canada’s publicly funded health insurance never imagined the additional decades of longevity, the degree of frailty of the oldest old, nor the need to include LTC as we now think of it into the Canada Health Act.
What this translates to is a very different experience for users of Canadian hospitals or medical services compared to users of Canadian LTC. In Canada, all that one is required to do to receive hospital or medical services is to show one’s provincial health card. While there may be some quite modest charges for assistive devices like crutches or costs for ambulance transfers, and some procedures may be elective and not covered by universal health care, on the whole, Canadians generally go to publicly funded hospitals or doctors’ offices, receive publicly funded health care services and return home without thinking twice about it, and none the poorer.
However, without this truly universal health care coverage for LTC, Canadians receive LTC from a mix of not-for-profit and municipal (local government) organizations or for-profit companies, including smaller family-run homes as well as large well-known companies.
Funding Models
While the exact funding model varies from province to province[4], generally the resident pays a daily housing rate (often $60-90), which is based on a calculation of the age and services of the building and the type of room (four-room, two-room or single occupancy). Subsidies are available from the provincial government. No one will be denied LTC based on an ability to pay nor can a person be evicted for non-payment of fees. The government transfers a pot of funding to provide for the “nursing” part of the nursing home budget, which covers everything that is not part of the “housing” component. This is the same regardless of the ownership (non-profit, municipal or for-profit) of the home. Financial profits are supposed to be realized through additional services not covered in the socialized LTC model.
Ontario's LTC situation (February 2019)[5]
- 626 homes are licensed and approved to operate in Ontario
- 58% of homes are privately owned, 24% are non-profit/charitable, 16% are municipal
- About 40% of homes have 96 or fewer beds
- About 300 homes need to be redeveloped to meet safety codes or other structural improvements (more than 30,000 beds)
- The average time to placement is 161 days
The wait list for long-stay beds, as of February 2019, was 34,834. While people are waiting for LTC home beds, they are often caught in a limbo – either waiting in acute care hospital beds, causing them to be known as “bed blockers,” or they are waiting at home with home care services, which do not adequately meet their needs.
Ontario has created a new category of people waiting for LTC home beds, known as “Alternative levels of Care” (ALC). Seniors who are ALC are often housed in otherwise unused hospital wings, sometimes in retirement homes or wherever there is space in the system.
Outbreak in British Columbia
British Columbia’s Provincial Health Officer Dr. Bonnie Henry declared an outbreak of COVID-19 in early March in North Vancouver, British Columbia (BC), on Canada’s Pacific Coast. By late March 8, the first LTC resident died. Within 14 days, seven more residents died, and 36 residents and 18 health care workers tested positive.
In what would become a model for proactive response, the province of British Columbia under Dr. Henry’s leadership took several immediate steps: She stopped all visits to LTC homes, enacted a requirement that staff only work at a single health care location, transferred funds to top up salaries to allow LTC facilities to turn multi-site part-time workers into single-site full time employees, created a direct telephone phone line for personal protective equipment (PPE) to get to LTC homes and prioritized PPE and testing to both LTC and acute care settings. This became the formula for a successful response in LTC and flattened the very dangerous curve. Unfortunately, this BC response model was not replicated across the country. As each province has its own health system and provincial health officer, as well as its own government and approach, a patchwork of responses led to a lack of coordinated response.
Cause for Alarm
Advocates quickly turned to the largest provinces, Ontario and Quebec, and began raising the alarm bell to an even greater degree. Reliable, accurate information was sorely lacking in Ontario and Quebec and so were the policy responses. Outbreaks in these provinces started quickly and only got exponentially worse. Provincial responses varied[6]. Unsurprisingly, where early action was taken, the COVID19 virus was better managed.
Advocates at CanAge[7], the Advocacy Centre for the Elderly[8], the National Initiative for Care of the Elderly, the National Institute on Ageing[9] and others emerged as leaders in this public health crisis and began creating downloadable tools to help people decide whether to remove a loved one from LTC[10]. Helpful trackers were created by the Toronto Star[11] and think tanks also created trackers for deaths, infection rates, locations and spread.[12]
Commissions have already been announced into LTC in the near future for Ontario and Quebec. In Ontario alone, there are four types of commissions or investigations announced. The federal government has so far stopped short of announcing a commission or inquiry but has indicated several times during daily briefings by the Prime Minister Justin Trudeau that answers would be sought. There is hope that the findings of the various commissions will lead to substantive change and a sense that Canada has reached a watershed moment in its LTC system. However, advocates and experts in the sector are consistently reminding government that the solutions to LTC in Canada are well known, and that there is no need to wait to implement changes such as staffing, funding transfers and investments in the physical structures of LTC buildings.
