COVID-19 Pandemic in Long Term Care

By Brent Binions
Board Member and Former President & CEO, Chartwell Retirement Residences

There has been a great deal written and said about long term care (“LTC”) in Ontario during the COVID-19 pandemic crisis. The pandemic has taken the lives of more than 1,800 LTC residents in Ontario, tragic numbers that are not acceptable, and we need and will find ways to do better in the future.

Much of what has been written or said about what has happened has not been based on the facts, but rather on political posturing of individuals and groups pursuing their own agenda. We wish to set out the facts behind the many myths that have been brought forward.

Below is data supporting evidence of what really has been happening:

Myth 1: Private LTC homes had a higher likelihood of a COVID-19 outbreak

The Real Story

In a study entitled “For-Profit Nursing Homes and the risk of COVID-19 outbreaks and resident deaths in Ontario, Canada,” with Nathan Stall as the corresponding author (the “Stall Report”), it was clearly delineated that the incidence of a COVID-19 outbreak in a LTC home was correlated with the incidence of COVID-19 in the health region surrounding the LTC home.

Given the number of people (staff, visitors, trades) that go into LTC homes every day, the above finding makes sense. The more people in the community surrounding a LTC home with COVID-19, the more likely residents or staff in the LTC home will have COVID-19. The data was also clear that the incidence of having an outbreak was not correlated to ownership type, be it private, municipal or not-for-profit. It was correlated to outbreaks in the surrounding communities.

As an added note, the Stall Report showed that the incident of outbreaks was also correlated to the size of a LTC home. Again this intuitively makes sense. A 60-bed LTC home has approximately 60 staff entering the home. A 200-bed LTC home has approximately 200 staff entering the home. The more people coming into the home, the higher the likelihood of an outbreak.

Myth 2: Outbreaks in private sector LTC homes resulted in more residents in the home acquiring COVID-19 with more deaths because care levels are lower in private sector LTC homes.

The Real Story:

This item needs to be broken into two parts. It is correct that of homes that went into COVID-19 outbreak, more residents acquired COVID-19 on average in private sector LTC homes than residents in municipal or not-for-profit LTC homes.

The second part is to understand why this occurred.

The Stall Report makes it clear that the higher number of residents acquiring COVID-19 in private pay LTC homes per outbreak is directly correlated to older design standards— specifically the presence of three and four bed rooms. 53.6% of private sector LTC homes have older design standards, while only 18.5% of not-for-profit homes and 11.9% of municipal homes have older design standards (see Myth 5 below for the reason why). It is noted that 13 of the 15 homes with the highest infection rates in Ontario were private-sector homes with older design standards.

It would be valuable to understand why these old design standards have had such an effect on the outcome. First, the average total square feet per resident of a home built to the new standards is just over 600 square ft. per resident. In an older home, it is 325 square ft. per resident. There is no space to isolate in an older home. And with three and four people in a room sharing one bathroom, it was extremely difficult to stop the spread.

This lack of space was made worse by the lack of understanding at all levels of how the COVID-19 virus spreads. For the most part, Public Health units were not testing asymptomatic individuals through February, March and April. It is not clear whether this decision was based on the idea that asymptomatic testing was not useful or simply because testing kits and testing capabilities were available in only limited quantities and these kits were prioritized for the expected acute care surge, which never came.

Residents were not tested until they were symptomatic and once a home was declared in outbreak, no further testing of residents was conducted, even if symptomatic. During this time, cohorting, to the extent possible, was done based on showing symptoms. Thus it is quite likely that we inadvertently grouped asymptomatic residents with non-infected residents, thus spreading the virus.

In late April/early May the Ontario government mandated testing of all residents and staff. It was found that there were many asymptomatic positive COVID-19 cases.

At one point in time, early in the outbreaks, some Public Health units were advising that asymptomatic employees could come to work even though they had tested positive for COVID-19. It was thought that asymptomatic individuals could not spread the virus. This turned out to be incorrect.

The Stall Report did not look at timing of outbreaks as related to size of outbreaks in homes. What operators can clearly see through their own experiences is that timing played a significant role in the severity of outbreaks. This was more the “luck of the draw.”

