The COVID-19 pandemic had a devastating impact on long-term care institutions in Quebec. More than nine per cent of the residents of the centres d’hébergement et de soins de longue durée (CHSLDs) died from this – a significantly higher percentage than elsewhere in Canada and in the world. Well before the pandemic, long-term care institutions in Quebec had been neglected. They faced the loss of their own governance and management; a shortage in medical staffing, nurses and attendants; and dilapidated premises. At the onset of the pandemic, these institutions were forgotten, with an absence of protocols to prevent and control infections and the continuation of staff mobility practices that led to further spread of the disease. Urgent corrective measures must be adopted but, above all, there must be a comprehensive reform of these institutions. The current priority for institutional solutions for these people must be reassessed in favour of home support services.
In the first wave of the COVID-19 pandemic, Quebec had the highest COVID-19 mortality rate in Canada and one of the highest in the world. Indeed, with a rate of 721 per million inhabitants, it far exceeded the Canadian average of 263; came just after Spain and its 743 deaths per million; and even surpassed the United States (680), the U.K. (661), Italy (618) and France (533). By Oct. 27, 2020, about 91.9 per cent of deaths had occurred amongst those over 70 years of age (5,631 of 6,130 deaths). The abnormally high mortality rate in Quebec was directly attributable to the victims’ place of residence. Indeed, 88.3 per cent of these deaths occurred in collective living environments: 4,068 (66.3 per cent) in CHSLDs; 1,038 (16.9 per cent) in residences for seniors; and 309 (five per cent in intermediate care facilities.
CHSLDs in Quebec
The CHSLDs in Quebec are institutions dedicated to individuals with severe disabilities. The proportion of people over 65 years old living in the CHSLDs is 2.5 per cent compared with 3.3 per cent in Ontario and 3.0 per cent in B.C. In Quebec, there are 315 public CHSLDs – 59 that are private but managed under agreements with the province – as well as 43 completely private CHSLDs. The CHSLDs under management agreements are subject to the same rules as the public CHSLDs, in particular with regard to the conditions and procedures for admission, the financial contributions of residents and the working conditions of employees. In total, there are 40,400 places in CHSLDs, most in public institutions (30,345) or private ones under agreement (6,411). The proportion of public institutions is higher in Quebec (76 per cent) than in Ontario (42 per cent) and British Columbia (66 per cent)
In the first wave of the pandemic (until Sept. 10, 2020), there were 9,221 cases (22.8 per cent of residents) and 3,676 deaths in these centres – a mortality rate of 9.1 per cent and a case fatality rate of 39.9 per cent. Table 1 (below) shows that these rates were considerably higher than the ones observed over the same period in Ontario and British Columbia. The mortality rate also exceeded the estimates of countries that are part of the Organization for Economic Co-operation and Development (OECD): United States (2.3 per cent), U.K. (4.2 per cent), Spain (5.3 per cent) and Belgium (4.5 per cent). If the lower mortality rates in Ontario and B.C. had been achieved in Quebec, there would have been between 2,747 and 3,434 lives saved in CHSLDs during the first wave of the pandemic.
Decades of negligence
Reforms in 2003 and 2015 merged the CHSLDs with hospitals and other health and social service institutions. The CHSLDs lost their separate boards of directors and their own management. Dozens of CHSLDs have since come under the governance of enormous administrative entities with current managers being responsible for all the CHSLDs in what is often an extremely vast territory.
The 2015 reform was also accompanied by a cut of 1,600 mid-level and clinical managers, which seriously affected the CHSLDs.
There are now five hierarchical levels between the overall, distant management of the establishment and the local management of the CHSLD. Before an urgent situation could be signalled to the top authorities and the directives could come back down to the CHSLD, several days, even weeks, could go by.
The medical staffing of CHSLDs was weakened by the health ministry’s policy of prioritizing care in doctors’ offices in a bid to improve citizens’ access to a family doctor. To reach the quotas imposed by the ministry, many family doctors had to leave their practices in CHSLDs.
Similarly, there is now a shortage of nurses in CHSLDs because of the little attraction for this type of practice and the priority of hospital work. The ratios of patients to nurses in CHSLDs consequently rose, making it impossible to provide quality monitoring of patients and more intensive interventions when serious problems arose.
There was also a shortage of client-care attendants (CCA) even before the pandemic. Poor working conditions made it difficult to recruit these workers and, especially, to retain them. Their salaries had become uncompetitive and the climate at work had progressively deteriorated, with an increase in workload and pressure to perform.
