By Jessica Smith Cross and Sneh Duggal
Ontario must overhaul long-term care after the COVID-19 crisis is over to fix the “cracks and holes” in the system, said Premier Doug Ford Wednesday as he announced a short-term action plan to help the vulnerable residents of the care homes ravaged by the novel coronavirus.
“The system needs to be changed, it will be changed, and with consultation and collaboration with people from long-term care, seniors’ residences, and make sure that we have higher standards,” he said.
“This is a wake-up call to the world, not just Ontario but right across the country and around the world.”
Ford didn’t say what systemic changes he’s considering, but noted that 80 per cent of long-term care homes are government-funded and privately owned, and standards need to be raised. He framed the larger issue as one he was elected to fix as part of his ethos of reforming government to run more efficiently, informed by the practices of the private sector.
The premier didn’t commit to holding a public inquiry, but didn’t rule one out, and spoke about the need to inform the public where the cracks in the system are and what the government intends to do to fix them.
His comments came as he and Minister of Long-Term Care Merrilee Fullerton announced an action plan for long-term care, which includes temporary measures to get a handle on the escalating crisis.
As of Tuesday, there were 98 outbreaks in long-term care, and 144 associated deaths of residents, according to provincial data.
The province’s new action plan includes an aim to boost testing of symptomatic staff and residents in long-term care homes and those who have been in contact with someone with COVID-19. Fullerton said the government would also start testing asymptomatic individuals in select homes to try to get a better understanding of how the virus is spreading.
“It is heartbreaking when you realize it gets through our defences and that’s what happened,” said Fullerton. “It’s the asymptomatic spread and we know it’s coming from the community.”
Ford said “COVID-19 SWAT teams" with hospital, home and community care and public health personnel would be redeployed to homes to help manage outbreaks.
As for personal protective equipment, Ford said seniors’ homes would be entitled to “priority distribution” and that supplies would be sent to homes in need within 24 hours.
The government also said Ontario Health and public health units are creating regional teams to help homes with infection prevention and control, and that these teams would start to be sent to the “highest risk homes” within 48 hours.
The new action plan comes after the government issued an emergency order on Tuesday night that would ban long-term care workers from working in more than one facility, but the order doesn’t go into effect until April 22. This directive would enable long-term care workers to take unpaid leave from the additional sites they work at without losing their job. Fullerton said on Wednesday that this measure is temporary. The government encouraged homes to use emergency funding from the province to give part-time staff full-time hours to address staffing shortages.
Meanwhile, the federal government will be working with the provinces and territories to boost wages for essential workers — including those working in long-term care homes — who make less than $2,500 a month, Prime Minister Justin Trudeau announced on Wednesday morning.
Trudeau said he would discuss with premiers during a meeting scheduled for Thursday evening "the importance of getting this wage boost in place as quickly as possible."
"We all need to do better, we all need to take leadership for the seniors who’ve built this country," the prime minister said.
"For many workers looking after the most vulnerable Canadians, including seniors and those with disabilities, we know conditions have gotten more difficult over the past weeks and you need support right now."
Systemic changes
The premier isn’t alone for calling for systemic changes to long-term care.
For her part, Fullerton said work was underway to study staffing issues in long-term care, but that work was interrupted by the pandemic. That work was prompted by the Public Inquiry into the Safety and Security of Residents in the Long-term Care Homes System headed by Justice Eileen Gillese, prompted by the Elizabeth Wettlaufer serial killings. Gillese’s report highlighted staffing problems and called for increased funding to address them.
Kerry Bowman, a bioethicist with the University of Toronto, said the long-term care system needs “massive structural changes," something that has been clear at least since the SARS crisis 17 years ago.
He said there are a lot of good people working in long-term care homes and many good facilities, but there have been warning signs for years that the system was in trouble, including horrifying instances of abuse and neglect that have been covered in the media.
"There have been red flags, left, right and centre, and not occasionally, over and over and over," he said.
Funding has been cut to the bone, and the interplay between the public and private sectors, in terms of funding and operation of the homes, has resulted in the staffing problems that COVID-19 has accentuated.
"We have ignored these red flags for months and years and now we're paying the price for it," he said.
"I think the system is so broken it has to be essentially rebuilt," he said. "We can't simply look to plug a few holes and go back to the status quo, because the status quo is dangerous. From an ethical point of view, it's incredibly problematic."
Dr. Samir Sinha, director of geriatrics at Sinai Health System and the University Health Network, said that both long-term care homes and retirement homes have systemic vulnerabilities to infections that include housing older, frailer populations in close quarters.
The staffing issue that the government is seeking to curb with an emergency order — staff moving between multiple homes, and potentially bringing infections with them — was a vulnerability before the pandemic, and will remain one afterwards, according to Sinha.
More than two weeks ago, British Columbia announced its plan to tackle some of the same staffing problems Ontario has been suffering from, he said, essentially nationalizing nursing homes by taking over the staffing to ensure homes are properly staffed and workers stay with only one home, and standardizing pay across unionized and non-unionized workers, and public and private homes.
It comes after the province launched a similar plan for nationalizing home care contracts last year.
Sinha said whether or not Ontario should follow B.C.’s approach is a “political decision” for others to decide on, but he does think LTC workers need to be enabled to have full-time work and benefits on a permanent basis.
Sinha also pointed out that retirement homes see even more staff traffic, as residents rely not only on the care providers who work for the retirement homes themselves, but can also arrange for government-funded home care visits or hire their own support workers privately.
Ontario could reduce staff traffic in retirement homes by using the LHIN system to better organize which services providers work in which retirement homes, or by giving the homes the public funding that the LHIN would have paid other services providers, and then letting the homes organize care for their residents, he said.