Ontario and Quebec LTC facilities did close for visitors at the beginning of the outbreak but few of the other steps modeled by BC were taken. For instance, the Ontario Chief Medical Officer of Health, David Williams, continually refused to prioritize PPE or testing in LTC homes in Ontario despite escalating pleas from advocates, families and seniors. Indeed, it was not until Ontario Premier Doug Ford announced that a new “COVID-19 Action Plan”[13] effective April 22 that steps by BC would be implemented in Ontario LTC homes, including:
- Enhancing testing for symptomatic residents, staff and those exposed to COVID-19; expanding screening of asymptomatic contacts; and leveraging surveillance tools to enable care providers to move proactively against the disease
- Supporting LTC homes with public health and infection control expertise; providing training and support for staff working in outbreak conditions
- Redeploying staff from hospitals and home and community care to support the LTC workforce and respond to outbreaks, along with ongoing recruitment initiatives
Within less than 48 hours, the government announced it would also immediately act to deliver the same or similar measures. The reality of this plan was starkly different from the ambitious tone and goals stated above. In fact, testing remained far less than required or promised, PPE did not get deployed efficiently, and staff recruiting measures remained subpar.
Ontario and Quebec: Bad to Worse
With the spread of COVID-19 out of control in Quebec’s LTC homes, the Premier of Quebec François Legault took the unprecedented step of calling on Prime Minister Trudeau to send military troops to work in their worst-hit homes on April 22. Ontario followed suit the same day. More than 1,000 members of the Canadian Armed forces were sent into the worst-hit homes.
The military was so appalled at the conditions in those homes that they sent a whistleblower report to the federal government, first for Ontario[14] on May 20, and then for Quebec shortly after. The Ontario report was particularly horrific, detailing cases in which residents hadn’t been fed or bathed and were crying out for help. One resident was forced-fed, choked and died. Cases of cockroach infestations, poor hygiene, people being left in their own feces for hours or days were also detailed.[15] Prime Minister Trudeau, visibly shaken during his daily briefing, called the report deeply disturbing and said, “We need to do a better job of supporting our seniors in LTC right across the country, through this pandemic and beyond.”[16]
Canada vs OECD Countries
The Canadian Institute for Health Information (CIHI) is the key organization in Canada for reliable non-partisan health information. In a recent report it found that as of May 25, only about 18 percent of cases of COVID-19 were in LTC homes but accounted for about 81 percent of all measured fatalities[17]. The study found that while Canada’s overall COVID-19 death rate was fairly low compared with other Organization for Economic Cooperation and Development (OECD) countries, it had the highest proportion of deaths occurring in LTC[18]. Indeed, Canada at 81 percent was nearly twice the rate of LTC deaths to the average OECD country[19].
Perhaps because of its very large geographic size (9.9 million square kilometres or 3.8 million square miles), the CIHI snapshot’s finding that variation amongst Canada’s provinces and territories was greater than variation among OECD countries should not be completely surprising. Indeed, as of May 25, Newfoundland and Labrador, Prince Edward Island, New Brunswick and the territories had no reported deaths in retirement homes or LTC facilities. By contrast, LTC home deaths accounted for 70 percent of all COVID-19 deaths in Quebec, Ontario and Alberta and 97 percent of all deaths in Nova Scotia.
Indeed, Canada at 81 percent was nearly twice the rate of LTC deaths to the average OECD country. As of June 30, most LTC homes in Canada remained substantively closed to visitors. Alberta began instituting outdoor visits earlier than most provinces, followed by Quebec. Ontario finally allowed some outdoor visits on June 18[20]. This required visitors to be subject to strict health and safety protocols, including passing screenings at each visit, confirming they’ve tested negative for COVID-19 within the previous two weeks, and complying with infection prevention and control protocols (including wearing a face covering during visits). Additionally, LTC and retirement homes, as well as other residential care settings, must meet the following conditions before they welcome visitors:
- Homes must not be in outbreak
- Homes must have an established process for communicating visitor protocol and safety procedures
- Homes must maintain the highest infection prevention and control standards.
Indoor visits to LTC homes in Ontario were promised a week after the state of emergency was lifted. For many families who have not seen their loved one, that feels like a time with no end in sight.
Some called for a more standardized “Essential Caregivers Program” for LTC in which designated family or friends could be identified as part of the resident’s essential care team, provided with training and then given an identification badge. This type of caregiver would be then allowed inside an LTC home, possibly even if the home was in outbreak. Staff would then assist with donning and doffing the PPE required and to oversee infection control.