The vast majority of homes with the worst records for size of outbreaks were homes that went into outbreak early, when we did not understand asymptomatic spread between residents and between staff and residents. This was also a time when masks were not required (universal masking was mandated on April 9, 2020), and there was a severe shortage of PPE to help limit the spread.

All of these factors contributed to more severe outbreaks in some homes.

One further note on this issue, the Stall Report shows that the incidence of deaths among residents who acquired COVID-19 was quite similar across all ownership types.

Case Fatality Rate

For Profit     27.5%
Non-Profit     29.7%
Municipal     25.0%

Myth 3: Private-pay operators rationed personal protective equipment (“PPE”) because they did not want to spend the money needed to buy more.

The Real Story:

All LTC operators in Ontario are required to keep a pandemic supply of PPE on hand that would cover a home during a normal outbreak for two weeks. This supply proved woefully inadequate to combat the scope and scale of the pandemic. And it was made much worse by the panic buying of PPE that was going on all over the world.

Added expenses were never an issue for any LTC home of any ownership type. They simply could not access enough PPE. They were bidding against orders placed by governments around the world. To the extent rationing took place it was because there was a legitimate fear among operators of completely running out of PPE. There was a shortage of surgical masks, N-95 masks, gowns and face shields. And to the extent that these items could be purchased, they were not prioritized to LTC but rather to emergency response and acute care settings.

Some unions took exception to the rationing and there were even some court cases. But an operator cannot give out what they do not have and cannot buy.

In the midst of the panic buying, some of the larger operators pooled funds to place a very large order for PPE. When it arrived it was shared among any operator who requested access to the supply.

However, it is noted that even today there are some items of PPE that are difficult to access, especially N-95 masks.

Myth 4: Private LTC Operators did not have enough staff during the outbreak crisis because they do not pay their employees a high enough wage.

The Real Story:

This issue has numerous sub-issues that require discussion.

  1. Staffing levels prior to the outbreaks
  2. Wage rates for staff
  3. Use of part-time staff (“PT”)
  4. Limits on PT employees working at multiple LTC sites

a) Staffing levels prior to the outbreaks:
There can be no doubt that staffing levels in LTC homes in Ontario have been too low for years. Resident acuity levels have continued to rise and staffing levels have not kept up to meet the true needs of our residents. In Ontario, funding for nursing care services sits in a Nursing Envelope. These are the funds received by each home for care. The amount is set by government. Operators spend these funds on nursing care services only. If the money is not spent, it must be returned to the government after a yearly audit.

There are numerous briefs and studies showing the amount in the Nursing Envelope is inadequate to meet the care needs of LTC residents.

This problem has been made worse by a shortage of supply of Personal Support Workers (“PSWs”). Many homes were working short-staffed before outbreaks hit. Much of this shortage in supply has been caused by a change in qualification standards for PSWs put in place by the last government. Our prospective employees do not have a significant amount of disposable income to allow them to afford the now required college tuition, plus six months of school time. A much better system would be a practical training model, where students spend three one-month terms in class, each followed by three months of practical training in a hospital, LTC or retirement home. Such training would better equip new employees to perform their jobs upon graduation after the one-year course is completed. And they would get paid for their work during 9 of the 12 months to improve affordability.

During the crisis, operators have been allowed to use non-college trained resident care assistants (“RCAs”) in place of PSWs. They have done a good job. We need to change our system of how we qualify our PSWs to ensure that the supply of workers can meet the demand as we increase our level of service to our seniors in the future.

The latest staffing data provided by the Ministry of Long Term Care is from 2018. All homes complete staffing surveys each year. The 2018 data indicates that staffing levels for average direct care hours per resident days was as follows:

For Profit     3.18
Not For Profit     3.16 (Combination of municipal and not for profit)

As can be seen, utilizing the funding provided by government for direct nursing care resulted in slightly higher staffing levels in for-profit homes. Note, on top of this government funding, some municipal and NFP LTC homes subsidize their staffing levels through municipal tax dollars or donations. According to that 2018 study, on average, those subsidies provide municipal and NFPs with an additional 5.9% in enhanced streams of funding for staffing.

