ViewPoint: Nursing Homes and Covid-19

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Long-term care (LTC) and retirement homes have sustained 7.2% of the Canadian total COVID-19 cases, but 72.3% of total deaths.

Deaths in Canadian LTC homes from COVID-19 made up 72.3% of the total, while OECD countries overall reported LTC COVID-19 deaths at an average of 38% of their totals.

A larger proportion of Canada’s seniors live in LTC homes than in the other countries in the comparison.  But, crucially, Canada’s LTC facilities have fewer health care workers per 100 residents than the OECD average.

87% of all COVID-19 cases within LTC facilities in Canada, and 93% of LTC deaths, were in Ontario and Quebec.

The high proportion of COVID-19 deaths among seniors in LTC homes has exposed long-standing deficiencies in long-term care in Canada generally, but Ontario specifically..

In April 2020, the governments of Quebec and Ontario each requested assistance from the Canadian Armed Forces (CAF) to help manage COVID-19 outbreaks at 20 LTC facilities in Quebec and 5 in Ontario.

The CAF submitted reports, which noted insufficient supplies of personal protective equipment, poor quality of care, chronic under-staffing and inappropriate behaviour towards residents.

Ontario’s Long-Term Care COVID-19 Commission issued a report in October 2020,  recommending increasing the levels of staffing in LTC homes, and improving infection prevention and control measures.

A June 2020 report on LTC home staffing by the Royal Society of Canada stated that “the pandemic just exposed long-standing, wide-spread and pervasive deficiencies in the sector” and made recommendations to address “the workforce crisis in nursing homes.”

The report noted that nurses are the primary regulated health care professionals within LTC facilities, with physicians only rarely on site.

But nurses provide little direct care to residents and 90% of direct resident care is provided by unregulated and unlicensed care aides or personal support workers (PSWs). The report noted that care aides and PSWs:

– receive low wages
– receive minimal and variable education across the country
– very often work part-time without benefits
– are often contracted through agencies and are unfamiliar with the LTC facility where they work
– are never included in decision-making and family conferences, despite spending the most time with residents
– have high levels of work-related stress and burn-out
– 90% are women, 70% of whom are older than 40 years, often from racial minorities and marginalized groups
– 25-30% work more than one job
– 75% report having insufficient time to properly complete care tasks

The report made recommendations for national standards for staffing and training.

Long-term care facilities continue to be understaffed, poorly regulated and vulnerable to predation by for-profit conglomerates and private-equity firms.

58% of LTC homes are privately owned, 24% are non-profit and 16% are municipal.

Private corporations, left to their own interests and devices, will not keep staffing at levels where they can provide solid adequate care.

For-profit LTC homes have larger COVID-19 outbreaks and more deaths of residents from COVID-19 than non-profit and municipal homes, with a 1.96-fold increase in the extent of outbreaks and a 1.78-fold increase in the number of resident deaths due to COVID-19, compared with non-profit homes after adjusting for surrounding health region numbers.

This finding was mediated mainly by the higher number of for-profit homes with outdated design standards (which meet or fall below 1972 standards) and higher resident populations.

All comparisons favoured municipal homes, which generally operate with the support of municipal contributions and benefits that allow for greater staffing levels and capital expenditures

1996, when Mike Harris got rid of the resident-staff ratio, was when the present-day nursing home crisis began.   After that, staffing levels dropped and it became harder to take care of residents.

No homes in Ontario are working at the proper staffing levels, and staff are over-loaded with too many responsibilities and too little time to perform them.   The province needs to mandate staffing ratios again.

Ontario has not had a staffing standard since Premier Mike Harris and the Ontario PCs removed it.

Former Liberal Premier Dalton McGuinty – whose health minister publicly cried in response to a 2003 Toronto Star investigation of long-term care horror stories – promised to reinstate a minimum care standard but failed to do so.

Twenty-five years ago, Mike Harris and his Progressive Conservative party ousted Bob Rae’s NDP government in Ontario, starting the so-called “Common Sense Revolution.”