During the time of COVID-19, there have been significant calls for an end to the for-profit model. Officials are now discussing if Canada should include LTC services in its Canada Health Act, which would end all private ownership of LTC in Canada. It is a very appealing argument and currently very popular[21]. However, right now, approximately 50 percent of all LTC home spaces are provided by for-profit homes, and with a shortage of beds, it seems unclear how moving to shut the for-profit model would affect those spaces.
Dr. Pat Armstrong, a leading expert in LTC in Ontario, suggested that the Canada Health Act could continue to oversee universal health care in its current state. A new parallel piece of legislation might be drafted, which would cover LTC and include it in universal health care, without triggering a constitutional amendment and possible constitutional crisis. Provinces rarely, if ever, voluntarily cede power to the federal government, which is what it would take to include LTC in federal purview. However, just the fact that the provincial and federal government are even in discussions about opening up a constitutional amendment is nearly unprecedented and speaks to the severity of the impact that COVID-19 has had both on the LTC population, but also the psyche of the Canadian public.
Prime Minister Trudeau pledged to work with the provinces to bring in national standards and extra funding but made clear that provincial governments are directly responsible for nursing homes. He said, “This pandemic has shown from the beginning that the job isn’t being adequately done.”[22]
Standards and Regulation
Calls are being considered by all levels of government to have national quality standards for LTC, which do not exist by agreement or any form of legislation. Currently, it is up to each province to implement such legislation. In thinking about whether Canada should have standards and what those standards should entail, the Australian model is being closely considered as it is a country with a similar division of governmental powers and a similar mix of public and private-funded LTC facilities. Key aspects of that model include not only national standards, but also a national oversight body with the ability to regulate, license, fine or take over management of a non-compliant home.
It is expected that any such standards would include staffing ratios; professional staffing mixes; training standards for each level of staffing; medication protocols; building standards, including mostly single rooms with private bathrooms; heating and cooling requirements; inspections; disaster response; abuse prevention and reporting; infection control; vaccine distribution and uptake; dementia training and associated resources.
Fixing LTC in Canada has become an urgent issue. While governmental commissions and inquiries and ombudsman reviews are starting up soon, it is important to remember that we do not need to wait to take needed steps. The recipe for improvement for LTC is clear.
Fix Funding. It is painfully clear that the provinces cannot, or will not, fund the perpetually cash-starved LTC sector. Dedicate and transfer appropriate federal funds to the provinces for delivery of LTC home services but have those federal funds tied to meeting national quality standards. Create a federal LTC Home Regulatory Authority and tie funding and licensing to this body; work closely with the provincial governments to ensure support.
Fix Staffing. Improve wages, benefits and create pensions. Pay the same level of staffing the same amount no matter if they work in hospital, home care or LTC. Provide full-time, single-site jobs. Create incentives to enter the field such as educational grants. Add geriatric care expertise to Canadian immigration priorities to attract newcomers with this needed skill set. Put doctors and add registered nurses back into LTC facilities. Increase the number of skilled professional staffing ratios by inverting the current trend of downshifting medical care to often inconsistently trained, poorly paid personal support workers and aides. Train all medical professionals with mandatory geriatric training and placements. Give staff paid sick days and ensure they do not come to work sick. Train and certify essential caregivers as key, albeit unpaid, part of the care team.
Fix Buildings. Make needed upgrades to facilities. In Ontario alone, we stand to lose 30,000 of about 78,000 LTC beds because they will not pass fire safety standards in five years. Create dedicated “swing space” for residents to live in while their original rooms are being upgraded. Eliminate multi-person ward rooms and shared bathing facilities. Upgrade HVAC systems and install air conditioning in all resident rooms.
Fix Infection Control. Ensure that all residents are vaccinated for flu, shingles, pneumonia, under Canadian National Advisory Committee on Immunization (NACI) recommendations. Revamp Canada’s vaccine approval, purchase and distribution systems and test them by integrating the vaccines we already have that are proven effective, so that we can have a system in time for a much-hoped-for COVID-19 vaccine. Create effective supply chain management and integrated data systems for procurement of PPE and needed supplies, using the Alberta model[23].
Fix the Institutional Model. No one wants to be in a large institution. Move away from the medical, institutional model to an emotion-focused model, such as the Butterfly Model, the Eden Alternative, the Green House model and others. Adopting one of these transformative models of care makes residents and staff happier and safer, while also creating person-centred supports for aging.
LTC homes in Canada can get better. We know what needs to be done. We simply have to do it. And with most of Canada’s LTC homes still in isolation and a second wave of COVID-19 possibly around the corner, we had better start right away.