The long-term care homes and regions that acted early and proactively to take precautions fared better throughout the pandemic

The current post shares the executive summary of the April 30, 2021 report of Ontario’s Long-Term Care COVID-19 Commission. The headline is based on one of the comments at the conclusion (in the second to last paragraph) of the executive summary.

Click here to access the report >

Click here to access the transmittal letter >

Click here for previous posts about COVID-19 >

In the text that follows below, I have added a paragraph break to bring emphasis to the following note:

Dr. Williams told the Commission that “the evidence wasn’t there for that.” He did not act as if asymptomatic spread might be occurring and did not issue directives on that basis. He stated that the evidence was not clear until the summer.

The executive summary of the report reads:

Executive Summary

To care for those who once cared for us is one of the highest honours.

–Tia Walker, author

In late 2019, a novel coronavirus emerged in Wuhan, China. It quickly spread around the globe. In March 2020, the World Health Organization declared the virus that came to be known as COVID-19 a pandemic. Life in Canada, as in most countries, ground to a halt. As COVID-19 took hold through the spring of 2020, it ravaged the elderly, particularly those in congregate settings such as long-term care homes. By late spring, it was apparent that the infection and death rates in Ontario’s long-term care homes were among the worst in the world. Of all COVID-19 deaths in Ontario in 2020, 61 per cent were long-term care residents. By the end of April 2021, 11 staff and almost 4,000 residents in Ontario’s long-term care homes had died.

As the rate of infections and deaths in long-term care mounted, a horrified public demanded answers: How – in a wealthy province like Ontario, with a sophisticated health and social welfare system – were the elderly dying at such alarming rates?

The provincial government created the Long-Term Care COVID-19 Commission in the summer of 2020, as the first wave of the pandemic eased, to investigate the cause of the spread of the virus in long-term care and how it affected residents, staff, volunteers and family members. The Commission’s purpose was to shine a spotlight on this tragedy, to determine its causes and to make recommendations to help prevent the future spread of disease in long-term care homes.

That spotlight revealed that Ontario was not prepared for a pandemic and that the province’s long-term care homes, which had been neglected for decades by successive governments, were easy targets for uncontrolled outbreaks. Staff, long-term care residents and their families suffered terribly during this pandemic. Residents and long- term care staff who lost their lives to COVID-19 paid the ultimate price.

The province’s lack of pandemic preparedness and the poor state of the long-term care sector were apparent for many years to policymakers, advocates and anyone else who wished to see. Ontario’s policymakers and leaders failed during those years to take sufficient action, despite repeated calls for reform. Rather, the commitment and resources needed to prepare for a pandemic and address long-neglected problems with long-term care were shunted aside in favour of more pressing policies and fiscal priorities. Many Ontarians took little or no notice until there was a parade of sickness and death in long-term care homes.

In 2003, Ontario was hit hard by an outbreak of Severe Acute Respiratory Syndrome (SARS). After SARS, several reports were prepared outlining what needed to be done to ready the province for a pandemic. All warned of dire consequences if the province failed to take these actions. For a time, those warnings were heeded. In the years following SARS, the province made influenza pandemic plans, created a stockpile of emergency supplies and began earnest preparations.

As the years progressed, however, pandemic preparedness ceased to be a priority; instead, it gave way to the “tyranny of the urgent.” Public health scares such as H1N1 and Ebola resulted in passing attention being paid to emergency readiness, but there was no lasting resolve to ensure the province was ready for a pandemic. By the time COVID-19 arrived, successive governments had allowed 90 per cent of the province’s stockpile of personal protective equipment (PPE) to expire and be destroyed, without replacement. There was no comprehensive plan to address a pandemic.

Worse yet, there was no plan to protect residents in long-term care.

Pre-pandemic, there had been numerous warnings that Ontario’s long-term care sector needed a significant overhaul. The infrastructure in many of the homes was outdated and not up to current standards. Containing a virus in such a setting would prove to be difficult.

In addition, the long-term care workforce was stretched to the limit long before COVID- 19 struck. Several reports had called for additional staff to care for a population that suffered from more dementia and other complex medical issues than in prior generations. And yet, there was no plan to provide a surge of workers to replace those who inevitably could not or would not come to work in a pandemic. In most of the homes badly hit by COVID-19, the staffing collapsed. There were too few staff to take care of the residents. Those who continued to work were overwhelmed and overworked.