Pledging to tackle Ontario’s deficit, the Harris government pushed tax reductions and slashed public spending on health care, education and social services. The government closed hospitals and eliminated the jobs of thousands of nurses, infamously comparing them to obsolete hula hoops.

Harris compared the laid-off hospital workers to the people who lost their jobs after the hula hoop fad died down in the early 1960s.

How Ontario cared for seniors did not escape the cuts. Harris’ government reduced the public role in long-term care, relaxing regulations and lessening public oversight. This wasn’t the start of Neoliberalism and privatization, but it certainly opened the doors much, much wider.

The Harris government ignored the law passed in 1994, that would have created a public home care system like every other province in Canada has.  Instead, they created the Community Care Access Centres (CCACs) and then forced them to divest services — even when it was demonstrated that privatization would cost more in the long run. This was the start of the despised system of “competitive bidding” in Ontario’s home care.

Today, we have 14 Local Health Integration Networks (replacing the CCACs), each with their duplicate administrations.  The Harris government opened the system to for-profit bidders and today chain for-profit companies have gained the majority of the “market share” as they call it.

Under the Harris government, the growing corporate business of caring for seniors flourished and corporate players such as Sienna Senior Living, Revera, Extendicare and Chartwell expanded their reach, providing seniors with independent living, assisted living and long-term care housing – for a price.

In the past, Ontario did have a standard of care, but it was taken away by the Mike Harris Progressive Conservative government.  At the time of its abolition, the standard was insufficient – it was set at only 2.25 hours per resident per day.  Since that time the homes have changed dramatically: residents are much more impaired, with higher levels of dementia, disability and medical acuity.   Requiring more intensive care.

CUPE and OCHU (Ontario Council of Hospital Unions) have been campaigning for a legislated minimum average of 4.1 hours of nursing and personal care per resident per day in long-term care (LTC) facilities.

There has been total consensus on the necessity of legislated staffing standards among advocates, including family and resident councils as well as unions.

To its credit, in November, 2020, the Ontario Ford government has acted on the key recommendation made by the Ontario’s Long-Term Care COVID-19 Commission — that the province will mandate having four hours of daily care per patient in long-term care homes.

The only opposition to these standards was the Ontario Long-Term Care Association (OLTCA), which mainly represents for-profit nursing homes.

Although the OLTCA acknowledges understaffing as a critical issue, it doesn’t want a legislated minimum standard. In fact, it has called for “flexible staffing.”  OLTCA is saying they need more staff, but they’re asking to substitute lower trained staff for higher trained staff.

Lower trained and lower paid.

It’s pretty clear that in addition to more staff, LTC needs staff with the right kinds of training.

The Canadian Center for Policy Alternatives (CCPA) in a report says Ontario needs to invest $1.6 billion to raise staffing levels in long-term care to the widely-recognized minimum standard of 4.1 hours of direct daily care.

An additional $285 million would fund wage enhancements to bring non-unionized workers up to the standards of unionized employees.

Although the required investment would boost long-term care spending by 40 per cent, it would only be a 1.2% increase in the entire Ontario budget.

In other words, a relatively small amount of money has been required to improve working and living conditions in nursing homes.

So what has prevented successive Ontario governments from taking action even as lack of staffing has known to be a major barrier in providing care?

The CCPA report, points to Ontario’s decades of fiscal restraint.  Ontario’s per capita public spending is the lowest across Canada – and has been the case for long before Doug Ford got elected.

The problem lies within the logic of Neoliberalism, whereby governments have reduced public spending to pay for tax cuts (generally for the wealthy), while increasing privatization.

According to the Financial Accountability Office, based on 2017 figures, Ontario’s budget would be $29 billion more if it spent at the same level as the average spending of other provinces.

In other words, there have been viable ways to pay for proper staffing all along. But successive governments have chosen to limit the spending capacity of the state.

