Have long-term care systems learned from early pandemic failures?

Natalie Stake-Doucet is haunted by deaths she witnessed working as a long-term care nurse in Montreal during the early waves of the pandemic.

"Where I worked, half the residents died in six weeks," says Stake-Doucet, president of the Quebec Nurses' Association. Now on leave, she panics at the thought of returning to a long-term care facility and seeing more death. "I still have nightmares about it," she says.

More than 80% of all COVID-19 deaths in Canada during the first waves of the pandemic occurred in long-term care, mostly in Quebec and Ontario.

The crisis exposed shocking neglect and instances of substandard care, with some residents suffering malnutrition and lying in soiled bedding for days as staff struggled to contain outbreaks.

Better infection control practices and the rollout of COVID-19 vaccines to older adults and health care workers helped to stem the tide of deaths. But Stake-Doucet and others worry that many of the problems that contributed to the disaster remain unaddressed—especially now that pandemic precautions are being abandoned and vaccine efficacy is waning.

Lagging vaccine uptake

Widespread vaccination was "probably the single most important thing that happened to protect a lot of homes from the subsequent COVID waves," says Stake-Doucet.

By the end of 2021, more than four in five nursing and seniors' homes reported that at least 95% of staff and residents had received two doses of COVID-19 vaccines, according to a recent report from Statistics Canada. This strong uptake helped to reduce infections and deaths among long-term care residents by more than 90%.

However, uptake of booster vaccines, which can help maintain that protection, has been weaker. As of mid-August, just over half of Canadians aged 70 and older were fully up to date with four vaccine doses. And the federal government has since dropped that age group from its key updates on vaccination rates.

Pandemic precautions relaxing

Nearly all long-term care facilities reported adopting at least one new infection prevention and control measure in the first year of the pandemic—most commonly, improvements in hand hygiene, personal protective equipment, and screening.

But less than half of nursing and seniors' homes continued improving upon those measures in 2021, according to Statistics Canada. And despite calls for facilities to improve airflow and reduce crowding, less than a third updated ventilation systems, while fewer than one in five converted multi-bed rooms to become private or semi-private—a change that experts estimated could have prevented hundreds of deaths in Ontario alone.

Constantly changing ministry directives complicated the early pandemic response, says Morgan Hoffarth, past president of the Register Nurses' Association of Ontario and director of care at a long-term care facility in London, Ontario.

"It was really confusing—the amount of changes, the frequency of changes and the timing of the changes—and they didn't always come with a very clear explanation," Hoffarth says.

No way to track outbreaks

National guidelines on infection control in long-term care brought clarity, but they haven't been updated since last year.

Some recommended measures, like mask mandates, remain in place in facilities across the country. Others, including vaccination requirements in Ontario and Quebec, and health screening in Alberta, have fallen by the wayside.

Brad LaFortune, a seniors' advocate and executive director at Public Interest Alberta, worries his province dropped precautions too soon. In 2021, when Alberta lifted most pandemic restrictions for the general public, more than half of long-term care homes in the province had at least one resident with COVID-19, surpassing Ontario and Quebec's counts at the time.

Now, "people at the door won't have to ask or check for symptoms or ask about recent travel for people who are coming in and out of the facility, and that's a big one," says LaFortune. "Is that going to hasten another wave?"

Provinces have been sharing less information on long-term care outbreaks since they began easing restrictions on the sector earlier this year, making it difficult to know what's happening across the country.

According to Samir Sinha, director of health policy research at the National Institute on Aging, it's no longer possible to track COVID-19 cases and deaths in long-term care in an "accurate and reliable way."

Worsening staffing shortages

Inadequate staffing is widely acknowledged as having been a major factor in the early pandemic crisis in long-term care.

More than four in five facilities reported at least one staffing-related challenge in 2020, according to Statistics Canada. And half or more nursing and seniors' homes have reported increasing challenges since then, including critical staffing shortages impacting resident care and worker safety.

