The COVID-19 pandemic has led to thousands of deaths; of these, a disproportionate number has occurred in long-term care settings. The papers presented here deal with a number of issues highlighted by this crisis in several jurisdictions, including Ontario, Quebec and the Netherlands. Analyzing these may give us some insight into what is necessary to prevent this disaster from happening again.

Introduction

The COVID-19 pandemic has led to thousands of deaths, of which a disproportionate number have occurred in long-term care (LTC) settings. The papers presented here deal with a number of the issues highlighted by this crisis and give some clues as to what is necessary to prevent this disaster from happening again. These issues are not unique to Ontario; there were similar problems in many other jurisdictions, including Quebec (Lavoie-Tremblay et al. 2022) and the Netherlands (Meershoek et al. 2022). Analyzing these may give us some insight into how best to manage future infectious disease outbreaks.

Background

LTC is defined as the services needed to meet a vulnerable person's health or personal care needs when they can no longer perform everyday activities on their own (NIH NIA 2017). As such, it includes a variety of services that can be provided in a variety of settings by a variety of caregivers. The needs may be short-term (e.g., wound care after surgery) or long-term. The caregivers may include unpaid family members and friends but also paid workers. The services may include combinations of personal care "activities of daily living" (e.g., bathing, dressing, eating, mobility, taking medications), homemaker services (e.g., meals, transportation), home healthcare (e.g., nursing care to help a person recover from surgery or illness), and physical, occupational or speech therapy. The settings where these services may be provided can include the hospital (if alternative locations to receive the needed care are not available), the person's home, adult day care centres, retirement homes and/or nursing homes.

It is important to note that most LTC services (with the exception of medically necessary services delivered in hospitals or by physicians) do not fall under the terms of the Canada Health Act (1985). As such, there is no requirement for these services to be publicly paid for in Canada, although some provinces do choose to do so for some services for some populations. This special issue of Healthcare Policy focuses on care in LTC institutions (nursing homes).

In Ontario, LTC homes focus on providing care for individuals with extensive medical, physical or cognitive needs, who require access to 24/7 nursing care. According to the most recent data available at the time of writing, 54.8% of Ontario LTC residents were 85 years of age or older and the majority required support in activities of daily living (NIA 2020). Data from 2019 showed that 90% of LTC residents in Ontario had some type of cognitive impairment (OLTCA 2019).

Ontario LTC facilities are governed by provincial statutes, legislation and regulations, which events showed were often inadequate to deal with the problems that arose during the COVID-19 pandemic. Facilities in Ontario are licensed by the Ministry of Long-Term Care and governed by the Long-Term Care Homes Act, 2007, while nursing and personal support services are governed by O. Reg. 79/10 (Government of Ontario 2011; Ministry of Long-Term Care 2020).

Within LTC, there are multiple ownership structures. In Ontario, these include for-profit, not-for-profit and public (municipally owned). As of March 31, 2021, there were 627 licensed LTC facilities in Ontario with 78,902 long-stay beds; 57% of these facilities were privately owned, 27% were non-profit/charitable and 16% were publicly (municipally) run (CIHI 2021). Paid nursing care was provided by a mix of personal support workers (PSWs), registered practical nurses (RPNs) and registered nurses (RNs). Boscart et al. (2018) found that PSWs provided the bulk of nursing care (76.5%) in Ontario LTC facilities, followed by RPNs (17.3%) and RNs (5.9%). Additional services provided in LTC included dietary services, physiotherapy, recreation, food services, social work, administrative services and housekeeping/cleaning.

The funding models vary. In Ontario, the provincial government provides funding for nursing homes that is intended to cover the cost of staff and supplies for certain services (particularly nursing and personal care, plus some support services, as well as the costs for raw food). However, residents must also pay a fee for their accommodation costs. Government agencies determine who is eligible to be admitted to an LTC home and manage the wait lists.

On March 17, 2020, the provincial government declared a state of emergency because of COVID-19 (Rodrigues 2020). On March 22, 2020, the Minister of Long-Term Care issued the first of many operational and policy directives under the Long-Term Care Homes Act, 2007, many of which are listed on the AdvantAge Ontario website (AdvantAge Ontario 2022). Intended to address the myriad issues related to the pandemic, these directives referred to procedures and precautions, infection prevention and control (IPAC) measures and restrictions on visitation.