b) Wage rates for staff
Much has been said and written about the low-pay minimum wage jobs that exist in LTC, especially among privately-owned homes. The hourly wage for a PSW in a privately-owned home with two years of service is over $22/hour. When you add in benefits such as statutory holiday pay, uniform allowance and other benefits, a PSW makes just over $50,000/year. This is very close to the average wage for employees in Ontario, which is $52,260/year. Note that full-time LTC employees also have full medical coverage, fifty per cent dental coverage, life insurance, short-term disability, a 4% matching pension and 12 sick days/year. This is not a low paid sector. It is very close to the Ontario average with good benefits.

c) Use of part-time staff
It has been suggested in numerous articles that LTC operators use PT workers because they are cheaper. This is false. PT workers are paid the same hourly wage as FT workers and they do receive some benefits, including typically life insurance, 4% matching pension and 3 sick days. They also receive an additional $0.30 per hour in lieu of the other benefits. The actual cost to the employer is quite similar.

For every FT position there is a matching PT position. Thus 50% of employees in a LTC home are PT. Note, this is not 50% of the hours. Those are spread 71% FT and 29% PT (10/14 shifts FT, 4/14 shifts PT). As well, a home needs extra PT employees to fill in for other FT and PT employees when they are ill, on vacation or on other types of leave. This means that most homes would have about 45% FT employees and 55% PT employees on their payroll.

If you give a PT employee two PT positions in a home, they would have to work every weekend as every position contains one weekend every two weeks. This would not only be a breach of our collective agreements, but it is very difficult to find employees who want to work every weekend.

It would be possible to increase the percentage of FT workers by going to 12-hour shifts or having FT employees work 2 out of every 3 weekends. Unions have consistently rejected these possibilities. Operators also have concerns regarding a 12-hour day for PSWs. It is heavy and stressful work. Our average age of PSW for the LTC sector is close to 50 years of age.

d) Limits on PT employees working at multiple LTC sites
Part way through the COVID-19 outbreaks, the government moved to limit the ability of employees to work at more than one LTC site. At the time, this was a necessary decision. The leading cause of outbreaks in LTC homes was the virus being brought into the homes by staff and unknowingly transmitting it to residents and other staff.

A key problem at the time was lack of timely testing. In the beginning, testing was only done for symptomatic individuals. We now know that asymptomatic carriers can pass on the virus and indeed this is what was happening. Asymptomatic staff could move from one home to another spreading the virus. Once regular testing for all employees commenced, we were in a much better position to control the spread of the virus.

The limit on employees working at multiple sites further exacerbated the staff shortage that existed prior to the outbreak. This combined with the loss of staff, who had to isolate due to having COVID-19 or having been exposed to COVID-19, or those who chose not to work due to fear, day care issues or other personal reasons to create a crisis in available staff.

During the outbreak it has been possible to give any PT staff member who would come to work a FT position. At some point, the situation will normalize and all employees will come back to work. FT employees will reclaim their FT positions and PT employees will return to PT.

If we continue to limit employees to one site, in order to pay their bills they will be forced to work at another non-health care location. Now that outbreaks in LTC homes are under control, the risk of contracting COVID-19 in other workplaces is the same or higher than in LTC homes.

If we had in place weekly mandatory testing with a less invasive process then the nasopharyngeal swab, it should be low risk having employees working at more than one LTC site. Such employees would be tested twice per week, once by each employer. This would allow employees to gain work at two LTC sites in order to get enough hours to make a living, rather than forcing them to work at a retailer or restaurant for a second job at less pay, where no testing is conducted.

Myth 5: Canada has a higher average death rate among LTC residents from COVID-19 than other countries.

The Real Story

In the paper entitled, “Pandemic Experiences in the LTC Sector: How does Canada Compare With Other Countries” the Canadian Institute for Health Information (“CIHI”) advises that Canada’s LTC sector was especially hard hit by COVID-19 and deaths in LTC homes account for more than 80% of deaths in the country. The math is accurate. The conclusion is open to interpretation.