Adding to this already tenuous situation, much of the workforce lacked crucial training in infectious disease prevention and control and was also missing the leadership needed to guide them through these difficult times. In spite of the heroic efforts of those staff who remained on the front lines, long-term care residents continued to get sick and die.

Sadly, the second wave of the pandemic was more deadly than the first in Ontario’s long-term care homes. The story of how this province failed to protect its most vulnerable residents during the second wave is still unfolding. It is clear, though, that problems such as insufficient staff, lack of training and aging home infrastructure were too deeply ingrained to overcome in the period between the first and second waves. It is plain and obvious that Ontario must develop, implement and sustain long-term solutions for taking care of its elderly and preparing for a future pandemic.

The balance of this summary will explain how this investigation was conducted and the major issues it identified as having contributed to the suffering and death experienced in Ontario’s long-term care homes. It is the Commission’s hope that Ontario’s policymakers and leaders will – this time – heed the warnings.

Overview of the Investigation

The Commission conducted its investigation during the second wave of the pandemic, from September 2020 to March 2021. Despite the hard-earned lessons of the first wave, COVID-19 continued to batter long-term care homes during this time. The Commission heard from many stakeholders, including those on the front lines of the outbreak. These included families, residents, staff, hospitals, long-term care home licensees and operators, public health units, inspectors, experts, researchers, government officials, associations, advocacy groups, and others. In just over six months, the Commission heard from more than 700 people.

Because the investigation was conducted during the pandemic, the Commission received information in real time. As the issues confronting long-term care became clearer, the Commission issued two sets of interim recommendations. Consistent with its Terms of Reference, the Commission has not made any findings of fact with respect to civil or criminal responsibility of any person or organization.

It is important to specifically acknowledge the heart-wrenching stories that many residents, families and staff shared with the Commission. They suffered terrible trauma and yet were still willing, courageously, to tell their stories, allowing the Commission a glimpse of what it was like to live through this experience. People have suffered immeasurable loss. The Commission learned a great deal from these accounts. It is hoped that in sharing their experiences and their voices, those who came forward will help to spare others in the next pandemic.

Beyond thanking the surviving residents, residents’ family members and staff for reliving these painful events, it is now up to the province to do something about the problems these people described to the Commission. The resolve to act on this Commission’s recommendations cannot fail or falter with the passing of the next news cycle or economic downturn.

Many of the lessons of SARS were forgotten. We cannot forget the lessons learned from this pandemic.

The Commission makes its recommendations with the singular purpose of protecting long-term care residents, staff and their loved ones in the years to come.

Another pandemic should be expected. Next time, Ontario must be ready.

Overview of the Report

This report focuses on the actions and inactions that significantly contributed to the devastation experienced in long-term care during the COVID-19 pandemic.

The report strives to give readers an understanding of the state of the long-term care sector and pandemic preparedness before COVID-19. These topics are addressed in chapters 1 and 2. Chapter 3 addresses the response to the pandemic and some, but not all, of the successes and failures on this front. Chapter 4 looks at promising developments in long-term care. Ontario is fortunate to have many academics, advocates and providers who are continually developing new strategies to improve the well-being of the province’s elderly and long-term care residents. Chapter 5 contains the Commission’s recommendations. The appendices at the end of the report provide a primer that outlines the roles and responsibilities of key players in Ontario’s health and long-term care sectors, and a brief review of the Commission’s investigation process. They also include the Commission’s interim recommendations.

Long-Term Care before COVID-19

When she appeared before the Commission, the Minister of Long-Term Care, Dr. Merrilee Fullerton, used the term “neglected” to describe the long-term care sector and its population. Her description also applies to the attitude taken toward this population by successive governments that were unwilling to tackle complex and costly problems. Many of the challenges that had festered in the long-term care sector for decades – chronic underfunding, severe staffing shortages, outdated infrastructure and poor oversight – contributed to deadly consequences for Ontario’s most vulnerable citizens during the pandemic.

Ontario’s legislative promise to long-term care residents is to provide residences that are “a safe, comfortable, home-like environment” that support “a high quality of life.” Where legislated standards are not met – or the safety, security or rights of residents are compromised – the legislation further mandates that corrective action be taken. In order to ensure that the needs and safety of residents are being met, collaboration and mutual respect among the residents, their families, long-term care providers, caregivers, government, staff and others are essential.

