COVID-19 has exposed major faults in Ontario’s long-term care, expert says

By: James Burrows

With an inquiry into long-term care approaching, difficult questions are being asked about why Ontario’s long-term care facilities were hit so hard by the pandemic. 

More than 1,700 deaths, 64 per cent of all COVID-19 deaths in the province, have occurred in long-term care homes. 

According to CBC News, for-profit homes were more likely to suffer an outbreak (48.2% for-profit; 47.9% non-profit; 44% municipal) and had a higher percentage of resident deaths due to COVID-19 than non-profit homes or municipal homes (5.0% for-profit; 3.0% non-profit; 1.1% municipal). 

Tamara Daly, a professor at York University in the School of Health Policy and Management and the Director of the York University Centre for Aging Research and Education (YU-CARE),  believes understaffing, working conditions, and government oversight are key problems that need to be addressed.

“I think that COVID exposed all of the existing faults that were already exposed in the system,” she said.  “COVID was like water in a sidewalk full of cracks. It went everywhere that the cracks were.”

Ms. Daly has been researching and writing on government policy and long-term care for many years. She believes the difference in health outcomes between for-profit and not-for-profit facilities, run by charitable organizations and municipalities, mostly comes down to working conditions and how the two sectors have approached staffing.

“What we see at an aggregate level is that when funds are taken out of the system, and a portion of those fees are used to pay shareholders and executive compensation, you don’t have as much money left within the organization. Typically, non-profits and municipal homes use fees to support higher staffing levels and in for-profit homes that money is typically being taken out of the organization in the form of profit and compensation.

“As a result, you get higher staffing levels when you’re in a not-for-profit situation. Better staffing in many homes has served as a sort of bulwark against the system level understaffing that exists.”

While Ms. Daly believes front line staffing levels can help explain the difference in outcomes, additional resources must also be devoted to cleaning in LTC facilities.  

“COVID means more work; it’s a lot of work to don and doff PPE. It takes time to do infection control properly. We can’t just think about the front line workers. We have to think about the number of people who are in the home doing the cleaning because the cleaning regimen has to be bumped to prevent an outbreak. So, if we think in terms of more simple and straightforward responses, then we would do a better job of responding to COVID.”

According to Ms. Daly, oversight of long-term care has also changed in recent years, and this has led to even less pressure on many homes to improve conditions.

“About two years ago, the ministry went away from what are called Resident Quality Inspections (RQIs). Only 9 RQIs have been performed in the past year, and we have 625 homes across the province. The RQI is a bit more of a 360-degree examination. They go in, and they spend about two weeks investigating the home … that stopped happening to the extent that it should, and we’ve had more what are called critical incident inspections or complaint inspections, and those are very circumscribed.”

Even if problems are discovered, Ms. Daly said there are few enforcement mechanisms available. 

“We have a fairly toothless enforcement capability. Our inspectors didn’t really shut down homes until it came to COVID. It’s very rarely used, where the ministry takes over a home or stops allowing new residents to be admitted. We do have some consistently non-compliant operators, and you can go through the inspection reports, and you can see that non-compliance.”

According to Ms. Daly, revamping oversight with a focus on staffing levels and working conditions could go a long way to improve overall care and how COVID-19 is effectively managed in Ontario’s LTC homes. 

“I think if you were to start to publicly report on turnover rates and the proportion of time without an RN, you’d start to see organizations changing some of their behaviour. When you pay attention to the working conditions, you can at least lay the groundwork for good quality care to happen. But if you have poor working conditions, the only way you can get good quality care is completely on the back of the workers.”