The raw data provided in the report is based on pandemic statistics up to May 12, 2020. It shows that the Organization for Economic Cooperation and Development (“OECD”) average LTC deaths per million population was 112. Canada did indeed do worse than average as its number of LTC deaths per million was 142, (126.8%), of the OECD average. However, outside LTC, Canada had better than average results. The OECD average number of total COVID-19 deaths per million population was 266. Canada only had 176, being only 66% of the OECD average. Given a significantly lower death rate per million of population in Canada (66%) and a higher death rate in LTC 126.8%, the percentage of death in LTC comes in at 80.7% as stated. But this is mainly due to the lower rate of deaths in Canada overall.

It is noted that as of July 7, 2020, LTC deaths per million population in Ontario was 120 deaths (1,717/14.3 million population) which is much closer to the OECD average from two months earlier.

Our Canadian health care system did an excellent job on behalf of Canadians outside of LTC. Why did we not have the same result in LTC?

As discussed above, the physical structure of many of our LTC homes is a critical element in our failures. Prior governments put several different programs in place to redevelop old homes, but none of them worked as they were not financially viable. The sector so advised the government in report after report, but the problems were not fixed.

If you go back in time to the year 2000, the Conservative government put in place a program that added 20,000 new LTC beds. This program was completed over 8 years. But a little discussed fact is that the Conservative government also put in place a program to rebuild what were then called D homes. These were homes that did not meet the 1972 standards.

Most for-profit homes were built after the 1972 standards came into being. As noted, these standards no longer come close to meeting the needs of today’s residents and had three and four bed wards. Most D homes were owned by not-for-profits and municipalities because they had been in the business of delivering care and services to seniors even before it became a funded program by the Ministry of Health. Much of their funding was through the Ministry of Community and Social Services. The Conservative government merged these two programs into the Ministry of Health and Long Term Care in 1996 and began the expansion and renovation program in 1999.

Although it was the stated intent of the government to continue redevelopment programs for B and C homes, the new program put in by the Liberal government did not work. Only a small portion of B and C homes have been able to redevelop (less than 1,000 of the 35,000 beds). Why? Because the funding meant that to rebuild, an operator would have to donate a significant amount of money to the Ontario health care system.

Since the government controls 100% of revenue for LTC operators, it is incumbent on the government to put in place a program that works so that all older design homes can be redeveloped to the new standards to allow for better infection control and isolation protocols.

On September 11th, the Ontario government announced additional details regarding the enhanced capital development funding policy, which removes some of the important barriers to successful redevelopment of these older B and C homes.

Myth 6: LTC operators neither needed nor wanted outside assistance.

The Real Story:

What all LTC operators were looking for at the beginning of the COVID-19 outbreaks was clear, consistent and accurate guidance. However, we received conflicting advice from a number of sources, including Public Health, hospitals, and the provincial and federal governments. For example, advice on cohorting and masking was inconsistent at the beginning.

As noted previously, there was a severe shortage of PPE for LTC homes. Government assistance was late in coming.

Lack of testing, accuracy of testing, no testing for asymptomatic individuals, and extremely slow results from testing further encumbered the ability of LTC operators to deliver effective services and respond to the pandemic threat.

With the loss of staff referenced in Myth 4, LTC operators were desperate for staffing help. It took far too long for the government to intervene and set collective agreements aside so that staff could move from hospitals to LTC, especially when hospitals were running at an average occupancy of 65%.

As well, with hospitals running at 65% capacity, it should have been possible to move residents with COVID-19 from LTC homes, especially older design homes with 3 and 4 bed wards where isolation was impossible, to hospitals. This would have helped curb the spread of the virus in LTC homes. For the most part this was not done. Most LTC homes were left to fend for themselves.

Some hospitals did respond in a timely way by providing staff or accepting COVID-19 positive residents. In those cases, the LTC homes avoided catastrophic losses. However, homes that did not receive timely assistance were not able to effectively mitigate the impact of the virus on their residents and staff on their own, leading to the high profile outbreaks that have rightly outraged Canadians.

*This paper was developed by Mr. Binions for Chartwell and the public to better understand the conditions that preceded the impact of COVID-19 in long term care homes and the incidence of higher outbreaks under certain conditions.

Media inquiries:

Sharon Ranalli, Vice President, Marketing & Communications