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As Canada wrestled to control and withstand the COVID-19 pandemic, the greatest tragedies of the crisis played out behind closed doors, as outbreaks swept through personal-care homes from British Columbia to Ontario and Quebec.
As of Thursday, journalist Nora Loreto had linked 86.3 per cent of Canada's 6,765 deaths to long-term care facilities. Previous research by the International Long Term Care Policy Network's had pegged the figure at about 82 per cent.
Those numbers, together with harrowing reports from stricken nursing homes, paint a devastating picture of staff struggling to provide care, residents left to languish in beds and woefully inadequate infection-control measures.
In truth, it's a tragedy years in the making. It's not that COVID-19 exposed the weaknesses in Canada's long-term care system; those have been exposed for years by researchers and journalists, and via lobbying from the sector itself. What the virus did was make those challenges impossible to ignore.
"Now this is global and the public is up in arms, and governments are, at least right now, talking about it a lot," says University of Alberta professor Carole Estabrooks, whose work focuses on long-term care.
"They seem surprised and distressed, and they should be distressed, but it’s not clear why they’d be surprised."
So far, Manitoba has been lucky. Facilities here locked down before the province had significant community spread. Only one of the province's seven deaths due to COVID-19 was a long-term care resident, and there have been no large nursing-home outbreaks.
Yet while the province begins to open up, the way forward for long-term care facilities is harder to see. The virus is likely to be circulating for months, even years; a single case that gets into a nursing home could trigger an outbreak that kills dozens.
One way or another, COVID-19 will change long-term care forever. At the Long Term & Continuing Care Association of Manitoba, executive director Jan Legeros hopes the pandemic will lead to greater focus on the investments the sector needs.
"There’s going to be a substantive debrief that happens after this," Legeros says. "Even if we come up with a vaccine for this particular virus, there’s probably going to be another one. This has taught us that we can’t just talk about it, we have to act. We have to do the things that will ensure that next time we are a bit better prepared."
Manitoba has strengths to build on in its facilities, many of which operate as faith-based or secular non-profits. A report on the sustainability of the sector, released late last year by the Manitoba Association of Residential and Community Care Homes for the Elderly, highlighted that factor.
"Non-profit personal care homes are uniquely positioned to address these current and emerging challenges and contribute to the sustainability of Manitoba’s health and social systems," the report stated, emphasizing that non-profits represent community ownership, which can be responsive to local needs.
So what will the long-term care look like, in a post-COVID-19 world? To start that discussion, the Free Press spoke with several experts. All of them pointed to four key areas of concern: facilities, staffing, connecting with residents and standards and accountability.
"When you’re holding a system together with goodwill and duct tape, and something like COVID comes along and shocks it… there’s lots of reason to be optimistic to think we can solve this, but it’s going to take political will, and the will of the public," Estabrooks says. "We need to fix this. And we can."
In many cases, making nursing homes in Canada more resilient to epidemics will require changes to the facilities themselves. Many are housed in aging infrastructure built at a time when residents were, on average, younger and healthier than they are now.
In Manitoba, 40 per cent of personal-care homes date back to the early 1970s, when those facilities first became an insurable service. They were built around narrow hallways with shared accommodations; there are still some facilities in the province that have rooms with three or four beds.
"COVID-19 has shone a light on how problematic a shared room is with even one other partner," Legeros says. "How do you isolate when you don’t have anywhere to isolate to? This is something that we have been raising for many many years, and it’s the same across Canada."
Updating facilities will require looking at everything from ventilation systems to even the entire concept of residential care. Experts point to alternatives such as Europe's innovative green care farms, which enable seniors with dementia to live in small-scale, home-like facilities with an abundance of meaningful activities.
Michelle Porter, director of the University of Manitoba's Centre on Aging, hopes to see Canada looking to other jurisdictions for inspiration.
"Certainly part of the discussion that is happening is how we even conceptualize the whole model and places and spaces and all of those kinds of things," Porter says. "I think people would really like to see us moving away from hospital-like environments for large numbers of people."
That will take time and investment. Updating dated infrastructure would cost millions of dollars in Manitoba alone; Legeros believes the federal government will have to help foot the bill. New facilities will have to be built keeping the experience of COVID-19 at top of mind.
"COVID is going to change so many things for us," she says. "Even in new builds, we’re probably going to have to review the layout, etcetera, because so much has changed. That six feet of physical distancing is going to change the way we do everything."
