By Shawn Whatley
Munk senior fellow
Macdonald-Laurier Institute
Nursing homes struggled long before
the COVID-19 pandemic 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 per cent 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 Doug 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
per cent of COVID-19 deaths occurred in LTC home and retirement homes.
As such, new COVID restrictions limit occupancy to two, which removes at
least 5,000 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 – such as those with dementia – 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 per cent 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.
