COVID-19 highlights Canada's care home crisis
Authors: Paul Webster
Journal: The Lancet (2021)

COVID-19 deaths in long-term care have been called a national disgrace, and experts are calling for the army to intervene. Paul Webster reports from Toronto. When Canada's national health data agency reported in June, 2020, that Canada had the worst record among wealthy nations for COVID-19-related deaths in long-term care facilities for older people, many observers referred to it as a “national disgrace”. At that time, as the first wave of COVID-19 in Canada began to subside, its 2039 homes for older people accounted for about 80% of all COVID-19-related deaths. 6 months later, as the second wave of COVID-19 sweeps the country, little has changed, and Canada's long-term facilities remain dangerously prone to the disease. So far, COVID-19 has claimed more than 17 000 lives in Canada. The COVID-19-related death rate among older people in long-term care facilities in Ontario, Canada's most populous province, has prompted the biggest union representing long-term care workers to call for the Canadian army to intervene. The army was called into care homes last spring after COVID-19 outbreaks in Quebec killed 3890 residents and caused large numbers of staff illnesses and absences. Soldiers had to deliver basic services to the residents, while military medics delivered medical care. So far, COVID-19 is responsible for 2877 deaths in Ontario's long-term care facilities. Pat Armstrong, a sociologist at York University in Toronto who has studied Canada's long-term care facilities for almost 30 years, firmly believes that Canada's dismal record stems from a historical decision to exclude long-term care facilities from Canada's network of 13 provincial and territorial public health systems. “This has resulted in under-training and poor treatment of workers, substandard and ageing facilities, overcrowding, and poor infection control capabilities”, she says. Armstrong also argues, on the basis of a weighty body of published research, that a lack of government oversight and accountability to residents, especially in Canada's privately owned, profit-oriented long-term care facilities—which account for 54% of all facilities—has deeply darkened the picture. “There's plenty of evidence of lower-quality care in the privately owned facilities”, says Armstrong. “It was noticed very early on during the COVID-19 pandemic that some of the worst outbreaks were happening in for-profit, privately owned homes”, explains Nathan Stall, a geriatrician at Toronto's Mount Sinai Hospital, and lead author of a recent study investigating care quality and rates of mortality in 623 Ontario care homes. “When we investigated, we found that they tend to deliver inferior care.” Stall and colleagues found that the incidence of COVID-19 was higher among residents in for-profit facilities than those in other homes. And in facilities with an outbreak, 6·5% of all residents in for-profit facilities died of COVID-19, whereas 5·5% died in non-profit facilities and 1·7% in municipal homes. Stall emphasises that community-based spread of COVID-19 is the key driver of outbreaks in long-term care facilities of all ownership types. He also notes that not all for-profit homes have performed badly during the pandemic. Armstrong and Stall both agree that, beyond immediate emergency measures like sending in the army, a set of key reforms are urgently needed in all types of homes. The conditions of work for staff must be dramatically improved, and tens of thousands of new staff must be hired across the country. Overcrowded living conditions for residents must also be dramatically improved, they say, and better infection control and better medical care are also urgently needed. Don Melady, a Toronto emergency department doctor specialising in geriatric care, recommends that hospital emergency departments work with long-term care facilities and local and regional health authorities to develop plans to cope with outbreaks. “Simply separating symptomatic from non-symptomatic patients is inadequate because non-symptomatic individuals can be effective spreaders of COVID-19”, he warns. Jodi Hall, chair of the Canadian Association for Long-Term Care, an industry lobby group, agrees that governments across Canada should review their regulatory regimes for long-term care facilities. She also urges Canada's federal government to escalate its financial and regulatory roles in long-term care at a time when Canada's geriatric population is quickly growing. Gloria Yip, a spokeswoman for Ontario's Ministry of Long-Term Care, said in a written statement that measures are underway to “temporarily enhance wages” and, as in Quebec, “hire more staff, improve working conditions for existing staff, drive effective and accountable leadership, and implement retention strategies to make long-term care a better place for residents to live and a better place for staff to work”.