Nobody should forget that Canada set a sad record by leading the world with the highest proportion of COVID-19 mortality that occurred in long-term care (LTC) homes. A new seniors’ strategy should take account of pandemic lessons learned and take action that promotes independence for seniors and improves the quality of care. Although aspects of a seniors’ strategy can reflect pan-Canadian values, roadmaps to reform should be specific to each provincial health-care system.

In Ontario, the reasons why too many people died in LTC homes has been studied and well- documented. Testimony before the government-appointed Marrocco Commission, an independent inquiry investigating LTC and COVID-19, identified the root causes of fatalities. Empirical evidence points to staffing shortages and facility overcrowding as key shortcomings – issues that should be prioritized in upcoming policy reforms. Further, demographic change and growing demands for LTC services mean we should make major efforts to keep more people independent in their homes and out of facilities for as long as possible.

The Canadian Institute for Health Information (CIHI) analyzed a range of possible factors associated with higher mortality in Ontario LTC during the pandemic’s first wave. The analysis demonstrated that there was a higher risk of an outbreak in homes located in public health units not only because of the virus, but also when homes had a medical director present for less than a day a week, where there were critical shortages in personal support workers (PSWs) and a high usage of temporary PSW staff.

Facility overcrowding also had a major impact on LTC mortality. Homes that had three to four residents in a room had a higher risk of infection and mortality than homes that offered private or semi-private rooms. Eliminating four-person bedrooms would have eliminated 263 deaths during the pandemic’s first wave, the report said.

Similar to this, it’s been determined that for-profit LTC homes are more likely than not-for-profit homes to have three- or four-person rooms. Overcrowding is the underlying reason why for-profit homes tend to have disproportionately higher COVID-19 mortality than not-for-profit homes.

These analyses should convince policy-makers that facility redevelopment and PSW staffing levels and conditions must be urgently addressed to improve the quality of care in Ontario’s LTC homes. Fortunately, these issues are already being addressed through recent commitments announced by the provincial government.

Testimony before the Marrocco Commission by the Ontario LTC Association stated that 32,000 of the province’s roughly 78,000 beds were located within older homes where three or four residents would share a room. For more than 15 years, successive Ontario governments have stated their intent to redevelop these older homes. But, until recently, little progress has been made with construction of new facilities that conform to modern building standards that enhance infection prevention.

There are many reasons for this historical failure to redevelop. The ministry of health and long-term care could not agree with LTC operators’ estimates of appropriate funding for LTC redevelopment. Operators insisted that the ministry financial formula for redeveloping old homes did not provide adequate funding for increasing land and development costs. Operators also claimed that the ministry was overly prescriptive with building standards that increased costs well beyond the funding formula.

In fall 2020, the Ontario government announced a new construction funding program that recognized operators’ land and construction costs in redeveloping older facilities or building new LTC homes. At present 38,000 Ontario patients are on the waiting list for a LTC bed, and 32,000 beds in older buildings require redevelopment to meet current infection-control standards. This suggests that Ontario needs to build homes with 70,000 new beds to accommodate both people on the waiting list and the need for redeveloped beds.

Shortly after the new funding principles were implemented, the ministry approved operators’ applications to build (or rebuild) more than 20,000 new beds, and major Ontario LTC development was initiated – the first in the last many year. This is a fresh start. The government has committed to provide 30,000 new beds by 2028 along with more than 15,000 redeveloped spaces.

A staffing analysis was undertaken by the ministry of long-term care during the first wave of the pandemic in response to the recommendations of the long-term care homes public inquiry, a government-commissioned judicial inquiry to investigate crimes in Ontario LTC facilities. The outcome of that analysis, combined with staffing challenges experienced during the pandemic, resulted in a government commitment to increase staffing to reach a new average care standard of four hours per-day per-resident in the next three years. This increased care standard will be supported by an increased focus on human resources, which includes better training, recruitment and retention support.

This new approach to facilities and to staffing are important responses to the lessons learned. However, with the population of seniors in Ontario expected to increase by about four per cent annually in the next 20 years, it will be difficult for the system to provide adequate supports for frail elders if LTC facilities are the main option. Most studies of citizen preferences for seniors’ supports find that older people would prefer to avoid moving into an LTC home and want to maintain independence in their own residence as long as possible. This preference for staying out of LTC homes has likely increased as a result of the pandemic.

Maintaining seniors’ independence in the home means an increased focus on home care. Recent investigations have focused on the opportunity to provide better and more cost-effective home care through recognition of naturally occurring retirement communities (NORCs). NORCs develop as the result of seniors congregating together in communities which serve their needs. Researchers are finding that NORCs in high-rise apartment buildings are growing rapidly in popularity in Ontario cities and that a substantial proportion of urban seniors live in NORCs in cities like Toronto. Recognition of this type of living situation recently enabled Toronto Public Health to deliver mobile on-site COVID vaccination for seniors throughout the city.

The proximity of multiple clients in NORCs permits the efficient delivery of home care and volunteer services for seniors. Home care maintains client independence and is much more cost-effective than care in LTC facilities. Yet, Ontario has not recognized NORCs in developing a home care strategy. Planning to deliver congregate home services to NORCs offers a substantial potential improvement for the province’s home care system.

Other elements that should be considered in a new framework for Ontario’s Seniors Strategy include investments in community day programs and increased training of various regulated health professionals in geriatric care. Training of primary care physicians and nurse practitioners in geriatric competencies will help to ensure that we have more medical directors and primary care providers in our LTC homes.

Far too many frail Canadians have died in LTC homes during this pandemic. This should prompt a new strategy for seniors’ care. The evidence shows that we must focus on facility development and on expanding staffing supports to improve quality and safety in LTC facilities. Given the pressures to come from an aging population, we must increase home care options to reduce the future need for care in LTC homes.

This article is part of the Kick-starting Reform in Long-Term Care special feature. 

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Bob Bell
Bob Bell served as Ontario’s deputy minister of health from 2014 to 2018. Previously, he served as president and CEO of University Health Network, the chair of CCO’s clinical council, and the Cancer Quality Council of Ontario.

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