The challenge of meeting residents’ needs and ensuring their safety has increased over the last 20-plus years. As mentioned above, the health needs of residents in Ontario’s long-term care homes have become increasingly complex. With the present funding model, it has become difficult to provide the required level of care. This more medically complex population is susceptible to infectious diseases such as influenza, and outbreaks are common in long-term care homes. At the same time, the demand for long-term care has continued to grow along with the province’s aging population, resulting in pressure to quickly expand an overtaxed system.

Staffing at long-term care homes has long been recognized as a significant problem. Constant shortages, excessive workloads, high turnover rates and heavy reliance on part-time workers are common in the sector. This is difficult work and it is largely done by women, with a very high representation of racialized, immigrant women in personal support worker (PSW) roles. The province has received multiple reports that clearly set out the staffing shortfalls and the solutions required, yet few changes have been made.

The system of funding, management and oversight in the long-term care sector compounds these problems. Long-term care in Ontario is funded by the provincial government, with contributions from those residents who have the means to do so. While the government has ultimate oversight responsibility for the sector, it does not deliver long-term care services. Instead, it relies on municipal, not-for-profit and for- profit providers to supply care services to the legislation’s standards and requirements.

With an aging population and inadequate infrastructure, the demands for long-term care spaces and staff will increase significantly in the years to come. Years of neglect of long-term care have magnified this challenge. From 2011 to 2018, the population of those over 75 increased by 20 per cent (from 876,886 to 1,053,097). However, there was only a 0.8 per cent increase in the supply of long-term care beds – a net gain of 611 beds. There are now more than 38,000 Ontarians on the waitlist for long-term care beds. In this report, the term “bed” is used as shorthand to describe a space in a long- term care home and encompasses all aspects of care provided to a long-term care resident.

If Ontario continues to care for its seniors as it does currently, by some credible estimates the province will require an additional 96,000 to 115,000 long-term care beds by 2041 to accommodate the increased demand. While other solutions need to be explored, including better home care support, it is clear that more and newer beds will need to be built.

While the Commission repeatedly heard that COVID-19 has seriously undermined the reputation of for-profit homes, the need for tens of thousands of new and redeveloped beds will require significant capital. The substantial investment required to build new beds and redevelop old beds will amount to billions of dollars. The private sector has available capital for this task. There is, however, no reason that the accommodation and care of residents need to be handled by the same entity that creates or redevelops the beds.

Currently, there are not-for-profit, for-profit, and municipal homes. The characterization of homes based on their tax status is not helpful. It is more pertinent to consider if the owner is involved in long-term care as part of its mission or in order to profit. Some owners whose tax status is for-profit operate as mission-driven entities. Others have shareholders and owners whose motive is profit.

For example, in some cases, for-profit homes are owned by investment vehicles such as Real Estate Investment Trusts (REITs). While the REIT holds the licence and, therefore, the legal responsibility for the residents’ care, it hires a separate company to run its long-term care home and provide that care.

This may be an excellent financial arrangement for the investors, but it is more difficult to understand why it is a suitable arrangement for resident care. Care should be the sole focus of the entities responsible for long-term care homes. Mission-driven entities, whether for-profit or not-for-profit, should have the responsibility for the care of residents.

The same does not apply to building infrastructure and other elements not associated with resident care. It is worth noting that the province already has privately funded hospitals, courthouses and light rail systems. While each example is slightly different, all involve the construction of infrastructure that is paid for upfront by private investors who receive a return on their capital with profit over time. However, others actually operate the infrastructure – the courts, hospitals, etc. – once built.

The province should adopt this approach for long-term care.

This approach would allow the private sector to satisfy the demand for long-term care facilities by accessing the capital required to construct the facilities; it would simultaneously ensure that residents receive care from a mission-driven provider whose focus is care, not profits. In a manner similar to that employed in the hospital sector, the province would then fund annual payments for an agreed-upon number of years sufficient to ensure that the developers recover their investment and an agreed-upon rate of return. This procurement strategy would also allow the province to require, upon the conclusion of this period, that the province (and not the developer) would own the long-term care facility and the land on which it is built.

Now is the time to revisit the delivery model for long-term care and adopt a better way to provide care for Ontario’s seniors.

The oversight and enforcement of legislative standards is another problem facing long- term care. In her inquiry report on the Safety and Security of Residents in the Long- Term Care Homes System, released in mid-2019, the Honourable Justice Eileen E. Gillese found that the long-term care home inspection process required improvement. The pandemic exposed significant shortcomings with enforcement, which did little to ensure adequate infection prevention and control (IPAC) measures were in place in homes before the arrival of COVID-19.