Both Bowman and Sinha pointed to ageism for why action to protect vulnerable seniors wasn’t taken earlier.
"We have been talking for months now about the reason we all have to do physical distancing and make the sacrifices we're making is to protect vulnerable people within our society, but you know what — we have failed in living colour on this," Bowman said. "These are still early days in terms of the outcomes in long-term care and retirement care, and a lot of people may lose their lives."
That failure, according to Bowman, is a collective one society-wide.
"Ageism is the kind of prejudice in Canada we just do not talk about and it is so powerful,” he said. “If these were sports teams, if these were children, if these were anybody other than elderly people we would never under-react like this. It really shows how deep the prejudice is."
Speaking on a recent episode of the Santis Health podcast — From the Burgundy Chairs — Sinha said there's been a "whole spectrum" of reactions to the COVID-19 crisis both from seniors themselves and others.
He referred to some of the "sad reactions" that are occurring, such as "intergenerational tensions" seen through hashtags like #BoomerRemover on Twitter.
Sinha said "unnecessary deaths" were happening in the sector because he didn't think officials were "applying the best evidence."
"I feel that somehow it’s our ageist views or our views that some lives are more important than others that may be even shaping a level of inaction to a certain extent as well," he argued, adding that society has allowed systemic vulnerabilities to occur in the sector.
"We haven’t really ever valued as much as we should this sector, the people who live in it, because they’re hidden, they're towards the end of life, they’re not the movers and shakers in our society anymore," Sinha said, recounting comments he's heard from people as evidence of this type of thinking.
"Someone told me the other day...'this is a terminal admission, people go into these homes and they’re closer to death than anybody else, so if COVID-19 rips through, isn’t that OK?'" Sinha said. "It’s almost this kind of really weird and sad kind of statement that almost those ideas are a bit permissible. That really we’d never have these ideas about a young child because their whole life would be stolen, but is it so bad if this sector has a number of deaths? We have capacity issues anyways. You just start seeing really really weird reactions."
Political and stakeholder reaction
Shortly before the premier's announcement on Wednesday, Liberal Leader Steven Del Duca blamed the Ford government for being "asleep at the switch when it comes to protecting Ontario's seniors."
Referring to a CBC investigation that revealed only nine long-term care homes were subject to comprehensive "resident quality inspections" last year, Del Duca called it "absolutely astounding."
He called on the government to change testing guidelines so "all staff and residents can be tested" and for the government to "invest in the regular comprehensive testing" of seniors' homes.
But the NDP lashed out at Del Duca, saying his statements were "15 years too late" and that the previous Liberal government left the province "poorly prepared for a pandemic."
For her part, NDP Leader Andrea Horwath said the government’s emergency order comes too late and has two “loopholes” — it doesn’t apply to temp agency workers and it doesn’t take effect until April 22.
“Restrictions much tighter than these should have been put in place weeks ago,” she said in a statement. “We cannot waste a second now, and we cannot allow this government to leave huge loopholes open. The government has to fix the problem years of underfunding and neglect in long-term care has created: pay workers decently, give them full-time hours, and ban them from working at a second facility, no exceptions.”
Green Leader Mike Schreiner also called on the government to move more quickly, and to deploy emergency funds to help homes comply with the order more quickly.
“Government investment in long-term care homes has been lacking for years, so it is not fair to blame the current government entirely for this heartbreaking situation. But this government is responsible for how it responds to the COVID-19 crisis today,” he said in a statement. “Ontario cannot wait another week to act.”
At a media briefing Wednesday afternoon, Chief Medical Officer of Health Dr. David Williams said the timeline wasn’t made tighter because ordering a sudden change would have made the staffing shortages that already exist worse.
He said the order wasn't made sooner because of concerns about “labour law, contracts, and various things,” and he wasn’t privy to those conversations.
Meanwhile, the Ontario Long-Term Care Association welcomed the province’s announcement.
“Ontario’s long-term care homes are at the forefront of the fight against COVID-19, and the provincial government's action plan is another meaningful step to protect our most vulnerable when they need it most,” it said in a statement. “Premier Ford, Minister Fullerton and the Ontario Cabinet have responded quickly from the start, and today’s announcement means increased infection control and prevention measures and resources to ensure resident and staff health and safety continues to be the top priority as the pandemic evolves.”
Meanwhile, the Ontario Hospital Association welcomed the move to deploy hospital staff to help long-term care homes.
Our statement about Ontario hospitals reinforcing long term care and retirement homes to assist their resilient and committed staff & help care for residents and keep them safe during the fight against COVID-19 #onhealth #onpoli #canpoli @OLTCAnews @AdvantAgeOnt https://t.co/FrvuqEw2AN
— Anthony Dale (@AnthonyDaleOHA) April 15, 2020
"Unfortunately, at present the devastating brunt of COVID-19 is being felt in long-term care, retirement homes, and other congregate settings like shelters and community living homes," said president and CEO Anthony Dale. "Even as Ontario nears its peak among the general population, mortality rates are climbing rapidly in these settings, according to modelling by epidemiologist David N. Fisman."
Fisman, an epidemiologist with the Dalla Lana School of Public Health, said on Twitter that research conducted by him and his colleagues, not yet peer reviewed, indicates the incidence of death among long-term care residents in Ontario has taken off during the pandemic, compared to seniors living in the community.
This is figure is from a paper just submitted to CMAJ, but I think it's important for people to see this.
The green curve is incidence of death in LTC by date in Ontario, the pink is death in community living elderly (age > 69). Shaded areas are confidence imits. pic.twitter.com/cLBJdvpRHs
— David Fisman (@DFisman) April 15, 2020
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