We cannot solve the collapse of long-term care by increasing our commitment to the same “social compact,” writes Shawn Whatley.
By Shawn Whatley, December 9, 2020
Nursing homes have struggled long before the COVID-19 pandemic had arrived in Canada. Now, during the second wave, many front-line clinicians say our long-term care (LTC) system has all but collapsed.
In the pre-COVID era, patients waited a median of 159 days to get a bed in Ontario, with some areas at 263 days. Thus, it was not uncommon for some patients to wait more than one year, and up to 2.5 years in some areas, if they stood at the long end of the wait-time curve. The Conference Board of Canada raised the alarm 20 years ago and predicted we will need 199,000 more LTC beds in Canada by 2035.
Given chronic shortages, wait lists had grown by 78 percent in Ontario, between 2011 and 2018, with 35,000 patients waiting. Ontario only had 78,000 beds pre-COVID, and they were all full. Premier Ford promised 15,000 additional beds, in 2018, to help fix the crisis.
Then COVID-19 hit. The pandemic turned LTC struggles into outright failure.
I spoke with our regional homecare coordinator. “We just have no beds,” she said. “We are waiting between one month and a year for emergency placement."
She explained how all the older nursing homes cannot accept patients. They were built with three or four beds to a room. In its assessment from the first wave back in the spring, the Canadian Institute for Health Information (CIHI) reported 80 percent of COVID-19 deaths occurred in LTC home and retirement homes. As such, new COVID restrictions limit occupancy to two, which removes at least 5000 beds from the system. Half of the homes in central Ontario cannot accept new patients anytime in the foreseeable future.
Even when a bed opens up, many homes can only accept patients within strict limits on care. For example, wandering patients are standard fare for long-term care. But nursing homes find it extremely difficult to isolate a wandering patient for 14 days after admission, to guarantee a new patient is COVID-free. Most homes simply cannot do it with current staff and structural limitations.
Given that 45 percent of nursing homes are rural, and rural patients do not have other supportive housing options available, many patients are left to make-do at home. Case in point, the coordinator and I discussed two families. She had already assigned maximum hours of personal support allowed. We were fortunate to have excellent personal support workers (PSWs) willing to work in our community. But we still needed more help, especially in the evenings.
“It is virtually impossible to find PSWs who can work in the evenings. It’s up to families to care for these patients now,” the coordinator said.
Alzheimer’s patients often experience “sundowning”: they become more awake around the same time the rest of the family goes to sleep. Support staff fill the home during the day when dementia patients are relatively manageable. Come nighttime, many patients go from door to door, checking locks and trying to get outside. At some point, patients need more than any private residence can provide. Today, that point comes, too often, when patients can no longer walk to the bathroom. Crude facilities set up next to a bed in the Livingroom would horrify most people.
"Long term care has completely collapsed in our area. Many families are simply taking their parents to the emergency,” the coordinator told me.
Andre Picard, health journalist, wrote an excellent review of LTC homes for the Globe and Mail. While necessary, protecting the elderly from infection makes life in an LTC home even more challenging. The pandemic’s ‘one facility’ rule reduces available staff by restricting part-time staff to working at only one location. Facing this staff shortage, over-crowded facilities struggle to maintain care at a level of dignity patients deserve. The elderly experience isolation, depression, and deconditioning, in addition to bearing the bulk of COVID-related mortality in Canada.
What can be done?
We cannot blame COVID-19 alone for the current LTC crisis. The collapse of long-term care means that acute-care hospitals overflow with patients who do not need acute care. Back in January, before COVID upended things around the world, the acute-care bed crisis was so dire in Brampton that its town council unanimously voted to declare a state of emergency due to hospital overcrowding. Weeks later, COVID captured media attention.
Ageing and long-term care present a challenge to countries around the world. And solutions abound. People have found success with everything from patient hotels to finding options for care outside of LTC. For example, CIHI reported in August that one in nine LTC patients could be cared for at home.
We do not have a shortage of solutions. We have a shortage of political will. Matching patients who need care with provision of care is easy. The politics of figuring out how to pay for it is hard. Governments need to either allocate much more revenue to close what the Conference Board predicted would be the nearly 200,000 bed deficit, or they should warn citizens to make plans of their own. Giving the impression that the state will take care of everything – while taking credit for voters’ gratitude – always ends poorly, when the music finally stops.
Political leaders must make clear what government covers and what it does not. Despite 54 percent of LTC homes being privately owned and operated, many voters seem to assume that their tax dollars supply all the care required. Ownership itself might play a minor role for care inside a heavily regulated industry such as health care. As journalist Neil Macdonald wrote for the CBC, "Usually, Canada's elected leaders at least publicly play along with the fiction that every Canadian receives proper treatment, free of charge, in a timely manner. This has been the social compact in Canada for more than half a century: our governments tax everything that moves, and even tax each other's taxes, but in return, our medical needs are seen to free of charge, never mind some budget imposed on the hospital."
COVID-19 has poked the final hole in long-term care’s already leaky boat. We cannot solve the collapse of long-term care by increasing our commitment to the same “social compact.” Adopting solutions will require a level of honesty and will that most political leaders would prefer to avoid. LTC has become the single biggest policy issue facing politicians in the health policy space. We cannot avoid it. The even bigger question is whether we will try to patch our leaky boat or find a new one altogether.
Shawn Whatley is a physician, past president of the Ontario Medical Association, and a Munk senior fellow at MLI. He is author of the book titled When Politics Comes Before Patients—Why and How Canadian Medicare is Failing.