Finally, the state of the long-term care infrastructure is an ongoing concern. Ontario has many older homes that were constructed at a time when the building standards allowed ward-style rooms with three or four beds and shared bathrooms, making the spread of disease easier. The older standards were not designed to meet current IPAC practices. Not surprisingly, these older homes were hit hardest by COVID-19. While the government has and is trying to upgrade older homes, these homes nevertheless comprise a large percentage of the long-term care homes in Ontario.

The issues outlined above are by no means an exhaustive list of the challenges that faced the long-term care sector prior to the COVID-19 pandemic. Not all COVID-19 deaths could have been prevented. However, these problems combined to create fertile ground for excess mortality.

Not one of these long-standing issues was a surprise to the government or to those who have worked, lived or advocated in the long-term care sector.

Ontario’s Pandemic Preparedness

Like many jurisdictions, Ontario was unprepared for the COVID-19 pandemic. However, this need not have been the case. In 2003, Ontario bore the brunt of another deadly viral outbreak, SARS. After SARS, the Ontario and Canadian governments commissioned several studies that highlighted the failings of health and emergency response systems when it came to preparing for a deadly virus, at both the national and provincial level.

Excellent recommendations came out of those studies and, for a time, Ontario paid attention to them. The province strengthened its defences and began to prepare the health care sector to respond to a pandemic. Outbreaks of H1N1 and Ebola in 2009 and 2014–16, respectively, were grim reminders of the threat a disease outbreak could pose.

Despite these stark reminders, Ontario lost the will to make pandemic preparedness a priority. By 2017, the Auditor General was warning the government about major weaknesses in the province’s emergency management programs that could make Ontario vulnerable to a large-scale emergency.

The Chief Medical Officer of Health (CMOH) told the Commission that, when the province is not in the middle of a public health emergency, pandemic preparedness often falls by the wayside in favour of more immediate concerns: “It is hard to keep [pandemic preparedness] always at the front table because the tyranny of the urgent always pushes things aside.”

This is exactly what happened in the years leading up to the COVID-19 pandemic. The Ministry of Health did not do enough to meet its legislative obligation to plan for a pandemic, and the Ministry of Long-Term Care did not take sufficient steps to ready the vulnerable long-term care community.

As a result, the province had no up-to-date, cohesive pandemic plan in 2020. Ontario’s most current plan was primarily designed to address an influenza pandemic and had not been updated since 2013. Subsequent government attempts to expand the scope of the plan beyond influenza were incomplete by the spring of 2020. Compounding this issue, neither Ministry conducted simulations or drills for a pandemic. In particular, there were no drills focused on long-term care, where some of the most at-risk Ontarians live.

In 2017, before COVID-19 hit Ontario, the majority of the province’s stockpile of emergency health supplies, amassed after SARS, had expired and been ordered destroyed. By 2019, the province had destroyed 90 per cent of the stockpile, including surgical and N95 masks; these items were not replaced, even though the risks the stockpile was meant to address had not vanished. Instead of replenishing the stockpile, successive governments spent three years deliberating procurement policy options. Added to this, many homes lacked the necessary PPE to protect residents and staff. Prior to the pandemic, the province did not track the status of PPE supplies in long-term care and so was not aware of their supply status.

The economic cost of the pandemic has been significant, dwarfing the cost of proper pandemic preparation. Ontario’s gross domestic product declined by approximately $45 billion as a result of the pandemic. In addition, the province anticipates approximately $25 billion in additional expenses and has allocated approximately $1.4 billion to purchase PPE. These numbers do not include Ontario’s portion of federal spending. Against these numbers, the cost of properly preparing for a pandemic is insignificant.

COVID-19 may have arrived unexpectedly in 2020, but it was entirely predictable that a deadly pathogen would sweep the world at some point. It was also predictable that a pandemic could disproportionately impact Ontarians in long-term care. Successive governments should have taken the warnings and lessons from SARS seriously. They should have proactively prepared instead of taking an episodic and reactive approach. If they had, the human and financial costs of the COVID-19 pandemic would have been significantly reduced.

Pandemic preparedness must be a constant priority. The lives of those most at risk depend on it.

When COVID-19 slammed into an already vulnerable long-term care sector, the cost of that lack of preparedness was on full display.

The COVID-19 Crisis in Long-Term Care

When COVID-19 struck Ontario, it devastated the long-term care sector. At the time of writing, 11 staff and almost 4,000 residents had lost their lives. Deaths among long-term care residents represent more than half of all of Ontario’s COVID-19 deaths, even though long-term care residents make up only 0.5 per cent of the population. Many more residents and staff were infected, with a reported 14,984 resident and 6,740 staff cases by March 14, 2021.