In this portrait of a deficit of personnel, we cannot ignore the significant deterioration in the quality of work life since the reform of 2015. Between 2015 and December 2019, the costs related to salary insurance, to placement agencies’ hiring of the labour force, and to obligatory overtime exploded and added up to more than half a billion dollars.
It should also be stressed that the physical conditions are deficient in many CHSLDs. Although the proportion of shared rooms is lower in Quebec (22 per cent as compared with 63 per cent in Ontario and 24 per cent in British Columbia, we still observe shared bathrooms, inadequate ventilation systems, lack of air conditioning, and the unavailability of additional rooms for end-of-life care or isolation in case of infection. In contrast to hospitals, these installations have not been updated for decades.
Early management of the pandemic
When the pandemic first hit, the government prioritized freeing up hospital beds to handle the anticipated influx of patients with COVID. Thus, a massive number of patients no longer in active care and waiting for discharge to home or in other institutions were quickly transferred to CHSLDs. This phenomenon further accentuated the pressures in these institutions, which were already short of resources. This may also have triggered certain outbreaks due to infected patients or personnel brought in as reinforcements.
Add to this the lack of available personal protective equipment, which was instead requisitioned for hospitals as a priority, and all the conditions were present for a perfect storm.
From the onset of the pandemic, British Columbia formally prohibited the mobility of personnel working in similar homes, and even financially compensated workers who had suffered a loss of income as a result. This was not the case in either Ontario or Quebec, which continued to use mobile teams and placement agencies to alleviate absences of personnel. While the practice was later forbidden in Ontario, it is still tolerated in Quebec, even now during the second wave.
The handling of outbreaks was also inadequate at the start of the pandemic in early 2020. Identification of hot zones and the confinement of infected residents did not occur immediately. Inaccessibility to testing for COVID-19 also prevented the identification of asymptomatic carriers amongst the personnel.
During the pandemic, the CHSLDs prohibited the entrance of any individuals from outside the institutions. This directive prevented informal caregivers from continuing to visit their family members or friends. In addition to depriving residents of an important presence in this period of crisis, this measure also prevented these informal caregivers from providing essential daily care, thus further exacerbating the lack of care.
We know what followed: numerous uncontrolled outbreaks in CHSLDs; significant labour force shortages combined with the shedding of establishments’ other missions; the intensive recruitment of volunteers via the website “JeContribue”; and a call to the Red Cross and the Canadian army for assistance.
Necessary urgent corrective measures
To avoid a repetition of this drama in the CHSLDs, corrective measures must be rapidly implemented.
The designation of a responsible and accountable superior manager in each of the CHSLDs is crucial to ensure flexible and efficient management of these institutions and to enable them to react quickly in emergencies.
An accelerated recruitment and training program of attendants has been launched and salaries have been raised. While this emergency measure could mitigate the shortage of personnel in the short term, it must be accompanied in the medium term by a complete overhaul of these employees’ working conditions with supplementary training based on the emotional support of residents.
The prohibition of personnel mobility is essential. When movement of personnel between institutions proves necessary, each new employee must be tested before assignment to a new CHSLD. Regular testing of the personnel in a CHSLD is indispensable because asymptomatic individuals are major contributors to the spread of the disease. It goes without saying that the personnel must strictly respect all relevant measures, such as wearing a mask and washing their hands.
There must be a guaranteed number of extra doctors and nurses to optimize care for this vulnerable population.
Infection prevention and control teams must also oversee the CHSLDs, establishing or reinforcing protocols.
The presence of informal caregivers must be authorized and even encouraged. Because these individuals visit only their family members/friends and because they are therefore extremely vigilant regarding the risk of transmitting COVID to this person, the risk of this measure is relatively minor.
The establishment of hot zones within CHSLDs or in an outside designated institution is required to control outbreaks and ensure optimal treatment for these residents.
Last August, the health ministry published an action plan for the second wave, containing precise recommendations on how to avoid a repetition of the catastrophe of the winter of 2020 in the CHSLDs. While the intentions are good, the implementation of these recommendations should be monitored closely.
An opportunity to rebuild differently
In the medium term, when this crisis is over, we will have to rethink the governance and administrative framework of CHSLDs. The contractual arrangements with private CHSLDs are vital for these centres to be safe and provide quality care and services.
We must establish norms with respect to the ratios of residents per doctor, nurse or attendant. The interprovincial or international evidence and comparisons will prove useful here.
Renovating the CHSLDs is a vast but necessary undertaking, essential to correct the deficiencies and to bring these institutions up to today’s standards. While institutions will always be necessary for managing people with severe disabilities, priority should be given to home care to give people with functional decline the opportunity to stay home longer and to postpone admission to an institution. The funding system for long-term care is critical to carry out this major but necessary change.