The CCPA presented an alternative 2019 budget for Ontario that would increase revenue by $8.3 billion. Among the suggestions included reversing the Ford government’s tax cuts of $3.3 billion and increasing the corporate income tax rate by merely two percentage points to generate additional revenue of $2.4 billion.

The current corporate tax rate in Ontario is 11.5%, which the Liberal government gradually decreased from 14% in 2010.   Personal income taxes in Ontario have also been relatively low ever since the 30% reduction during the Mike Harris years (over half the Harris tax cut wealth went to the top 10% income earners).

The PSWs who provide the bulk of bedside assistance still earn wages disproportionately low for the demands of their job.

The conditions were bad before COVID hit, where PSWs were forced to work more than one job to make enough money to make ends meet.

Staffing levels in Ontario long-term care homes are at their barest, with many new PSWs quitting due to the overwhelming stress of the job.

Because of chronic under-staffing there aren’t enough PSWs to do the work, to feed and dress and bathe patients, and if residents have dementia or disabilities, it can be impossible to properly care for residents within the time frame they are given.

PSWs were also given a $4 pandemic pay bonus for the first four months of the pandemic crisis, but that’s since been withdrawn.

PSWs just entering the workforce aren’t prepared for what they’ll face.  One new PSW graduate showed up for her first day at work, went out on her lunch break and never went back.  She switched to waitressing, a lot easier work, less stressful and better paying.

PSWs just aren’t paid enough for the work.  People are getting burnt out and tired and discouraged.

Most PSWs love the work, but homes are consistently short-staffed and that means clients miss out.  They get just the essentials, their medication, that’s it… Personal care?   Nothing extra.  It’s been going on for a while, it’s just gotten worse with the pandemic.

Nursing homes need to provide full time jobs with better pay, regular, predictable schedules, with benefits and vacation time and pensions to attract and retain staff, instead of pushing them away.

The wage just isn’t there for what the work is, especially as dangerous it is during a pandemic.

Even full immunization of residents and staff will not allay the tragedy that has unfolded in long-term care — not just the deaths, but also the isolation and neglect, the stories of nursing home residents who’ve gone weeks without being showered or having their teeth brushed.

Residents with dementia have suffered terribly from a lack of human contact, leading to depression and loss of weight, mobility and speech.

The awful truth is that long-term care was designed to fail years before Covid-19.

This failure has to do with austerity, and it has to do with a Neoliberal agenda.

Nursing home operators have long complained that the Ontario Ministry of Health and Long-Term Care doesn’t pay them enough to provide adequate care.  But the business is not, apparently, a bad one to be in.  58% of nursing homes are for-profits, and the sector has been swallowed up by corporate chains and investment firms whose involvement correlates to lower staffing and worse care.

Now the LTC industry is pleading poverty, while paying lobbyists to seek increased funding and protection from lawsuits.

In response, Ontario’s Progressive Conservative government has introduced new legislation that would shield itself, as well as LTC homes, from COVID-19-related lawsuits, as long as the parties acted in “good faith” during the pandemic.  It places a legal wall around long-term care homes – some of which are currently facing class action lawsuits.

One lawsuit in particular, accuses 96 long-term care homes as well as the Ford government of negligence during the pandemic.

“The government of Ontario and the defendant owners and operators of long-term care homes ignored numerous red flags and failed to adopt timely and reasonable infection prevention and control measures to avoid exposing the elderly to the risk of infection with COVID-19,” the lawsuit claims.

By requiring challengers to prove that gross negligence has taken place, the government has set the bar high enough to prevent litigation from proceeding.

The COVID-19 pandemic has shown that the long-term care system is fractured along the lines of privatization, underfunding, and understaffing.

The absolute tragedy currently taking place in long-term care shows that the for-profit interests currently driving decision-making in long-term care in Ontario do not put patients first.

This crisis should be seen as a moment of clarity, where we as Ontarians can choose what values we want to build into a new long-term care system. The Ontario government must work with the federal government, labour organizations, health care stakeholders, and community members to develop a plan for long-term care that centres on public funding and control, respect for workers, and respect for patients.

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