As noted above, the long-term care sector was not sufficiently prepared for a pandemic, though it should have been. Making the problem worse, the province’s response was slow and reactive when the virus arrived and began to spread. Critical decisions came too late, and the government’s emergency response system proved inadequate to protect staff and residents from COVID-19.

In the aftermath of SARS, it was acknowledged that unless one acts quickly to contain a virus, the virus will gain the upper hand. Similarly, it was recognized that, in order to protect the public, public health authorities should follow the precautionary principle. That principle dictates that public health protection measures need not wait for scientific certainty before implementation. In his 1997 report on Canada’s tainted blood crisis, the Honourable Justice Horace Krever described this principle as follows: “[w]here there is reasonable evidence of an impending threat to public health, it is inappropriate to require proof of causation beyond a reasonable doubt before taking steps to avert the threat.” In an emergency, speed often trumps perfection. Unfortunately, in the first five months of 2020, many provincial public health measures were implemented too late to have a positive impact in long-term care homes.

The first government discussions about the new virus occurred in the first week of January 2020. Initially, preparations in Ontario focused on hospitals and not long-term care homes. In 2003, SARS had ravaged hospitals, and the province wanted to avoid a repeat of that experience. Early preparations to protect hospitals from the emerging COVID-19 outbreak included transferring patients from hospitals to long-term care homes to free up hospital beds; this effectively reduced the space available in long-term care homes for isolation of COVID-positive residents, contributing to the potential spread of the disease.

As a representative from the Ontario Hospital Association told the Commission, “I think it is fair to say that right from the very beginning long-term care has been treated separately from the rest of the health care system when it comes to the coordination of the pandemic response.”

There were ample warnings, however, that the virus posed a risk to long-term care residents. Those warnings were not acted upon with sufficient speed. In February 2020, reports surfaced of outbreaks among cruise ship passengers such as those on the Diamond Princess, and in churches and prisons in other countries. The rapid spread of the disease in congregate settings such as these – places where many people live or gather in close proximity to each other – showed that long-term care homes would also be at risk. It had also become evident by this time that the virus posed a higher risk to the elderly and those who had pre-existing health issues.

In late February 2020, a long-term care home in Washington State experienced a COVID-19 outbreak. On March 7, Canada’s first long-term care outbreak was reported in British Columbia. By March 11, long-term care homes in Italy had suffered 827 deaths and 12,462 confirmed cases. One expert told the Commission that, at this time “we knew that the virus almost seemed to target care settings. The initial recognition of community transmission in both Washington State and British Columbia was associated with high mortality outbreaks in long-term care.”

On February 27, the Chief Medical Officer of Health chaired a meeting that included representatives from Public Health Ontario, the Ontario Hospital Association, physicians, and Ministry of Health personnel at which “[m]ost expert attendees agreed that the widespread incidence of COVID-19 is imminent and essentially inevitable.” Alarm bells should have been ringing loudly in Ontario.

Yet in early March 2020, the government continued to publicly assert that the threat of the virus was low and was related to travel, despite mounting evidence to the contrary. This messaging was included in the briefing notes prepared for the Minister of Health when addressing the Ontario legislature on March 10. On the same day, the province’s 37th confirmed case of COVID-19 was an individual who had not travelled internationally. By this point the Minister of Long-Term Care, a medical doctor, had independently concluded that the risk was not low and refused to state in a video that it was.

Unfortunately, Minister Fullerton’s appreciation of the risk was not shared by the medical leadership in the government and did not translate into broader public communications. This included a failure to clearly acknowledge that COVID-19 could be spreading in communities instead of being tied only to people who had travelled. Community spread poses a risk to long-term care because it means anybody can bring the virus in – not just someone who has recently travelled. By mid-March 2020, government representatives were acknowledging that community spread could not be ruled out. However, as late as March 24 the Associate Chief Medical Officer of Health was still questioning whether community spread of COVID-19 was occurring.

Similarly, the government was slow to recognize and act upon the potential of asymptomatic spread – the possibility that a person not displaying symptoms could nevertheless infect others. By the end of January 2020, Chinese health officials had found that COVID-19 symptoms appeared within two to 14 days of exposure, and that people without symptoms could be infectious during that period, signalling the possibility of asymptomatic transmission. The Australian government’s Health Protection Principal Committee released guidance on January 30, citing international evidence that suggested asymptomatic transmission. They believed “a highly precautionary approach” should be taken. These findings were provided to Ontario’s Chief Medical Officer of Health by email on January 31.

