Ontario long-term care homes with worst outbreaks don't meet modern design standards

The Ontario long-term care homes hardest hit by COVID-19 are old facilities that haven't been renovated to modern standards, with residents still living in tighter quarters in multi-bed wards.

And according to one of the province's foremost experts in infectious diseases, it's just one way society has "screwed up" and systemically undervalued the care it gives older people and other marginalized Ontarians.

News reports have turned some of the homes where the gravest tragedies have occurred into household names — Pinecrest, Eatonville, Anson Place, Seven Oaks, and Altamonte. And after 43 deaths were announced there over the weekend, Orchard Villa joins the list. Each of these homes is licensed by the province for "C" beds, which means they meet, but don't substantially exceed, design standards set by the province 48 years ago.

That means some of their rooms are three- and four-bed wards, which are no longer allowed to be built. The standards set in the 1970s required less usable floor space per resident and only a toilet and sink per every fourth resident, instead of the ensuite bathrooms in each of the larger private and two-bed rooms required by the province today. A briefing deck created by the province also describes the older homes as more "institution-like" than the modern "home-like" plans.

According to analysis by QP Briefing, the homes where the virus has spread most effectively and where the most deaths have occurred are disproportionately homes with C beds. Of the 10 homes where the most residents have died, nine are licensed for C beds. Of the 10 homes where the virus has infected or killed 70 per cent or more of the residents so far, eight are licensed for C beds.

According to the Ontario Long-Term Care Association (OLTCA), 219 homes — a little over one out of every three LTC homes in Ontario — currently have C beds, and another 56 homes have mixed classifications.

The province launched a capital renewal program a decade ago, but it didn't see the expected uptake. It was relaunched in 2014, with the goal of renewing 30,000 beds by 2025. In a recent interview, OLTCA CEO Donna Duncan told QP Briefing the province's program for capital upgrades remains "unworkable" and underfunded, and her organization has been calling for changes that would see homes built and staffed according to the needs of the residents.

On Monday, Associate Chief Medical Officer Barbara Yaffe said the long-term care homes' physical designs can be a contributing factor to the severity of outbreaks among the vulnerable population, among others, because they can mean people live in close proximity to one another.

"I think that (at) the end of this situation there will be an opportunity to review what happened, what contributed to it, and what can be done to improve the situation," she said.

Yaffe's opinion on long-term care infrastructure is shared by one of the province's foremost experts in infectious disease, but Dr. Allison McGeer said it's just one way society systemically undervalues the care it gives older people and other marginalized Ontarians.

McGeer, director of the Infectious Diseases Epidemiology Research Unit at Mount Sinai Hospital and professor at the University of Toronto’s Dalla Lana School of Public Health and faculty of medicine, said long-term care homes' physical structures are likely contributing to the worst outbreaks.

While there's not yet enough data to determine if widespread COVID-19 transmission within a home is related to its age and design standard, she said, it is well-understood that communicable diseases spread more when people are living in close quarters, including multi-bed wards.

She offered two scenarios that illustrate how the transmission of the virus could be different based on the physical design of the building. In the first, an infected person meets four patients in larger private rooms and perhaps only comes into close contact with one resident, spreading the virus to that single person. In another case, that person visits four patients, each in small four-bed ward rooms, and comes into close enough contact with all of the residents in each room to spread the virus to that wider group.

The coronavirus has been able spread in long-term care before homes have been able to take measures to stop it because of two problems in recognizing it, she said.

"Older adults in long-term care tend to get this virus and carry it for a while before they get obviously ill with it and when they do get ill with it, they don't necessarily present with fever and cough, and that's what people tend to look for," she said. "Problem number two is that it took us some time to recognize that younger healthier adults have either no symptoms or very mild symptoms, so we also have circumstances where staff working in these homes have the infection and they didn't know it, and nobody else knew it."

She pointed out that the problems with aging facilities are are difficult to solve quickly. "I don't think we can upgrade long-term care homes in the middle of a pandemic effectively," she said. "We just screwed it up...and we're going to have to live with it."

McGeer also said the physical structure of long-term care homes isn't the biggest problem in the system, adding, "It's how we value care for the elderly."

"We have systematically underfunded it," she said. "It's not part of our public health system or our health system. We have made old, small, crowded buildings. We have not adequately educated and trained people. We don't pay people adequately to take care of those residents...We don't provide them with supplies to do it. You know, start to finish."

McGeer said she's pessimistic that the fundamental problem underlying the pandemic will change.

"Aside from cruise ships, it is systematically picking off the most vulnerable in our society," she said. "Whether it is long-term care facilities, people in homeless shelters, and I'm sure before we get to the end of it we will have seen it in Indigenous communities."

"I'm sure, if we get the data, people who are poor and people who are racialized, are likely to suffer more from this than the rest of us and I'm not sure we're going to come out of this building a more just and equal society, which is what, in my view, we need to be doing."

"I'd like us all to change," she continued, "but I don't think it is going to happen."

(Photo by Richard Lautens/Toronto Star)