Of the most tragic stories of COVID-19's deadly march through care homes, many began the same way: when staff, often lacking sufficient protective equipment, feared going to work in an unsafe environment. Facilities struggled to replace them, and the resulting shortages caused already heavily burdened care provision to collapse.
Staffing has long been a challenge in the sector. Wages for many non-medical workers are low; many positions are part time, and to string together a living wage, some workers take jobs at multiple facilities, increasing cross-infection risk. In April, the province restricted staff to working at one site while ensuring they could keep equivalent hours.
Over the long term, there will need to be more substantive changes, both to better prepare staff and to make it a more attractive profession. Ensuring sufficient ongoing access to PPE, improving training and regulation and putting more focus on work with vulnerable seniors will be key.
"It’s not seen as a desirable workplace, and that’s a combination of things," Estabrooks says. "But that can and should change. It’s really an honourable thing to take care of older citizens. We should be honouring it more, we should be valuing it with proper remuneration."
Meanwhile, Estabrooks says research is sorely lacking into how many care hours per resident produce the optimal quality of life for residents, and what mix of staffing types produces the best outcomes. Current provincial guidelines call for 3.6 care hours per resident, which Manitoba meets; many experts suggest boosting it to 4.1.
When nursing homes locked out visitors, it was a necessary measure to keep COVID-19 out. But that situation cannot last forever; particularly for residents with dementia, the lack of face-to-face time with loved ones can be confusing and scary, and even a risk to their overall health.
Earlier this month, the province announced it will allow outdoor visitation at long-term care facilities, as long as sufficient physical distancing is maintained. More can be done to ensure that residents have meaningful recreation and social connections, including investing in more recreational support workers.
"Staffing certainly needs to change," Legeros says. "We need to move away from such a heavy medical model into more of a social model, so that we can incorporate quality of life activities in the homes, as opposed to having it be almost like a hospital."
There have been some innovative solutions. A facility in Toronto launched its own in-house TV network, which brings arts, crafts and exercise programs to residents. A care home in France adopted a "happiness bubble," which allows residents and visitors to see and even touch each other, separated by a plastic seal.
In early April, the Long Term & Continuing Care Association of Manitoba launched a donation drive to secure tablets for residents to video chat with loved ones. The drive met its goal of accumulating enough devices for every care home in the province, and deliveries will be complete next week.
But sooner or later, facilities will have to find safe ways of allowing family to see their loved ones in person. As Porter points out, families are not just a source of love but of care, as well, such as by encouraging eating at meal times. Getting that support back into homes is critical to support residents' well-being.
"We should be making sure that personal-care homes are getting enough PPE that they can have family members coming in, and giving them training, and not just at end of life," Porter says. "They have protocols in place, they have experience now with it. Is it impossible to expand that so that individuals could be trusted to be able to come in?"
Long-term care facilities are the jurisdiction of each province. In Manitoba, experts are concerned by what they describe as a lack of dedicated government oversight of seniors' needs, including long-term care facilities and assisted-living environments.
"We don’t really have anyone at the provincial government level that their main responsibility is for thinking about this," Porter says. "We have a minister who’s got 'senior' in the title of his ministry. In terms of under that, we don’t have anybody who it's their full-time responsibility."
Legeros echoes those concerns, saying seniors' health must be given a larger spotlight at the provincial level.
"It’s a huge part of our population," Legeros says. "I think the care and attention that’s needed warrants a portfolio that has the ability to really spend some time looking at this issue. Hopefully now that COVID has shone this great light on long-term care, perhaps that’s something that will be looked at more carefully."
Beyond that, there is a great deal of opportunity to improve standards for care homes across Canada.
Legeros points to health information software used in 70 per cent of Canadian long-term care facilities that collects data on issues such as number of resident falls. Expanding it to all care homes in Canada would cost $13 million, thereby enabling facilities to better compare performance and share knowledge on areas of concern.
Above all, experts agree, moving forward with long-term care in the post-COVID-19 world will require significant advances in co-operation and investment from the top tiers of government.
"We need a national framework," Estabrooks says. "If the federal government and the provinces work together, this is a solvable problem. We have the Canada Health Act for hospitals, but that’s exclusively about health… long-term care is about health and social care. It probably needs a separate framework."
Melissa Martin reports and opines for the Winnipeg Free Press.
Updated on Friday, May 29, 2020 at 10:11 PM CDT: Fixes typo.
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