The Minister of Long-Term Care told the Commission that she had concerns about asymptomatic spread of COVID-19 as early as February 5, 2020. Others were worried too. On March 18, an associate medical officer of health in Ottawa wrote to Dr. Williams to warn him that “the evidence is now sufficient that there are more asymptomatic infections than symptomatic infections” and that “asymptomatic infections likely cause more new infections than symptomatic infections do.” Therefore, the email concluded, infected health care workers “who have not travelled and who are asymptomatic could be actively working in healthcare facilities.” Unfortunately, the Chief Medical Officer of Health did not share this concern or the concern of the Minister of Long-Term Care.

Dr. Williams told the Commission that “the evidence wasn’t there for that.” He did not act as if asymptomatic spread might be occurring and did not issue directives on that basis. He stated that the evidence was not clear until the summer.

Despite government inaction, some individuals within long-term care and local public health were taking proactive measures, having seen the threat of COVID-19 for what it was. The Medical Director of York Region’s two municipal homes reached out directly to the homes in Washington State and British Columbia to seek advice in the wake of their outbreaks. In a long-term care home in Richmond Hill, the CEO began contacting PPE suppliers in late January and instituted staffing and IPAC policies to protect residents well in advance of similar government directives. Kingston’s local medical officer of health monitored the situation in China and independently established a protocol to visit, inspect and audit all long-term care facilities in the region. When restaurants and bars were closed by the province, he had the public health unit’s food safety inspectors conduct inspections in long-term care.

The first outbreak in an Ontario long-term care home was declared on March 16, 2020. The virus then spread like wildfire.

Because the province had destroyed its emergency stockpile of PPE and numerous homes had an insufficient supply, many staff and residents were unable to protect themselves and others. As had been anticipated when the stockpile was created, the pandemic resulted in a restricted global supply and increased prices for essential items like PPE. As the virus raged, the province was left scrambling to secure supplies. Public servants worked around the clock chasing down whatever leads they could, and homes were instructed to ration their supplies.

Without sufficient PPE, staff did not feel safe at work. Without sufficient PPE, some staff who did not feel safe chose to stay home to protect themselves and their families. Due to a combination of illness and fear, an already precarious staffing situation was made much worse.

Decisions made by the province during the COVID-19 pandemic demonstrated a lack of urgency. As the world learned more about the new virus, other jurisdictions began to take a precautionary approach to protect residents. In many instances, Ontario lagged behind in taking similar precautions. Consider, for example, the decision regarding “universal masking” – the requirement that all people in a long-term care facility wear a mask at all times. One benefit of universal masking is protection against the spread of infection by those who have the virus but display no symptoms. These asymptomatic carriers inadvertently spread disease, not recognizing they are contagious.

By March 9, 2020, Public Health Ontario considered it a possibility that COVID-19 could be spread by asymptomatic people. A representative from the Office of the Chief Medical Officer of Health confirmed that this possibility would have, in his mind, invoked the precautionary principle. On March 18, the Chief Medical Officer of Health was warned that “when community transmission is evident or can be assumed, all HCWs [health care workers] should be assumed to be posing potential risk to other HCWs and to patients, and therefore that all HCWs should wear surgical masks from the time they enter the facility to the time that they leave.”

Hospitals in Toronto implemented universal masking on March 24, 2020. Toronto long- term care homes were advised by local authorities to implement universal masking on March 29. The Chief Medical Officer of Health did not order universal masking until April 8. In a pandemic, days make a difference. Delay is deadly.

The delay in ordering universal masking was likely necessitated, at least in part, by the lack of supply of PPE.

The province was similarly slow to require long-term care staff to work at a single home in order to prevent the risk of infection spreading. Under the Health Protection and Promotion Act, the Chief Medical Officer of Health has the power to issue mandatory directives backed by legislated sanctions. Rather than use that power to restrict staff to a single site, the CMOH first issued a memo on March 19, 2020, suggesting that actions “should” be taken and that in some high-risk settings “it may be possible” to coordinate employees to work at a single site. That recommendation became a directive, called “Directive #3,” on March 22. The directive stated that “wherever possible” it would be preferred for staff to work at a single site. The Directive was poorly worded, was not mandatory and was not universally followed.

