TORONTO — The brutal assault of the novel coronavirus on long-term care facilities in Ontario has exposed long-standing, systemic problems in a sector that otherwise seldom receives top-of-mind public attention.
Those issues range from who cares for the frail and how they do that to government funding levels and wait-lists for one of the 77,000 beds in the province's 626 long-term care homes.
To date, more than 100 homes have seen more than 1,200 cases of COVID-19 among residents, accounting for about half the 478 known deaths in the province, according to data from the Integrated Public Health Information System. More than 620 staff have tested positive.
The incidence among residents and the roughly 80,000 people who look after them is, however, likely higher given relatively low levels of testing and lags in reporting.
Prime Minister Justin Trudeau noted the grim situation this week.
"One of the things we've seen over the past number of weeks is a far more severe impact on a number of seniors residences and long-term care centres than we had certainly hoped for, or more than we feared," Trudeau said.
Experts, however, say the impact of COVID-19 shouldn't have come as a big surprise given chronic problems in Ontario's often cash-starved nursing homes — one-third only meet 1972 standards for space and other requirements — and the virus's propensity to strike hardest at older adults and those in poorer health.
Both factors have been prominent in the rapid and lethal spread through what has in recent years effectively become a $4.2-billion publicly funded system of slow-motion palliative care.
Since 2010 when Ontario tightened admissions criteria, the average age of residents has risen. More than half are older than 85, according to provincial data. Tens of thousands of people in need of a nursing home spot can spend months or even years on wait lists, meaning they are often in poorer shape by the time they do find one.
The result is more and more residents nowadays are impaired physically, leaving them incapable of performing even the most basic personal tasks such as getting out of bed, eating, brushing teeth, bathing or going to the washroom. Most have two or more chronic conditions, with almost two-thirds on a regimen of at least 10 different drugs.
Upwards of 40 per cent of long-term care residents in Ontario die of all causes in any given year — roughly 600 people a week — according to data from the Canadian Institute for Health Information.
Of growing significance is the vast majority who are cognitively impaired. About two-thirds are afflicted by dementia.
Much of the intensive care duties are carried out by low-wage part-time shift workers, who receive few or no benefits such as paid sick leave. Many personal support workers, who provide the bulk of hands-on care, have been forced to work in multiple facilities to make ends meet, making them significant vectors of coronavirus transmission across settings. Turnover is frequent and many have fled the field.
Even before the pandemic, about 80 per cent of homes in Ontario were warning of staffing issues, much of it related to inadequate funding. COVID has sorely exacerbated the situation.
"We're seeing loss of staff rates that are huge," said Donna Duncan, executive-director of the Ontario Long Term Care Association. "What we're finding in this scenario right now is, as COVID moves into the homes, you could lose as many as 50 or 60 per cent of your front-line staff."
Much of the personnel loss, she said, is due to infections that have forced vulnerable front-line workers — often working with little protective gear — into isolation and off the job. At least one has died. Quick back-filling for the difficult and essential tasks they perform has ranged from tough to near impossible.
Ian Da Silva, with the Canadian Personal Support Workers Association, said as many as two-thirds of Ontario's estimated 100,000 personal support workers were already inactive before the pandemic. A huge step toward luring both newcomers and the disenchanted would be to grant the workers official self-regulation status like other health-care professionals, he said.
An official designation, Da Silva said, would make the profession more attractive, allow for mandatory practice standards, and lead to a centralized database of qualified workers, information that would now have been especially invaluable. Social media has become one of the few ways to reach those who might be able to help.
"The way we entered into this pandemic was personal support workers were very much an afterthought," Da Silva said. "You need to ensure the front-line worker is a role in our society that is respected, and it simply is not right now."
Federal Health Minister Patty Hajdu recently alluded to the problems in long-term care as she reflected on the value placed on caregivers.
"We tend to devalue the work of caring for people, whether it is old people or whether it is children," Hajdu said. "I used to wonder...why it is that we valued more people who cared for vehicles than people who cared for people."
Two other factors play an outsize role in the spread of the virus through nursing homes. One has been space constraints in homes like hard-hit Pinecrest Nursing Home in Bobcaygeon, Ont., where COVID-19 has killed about half of its 65 residents. In such facilities, up to four residents might share a room, making isolation and social distancing all but impossible.
Ironically, another factor in the initial spread has been concerted efforts to create a homey setting for residents.
"A lot of the activities that they offer is to combat social isolation: getting people together into programs and outings and having visitors come in," said Dr. Henry Siu, assistant professor with Department of Family Medicine at Hamilton's McMaster University. "So it's a bit of a paradox."
Premier Doug Ford, whose mother-in-law is in a nursing home, has issued an extendable six-day ban on support staff working in multiple nursing homes although critics questioned its feasibility. Workers had until Friday to choose a preferred site, leaving some homes even worse off.
The bottom line, Duncan said, is that long-term care facilities are desperate for help and anyone who does step up should be tested for the virus and will need hard-to-come-by personal protection equipment.
"We need human beings to come in and staff up our homes right now," Duncan said.
Hajdu said the pandemic offered an opportunity to think about forging a stronger system of care.
"That is a large project for Canada," she said.
This report by The Canadian Press was first published on April 17, 2020.
Colin Perkel, The Canadian Press
