How Ontario's plan to stop nursing home staff from spreading COVID-19 falls short of B.C.'s

Both Ontario and British Columbia have recognized that care home workers employed at more than one site are vectors for spreading COVID-19 to vulnerable populations. But as the number of deaths in these homes has climbed, only one province moved quickly to shut the practice down.

This week, Ontario issued emergency orders to long-term care and retirement homes that staff must only work in one home, but they won't come into effect until next week. And they include one big loophole: they don't apply to agency staff, the workers who go from home to home, plugging holes in their schedules.

Meanwhile, staff movement was restricted in B.C.'s lower mainland about three weeks ago, and the rest of the province last week, covering its care homes, both privately and publicly funded, B.C. Seniors Advocate Isobel Mackenzie told QP Briefing in an interview this week.

The West Coast province moved quickly after it was home to the first COVID-19 outbreak in a Canadian care home, said Mackenzie. The first death occurred at the Lynn Valley Care Centre on March 8, and 20 people have died there.

"We discovered that we had focussed on restricting visitors, but in fact, the vector of transmission into Lynn Valley had been a care staff person who also worked in other care homes, and that's when we realized that this is a problem, we've got to restrict them to one site," said Mackenzie.

The root of the problem in both provinces is homes have been keeping their staffing costs lower by scheduling workers on part-time hours, leading them to cobble together employment from multiple venues. Suddenly ordering employees to work in only one home would aggravate staffing shortages, especially at homes where workers were paid less, said Mackenzie.

B.C. solved that problem by centralizing the organization of staffing and mandating that all workers be paid at a set wage, bringing poorer paid workers up to the standard in publicly operated care homes, with the province paying the balance at an estimated cost of $10 million a month. The province took those steps relatively quickly after Provincial Health Officer Dr. Bonnie Henry issued an order in late March allowing each of the province's five geographical health authorities to require that care home workers work at only one site.

"Her order effectively achieves a unified workforce at a unified wage rate, under her direction," said Mackenzie.

Ontario is taking neither of those steps — it isn't setting wages and it isn't centrally organizing staffing. At a media event Thursday, Minister of Long-Term Care Merrillee Fullerton was asked why Ontario wasn't going as far as B.C., and she replied that the risk of staffing shortages is why Ontario waited to order the staffing restriction, recommended by Ontario's chief medical officer of health four weeks ago, and why agency staff are exempted.

"In the context of a pandemic where staff may have to self-isolate, we needed a group that could be able to provide the safety for our residents in long-term care through shoring up the capacity of staffing and that's why the agency workers were not included," Fullerton said.

Mackenzie pointed out B.C. has two advantages Ontario doesn't that allowed it to move quickly — and are hard to acquire in short order in a pandemic. The organization leading the redeployment of workers to homes is the Health Employers Association of British Columbia, a group that coordinates employers' human resource and labour relations interests across the province's health-care sector and doesn't have an equivalent in Ontario.

Secondly, B.C.'s care aides — similar to personal support workers in Ontario — are registered, so it was easier to get a handle on the workforce that was available, said Mackenzie. In Ontario, personal support workers aren't registered, although that's something the voluntary Ontario Personal Support Workers Association has been calling for for years.

The lack of a centralized body to organize staffing makes it much harder for Ontario to ensure that the emergency order doesn't aggravate the existing staffing shortages, and to ensure compliance with the order, Mackenzie said.

"You can do this in a way that you don't create any greater staffing challenge than you already have, but in order to achieve that, somebody's got to have the big picture, moving the parts around the chessboard, to make sure every worker is working the same number of hours they were before, they're working in one spot, and every care home has the number of (full-time equivalents) they had before," she said. "You can make it work but you can't do it without [an] oversight body."

Ontario is taking steps to alleviate those concerns, announcing Friday morning that municipalities and local District Social Service Administration Boards will be empowered to reassign staff within their jurisdictions. It issued another order to Local Health Integration Networks, allowing them to direct home-care staff — largely personal support workers — to work in long-term care homes.

And importantly, it issued another new emergency order mandating that privately owned and run retirement homes must also restrict staff to one location. Those homes had been omitted from the order pertaining to government-funded long-term care homes issued earlier in the week, even though retirement homes also house a vulnerable seniors population, are experiencing outbreaks, and share many of the same staff that work in long-term care homes.

Overall, the staffing stop-gap Ontario is relying on — letting agency workers continue to move between nursing homes — is a concern to Mackenzie.

"I think the exemption for agency workers is a bit of a gap because you have not achieved what you're trying to achieve," she said. "But I can see their difficulty, because there's got to be a central body, essentially, deploying the workforce to make sure that every care home gets an appropriate level of staff."

Ontario is also not topping up wages for workers. B.C. took that move as a measure of fairness for workers who used to be working at multiple sites at different rates and are now restricted to one.

"The province has taken the approach that they had to do this and they had to do it fast, they didn't want to be bogged down in squabbles with operators for who is going to pay the bill," said Mackenzie, adding that the order also applies to totally private care homes.

Mackenzie said there is a debate on whether the changes should be made permanent in B.C. In part, that debate was already underway. Her office issued a report before the pandemic that looked at how provincial money paid to many privately operated care homes for staffing wasn't actually going toward paying staff. Secondly, she expects it will be hard for care aids who worked multiple jobs in lower-paying homes to accept a wage decrease.

Dr. Samir Sinha, director of geriatrics at Sinai Health System and the University Health Network, told QP Briefing that staff working at multiple homes was a vulnerability before the pandemic, and will remain one afterwards. He also noted that B.C. has COVID-19 in less than ten per cent of its long-term care homes.

In Ontario, that figure is about one in six.

"Right now as more and more homes go into outbreak every single day, my only concern is, will homes have the bandwidth and the capacity to make the arrangements they need so we can effectively limit the introduction and spread of COVID-19," said Sinha. "My only concern is that maybe a week from now, we truly haven't been able to limit staff movement between homes, which would remain then a vulnerability for COVID-19 to be spread between homes and get into homes as well."

Back in Ontario, the NDP has called on the government Thursday to "follow British Columbia’s lead in developing criteria for when Public Health will take over management of individual long-term care homes and other group housing for vulnerable people," which is something B.C. did prior to the pandemic with a problematic chain of group homes controlled by the Chinese government. Ontario has similar legal power to order long-term care homes to hire external management and has done so with homes in crisis, but those powers have not been used in relation to the staffing problems posed by the pandemic. The NDP also noted B.C. "took over control of staffing at some care homes" but did not call on Ontario do to the same.