It soon became apparent that Directive #3 was not effective and did not accomplish the goal of protecting the residents of long-term care. In speaking with the Commission, the Chief Medical Officer of Health stated that his powers did not allow him to issue a stronger directive – one that would have compelled employers to prohibit staff from working at more than one site. It was suggested that a Cabinet order was necessary.

A pandemic is no time to sort out the authority or jurisdiction of any public official, especially the Chief Medical Officer of Health.

The extent of the CMOH’s powers should have been clearly established long before the pandemic. On April 8, 2020, the Secretary of the Cabinet’s office reached out to the Ministry of Long-Term Care with an urgent request to strengthen the language used in Directive #3: “the goal is to have more direction … than encouragement.” The government issued the single-site order on April 14, and compliance was not required until April 22. British Columbia, by contrast, implemented a single-site policy on March 26.

The majority of those who died in the first wave of the pandemic did so or were infected between March 22 and April 22, 2020, while the province was mulling over who had the authority to issue a compulsory direction and the associated policy considerations.

Whatever impact the single-site order had, it came far too late for far too many.

One of the lessons from SARS was the necessity of having an emergency structure in place before the emergency began. The interim report of the Ontario Expert Panel on SARS and Infectious Disease Control, also known as the Interim Walker Report, had identified this issue in 2003 when discussing the province’s response to SARS: “without some of the necessary scaffolding and structures in place at the Ministry to respond in a highly coordinated manner to a communicable disease emergency, the province essentially had to develop the plan on a day-to-day basis.” The report could have been referring to the situation in 2020.

Without an established, practised plan in place, the government found itself making up its emergency response as it went along. As noted, a pandemic is an inopportune time to create a nuanced, well-thought-out and thorough response plan. In late March 2020, as homes began to go into outbreak, the government had not finalized its response structure. Indeed, it hired a third-party contractor in late March to do just that.

As a result, it was not always clear who was in charge. The same was true at the home level; the Commission heard from many staff members who noted that their home leadership was unable to make clear what was to be done and whose advice was to be followed. Once again, the province had failed to learn the lessons of SARS; in the final report of the Commission to Investigate the Introduction and Spread of Severe Acute Respiratory Syndrome, the Honourable Justice Archie Campbell had recommended that lines of authority be clear from the outset.

At the same time it was creating its new response structure, the province was still trying to determine what legislation would allow it to order emergency support for long-term care homes in crises. This also led to delays. With the government unsure of its powers to issue mandatory management orders, public health units and hospitals stepped in to fill the gap. In mid-April 2020, Durham Region’s local medical officer of health took the initiative to use his powers under the Health Protection and Promotion Act to order hospitals to intervene and assist homes in distress. Other local medical officers of health followed suit. The Ministry of Long-Term Care did not develop a strategy to facilitate management takeover of homes until later.

With the sector already chronically understaffed, COVID-19 caused staff numbers to collapse in many homes – in some cases up to 80 per cent of the staffing complement was lost either because they refused to work out of fear for their own safety or because they, too, had been infected.

Many long-term care homes lacked adequate infection prevention and control knowledge and expertise when the pandemic hit. Even though the long-term care sector has experience with infectious respiratory illnesses such as influenza, many long-term care homes did not have the resources, knowledge or experience to implement effective IPAC practices. Without this important line of defence, outbreaks within long-term care homes were inevitable.

While the province grappled with increasing its testing capacity, the demand for COVID- 19 tests continued to outpace laboratory capacity. Test results often took seven to 10 days to be received. Some results were lost. The Commission heard stories of homes receiving tests by fax and by regular mail. The delay in testing was the result of Ontario’s failure to plan over the years for a pandemic and to provide for an integrated lab response utilizing all of the province’s public and private laboratory resources.

As residents became infected, slow testing turnaround times made it difficult or impossible to separate the sick from the healthy – a practice called cohorting. It was especially difficult to identify and cohort residents who were infected but asymptomatic. By the time homes received test results, the disease had spread.

Even if they had received the test results in a timely manner, many homes had limited experience with cohorting practices. The limited provincial guidance in this area did not improve knowledge in the homes, and the Chief Medical Officer of Health’s direction on cohorting was unhelpful. Homes that did try to cohort failed to recognize that infected but asymptomatic patients were being moved from one room to another, inadvertently spreading the disease in the process.

Meanwhile, staff soldiered on without enough PPE – forced to reuse equipment or follow instructions on how to make their own out of pop bottles and plastic bags. One staff member likened the experience to combat: “It’s like you’re going to a war. You know you get bullets. You will get bullets on you. But you still have to step out there in the field and shoot.”

