What lesson can be learned from Covid-19?

Elders in long term care are a highly vulnerable population who, in the main, by virtue of physical or mental disorders must give up independent life in the community because they can no longer manage to sustain themselves. The majority suffer from some form of dementia so they are helpless to effectively advocate for themselves and are reliant on the facility or family caregivers to recognize and respond to their needs. Improved home care has allowed seniors to stay in the community longer, resorting to NH only when it is no longer possible to carry on in the community. Hence, the level of dependency and incapacity of residents of NHs and their resultant care needs have increased. In Canada just under 7% of those 65 and older live in a nursing home (NH) or seniors’ residence; but this number is age dependent and jumps to about 30% of those over 85.

In the best of situations, congregate living offers important advantages including care by trained health care staff, centralized resources like meals, physical health and personal care services, entertainment, and social interaction with peers. However, this centralization and close proximity to others poses significant hazards as was so tragically revealed by the well-publicized excess mortality rates in NHs caused by covid-19.

Some statistics revealed that during the Covid-19 epidemic private nursing homes that were part of a corporately owned chain of facilities had twice the number of infections among residents and 78% more deaths than public facilities. The majority of nursing homes (58%) in Ontario are for profit private facilities and virtually all seniors retirement residences are privately owned facilities. Naturally, private ownership means that some of the money earned by these facilities must be diverted into “profits” rather than being used for care services. These facilities and their owners were severely criticized during the pandemic for putting profits over care. However, covid-19 only highlighted already known data that mortality and morbidity in private NH facilities exceeds that in public and not for profit facilities.

NH facilities are appropriately regulated for safety, daily care, education of staff, public health measures and basic rights, but arguably, these regulations may not have kept pace with the evolving current care needs. The Covid-19 epidemic tragically brought into high relief flaws in the LTC system. Covid-19 penetrated into important cracks in our system of care often driven by outdated physical plants, zealous adherence to procedures that maximize “efficiencies” in service delivery and numbers of residents in a facility. Many of NH facilities are older, poorly designed for caring for demented, infirm residents over crowded. During the pandemic, multiperson rooms and cramped communal spaces for dining, “socializing” and entertainment facilitated transmission of the virus. Data and clinical experience during the pandemic suggested that staffing ratios were often inadequate and likely contributed to the inability of overstretched staff to properly respond to the clinical care and infection control needs imposed by the virus, culminating in higher mortality and morbidity rates. A significant, but less obvious factor in the dynamics of care provision during the pandemic was tension and sometimes breakdown in trust between management and front-line staff. This added to the already strained pressure on all parts of the system.

While covid intensified the vulnerabilities in our LTC system of care, no one working in the sector was surprised. We did not need the pandemic to know that there are many antiquated, inadequate physical facilities no longer up to modern care standards for managing complex mental, physical and social problems of resident seniors. The pandemic highlighted already known critical deficits in the ability of often dedicated staff to respond to seniors needs partly because of inadequate numbers of staff and limited training, revealed deficiencies in basic practices such as infection control and personal protection of both residents and staff.

Nursing homes in Canada are regulated by provincial governments that set standards for the function of these facilities which vary from province to province. Seniors’ residences are much more loosely regulated. Over the years regulations have addressed some of the obvious needs for instructing and guiding NHs in necessary care provision requirements attempting to define minimal acceptable standards. However, it has become clear that regulations need to be updated and enhanced based on new knowledge and data. For example, it has been well demonstrated that NHs are as much mental health care institutions as they are physical care. This means that standards and attendant regulations need to address these needs. Behavioural and psychological symptoms are present in almost all persons with dementia. There is a lot of research on how to manage such problems some of which need to be enshrined in regulations, for example creating non-restrictive safe environments for wandering, or required specialty mental services in each facility to institute and monitor medications. We know a lot about the design of dementia facilities, but this knowledge has not yet been systematically incorporated into regulations. Similarly, we have research on appropriate social environments for example, institutional noise control on NH wards that are commonly very noisy, that need to be part of explicit regulations.