According to a report by the University of Alberta's Parkland Institute, inadequate staffing is contributing to burnout among long-term care staff, which in turn is leading to higher rates of workplace injury and staff turnover, and lower quality care.

"Those working in long-term care are burned out, underfunded, under-resourced," says LaFortune. More workers are needed to meet minimum staffing ratios, he says, "so that every single person in the system receives the same basic level of care according to their needs."

More full-time positions would also reduce dependence on part-time staff working in multiple facilities—another factor implicated in the rapid spread of COVID-19 among residents.

British Columbia was one of the first provinces to limit the movement of health care staff between facilities, "making sure that people feel gainfully employed," according to Roger Wong, a clinical professor of geriatric medicine and vice dean of education at the University of British Columbia's faculty of medicine. Other provinces implemented similar orders, but most have since rescinded them.

Problems go beyond pay

Quebec's ministry of health says several measures are underway to recruit more staff, including an accelerated training program for practical nurses accompanied by a scholarship.

The federal government has provided provinces and territories up to $3 billion to raise wages of low-income essential workers, including in long-term care, as well $1 billion through its Safe Long-Term Care Fund to improve infection prevention and control.

Even before the pandemic, "workers in long-term care were really poorly paid," says Steven Grover, a professor of medicine at McGill University. "British Columbia, which was probably as good as it got, might have been up around $19 or $20 an hour, Quebec was down in the $16 or $17 range, and Ontario was in-between," he says.

While compensation for long-term care workers in Quebec has since increased to nearly $26 an hour, Grover says it's still not enough to retain staff.

Stake-Doucet says provinces must also address the poor working conditions, including long hours, that are driving staff away from long-term care.

According to Hoffarth, the same is true for Ontario. A report by the province's now disbanded COVID-19 science table looking at lessons from the early pandemic crisis identified staffing as one of the "foremost areas to address."

Improving working conditions and creating more full-time positions with better pay could reduce staff shortages and turnover, according to the report. Yet, "years of reports and commissions calling attention to the same staffing issues have had little impact."

Accountability lacking

Some long-term care workers feel that older people are not a priority for provincial governments.

"There was a huge focus in the first wave of COVID-19 around acute care and how our intensive care units are going to be overwhelmed… but it was the long-term care sector that was hit hardest," says Hoffarth.

Starting in November, hospital patients waiting for long-term care spots in Ontario will be charged $400 a day if they refuse to move to homes not of their choosing up to 150 kilometers away. The policy aims to free up 1,800 beds in hospitals grappling with emergency room closures but has sparked outrage from seniors and advocates.

Stake-Doucet was shocked by a similar policy of Quebec hospitals offloading COVID-19 patients to long-term care homes early in the pandemic, even though those facilities had less space and fewer oxygen supplies. At the same time, officials reallocated personal protective equipment from long-term care homes to hospitals.

"Long-term care in this country is a bit like the Wild West," Stake-Doucet says. "There's very little accountability."

In a report on Quebec's handling of the pandemic in long-term care, the province's health and welfare commissioner noted that the ministry of health and social services has a paternalistic attitude toward older people, evident in the lack of consultation of seniors during the pandemic response.

According to Grover, limited government oversight exists to ensure adequate staffing and other standards. "The average nursing home [in Quebec] gets inspected once every three years, and typically gets inspected during the daytime when staffing is at its peak."

In Alberta, too, "what we're seeing from this government is just a general paralysis towards seniors' care," says LaFortune.

Spokespeople for Quebec and Alberta say older adults have always been a focus for their respective governments and both increased funding for long-term care in their 2022 budgets. Ontario did not respond to requests for comment.

Quebec will invest nearly $2.9 billion over the next five years to implement a new long-term care action plan. Most of the money will be spent on addressing staffing shortages, including hiring more orderlies, nurses, pharmacists, dentists and managers.

Alberta, meanwhile, committed nearly $3.7 billion for community care, continuing care and home care programs in its latest budget, up 6.3% from 2021–2022. The province plans to open 1,515 new continuing care beds over the next year, including long-term care and mental health beds.