Discussion

As demonstrated in this issue, there are a number of factors that were associated with better or worse outcomes for LTC residents. Some had been in place before COVID-19 but had a greater impact with the pandemic. Analysis of inspection reports (Crea-Arsenio et al. 2022) highlighted how complaints were not always well dealt with, giving rise to questions about how accountability is organized. Other ongoing problems included neglect (Akhtar-Danesh et al. 2022). However, there were also exemplar institutions who provided higher standards of care and thus had better results (Baumann et al. 2022b).

As noted in a previous special issue of Healthcare Policy on approaches to accountability (Volume 10, 2014), accountability has multiple dimensions (Deber 2014). Accountability means being answerable to someone for meeting defined objectives; it accordingly must define who is accountable for what, to whom and how, including what the consequences are for failure to meet the desired outcomes. The policy instruments involved may include financial incentives, regulations, information directed toward potential users and professionalism (including report cards and clinical guidelines). The activities may include fiscal accountability to payers, clinical accountability for quality of care and accountability to the public. For example, owners of LTC homes should see themselves as accountable to the residents and their families for providing high-quality and safe care and also to the province and to their governing bodies for how they spent their money (Wyers et al. 2014). Ontario had changed their accountability process by delegating much of the responsibility for hospitals and LTC to the regional local health integration networks (Berta et al. 2014).

The studies in this issue note that the problems in LTC, in general, had not been dealt with well. As noted in Oldenburger et al. (2022), problems within the facilities included resident care, human resources, governance, leadership and management, financing, physical infrastructure and supplies and training and preparation. In terms of staffing, there were concerns around staffing levels, training (Berta and Stewart 2022), hours and skill mix (including the use of regulated vs. unregulated workers) and full time versus part time versus agency nurses (Baumann et al. 2014). There were additional issues concerning other on-the-job resources (Berta and Stewart 2022): supplies (including food) and the type of care given (e.g., frequency of bathing). With respect to the physical structures of the homes, there were also issues about quality (including how many residents were in each room) and cleanliness (including insect infestations) (CAF JTFC 2020). From a regulatory standpoint, there were issues with how best to deal with complaints and the consequences of poor care. There were also major issues concerning who set the standards and how these were enforced (Armstrong and Cohen 2020)

One possible approach to ensuring that LTC homes have the right number and mix of healthcare workers is to use forecasting models (Dass et al. 2022). Indeed, one response by the Ontario government has been to increase the number of hours of care that LTC homes need to provide to their residents. Recent government announcements have increased both the hours of care as well as the number of regulated and unregulated workers (Ministry of Long-Term Care 2021).

In addition, there were a number of issues that would be difficult to regulate relating to personal interactions. One key problem that arose during the pandemic was the role of family members. On the one hand, isolation was important to reduce spread. On the other, this isolation was shown to cause significant distress to LTC residents and their families (Baumann and Crea-Arsenio 2022a). Another problem was the ongoing issue about the role of for-profit LTC homes and how to ensure that they met appropriate standards (Warnica 2021).

In addition to concerns relating to accountability, the papers in this special issue suggest that there needs to be more emphasis on an overall quality model: One must look beyond such admittedly important pieces of care, such as staffing or bed numbers, to examine the system of care and how the institutions are run. For example, with staffing, numbers are important but so are leadership, extended orientation and full-time work. The inspection reports (more than 5,000 written over a two-year period) can be seen as a canary-in-a-coal-mine view of a system that is deeply in trouble (Crea-Arsenio et al. 2022).

Conclusion

These papers suggest that the LTC evidence is clear and the pieces that need reform are clear, but that these matters cannot be managed one piece at a time; some broader approaches will be necessary. The papers presented here speak to a number of issues exacerbated by the COVID-19 pandemic; we hope they can offer some clues as to what is necessary to prevent this disaster from happening again.

La COVID-19 et soins de longue durée : qu'avons-nous appris?

Résumé

La pandémie de COVID-19 a fait des milliers de morts. Un nombre disproportionné de ceux-ci a eu lieu dans des établissements de soins de longue durée. Les articles présentés ici traitent d'un certain nombre d'enjeux mis en évidence par cette crise dans plusieurs endroits, dont l'Ontario, le Québec et les Pays-Bas. Leur analyse peut nous donner une idée de ce qui est nécessaire pour empêcher que ce type de catastrophe ne se reproduise.

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