Staff told the Commission about crying before, during and after work, vomiting in locker rooms from stress, and watching residents whom they loved die in great numbers. Often, they would then be required to wrap the resident in a body bag, put them on a stretcher, and wheel them outside to waiting funeral attendants. They described the guilt they felt in not being able to be with residents when they died, and the awful position of having to choose between staying home to keep themselves and their families safe and caring for the residents they knew well. One staff member who ordinarily conducted enjoyable recreational programs described the despair of her new role caring for dying residents: “For one resident, I sat at bedside after he died with the iPad because the family wanted to see him one more time. So, I watched and listened as his wife and adult children spoke of their love and silently wept under my mask and face shield.” Many continue to be traumatized as a result of this experience and will require ongoing counselling and support.

In an attempt to stop the spread of COVID-19, the decision was made to bar visitors from homes. Visitors – particularly family members and loved ones – do more than visit, often taking care of many of the daily living needs of the residents. As a result of staff shortages, and with no family members to help, residents were confined to their rooms for extended periods without access to recreation programs or visitors. With visitor restrictions in place, the care burden on staff increased. One resident described the experience by saying it was as if reality had been suspended and a nightmare had set in. Many residents experienced symptoms of what is known as “confinement syndrome.” The term is typically used in medical literature to describe symptoms shown by people placed in solitary confinement. Due to visitor restrictions and limited staff, many residents died alone in their rooms, with no one to ease their passing.

For family members, the inability to visit and to know what was happening to loved ones was devastating. They watched, remotely, as fathers, mothers and grandparents deteriorated before their eyes. Many were not able to say goodbye. When visits resumed, many families expressed shock and sadness at the rapid decline in their loved one’s cognitive and physical functions and increasing levels of depression; in some cases, they remarked on how once vibrant and alert residents had lost hope and were totally unresponsive.

Even with the lessons learned during the first wave, preparations for the second wave were not enough to prevent it from being worse. In fact, more long-term care residents died during the second wave than during the first. It is still unclear why this was so, despite the months both the province and the homes had to prepare. Some noted that high-risk homes were not sufficiently prioritized, given that 5 per cent of homes accounted for more than half of all resident deaths. Others point to the higher prevalence of COVID-19 in the province as a whole, and therefore in communities surrounding many homes, as a reason for greater spread in long-term care during the second wave.

What is clear is that IPAC preparations, staffing support, and partnerships between homes and other entities such as hospitals should have been critical priorities. Hospitals managed some homes through the crisis. However, once hospitals handed oversight
of management back to the homes, there was concern that the problems that had given rise to these crises were not resolved. As part of the preparation for the second wave, the Ministry, through the Ontario Health regions, sought to formalize arrangements by pairing each home with a hospital. Using this partnership model, the Ministry created a hub-and-spoke system in which hospitals would assist homes with IPAC. However, this was not implemented until November 2020, and the delay meant that there was no chance for the hospitals to have a meaningful impact on creating an infection prevention and control culture before the second wave hit.

The province announced at the end of February 2021 that it was investing more than $115 million to train up to 8,200 new personal support workers. While long-term care homes certainly need more PSWs, this funding could not help homes through the second wave.

The Canadian Institute of Health Information (CIHI) cited a correlation between the lack of staff (particularly PSWs), the use of agency staff, and increased severity of a COVID-19 outbreak at a home in the first wave. There was also an association between these factors and greater resident mortality.

There should also have been a renewed role for provincial inspectors in the second wave. After not receiving any new funding for inspectors through the first wave, the government announced in November 2020 that 27 new inspectors would be hired to address COVID-19 issues. However, it takes eight to nine months to fully train an inspector. As a result, those newly hired inspectors would have been of little or no use during the second wave.

As more data are analyzed, it will undoubtedly be possible to better understand the factors that contributed to the spread of COVID-19, and therefore gain deeper insight into why Ontario’s performance did not improve during the second wave. However, this will bring little comfort to the families and loved ones of the long-term care residents who lost their lives to COVID-19 during this time.

Best Practices and Promising Ideas

Leaders at every level must put their hearts, as well as their minds, into reimagining the care of the elderly in this province. This will require a philosophy of care that is anchored in respect, compassion and kindness for the people who live and work in long-term care. It is not just about building more homes. There needs to be a transformation to a person-centred care model, which motivates different behaviours and rewards innovation that leads to better outcomes for residents and staff.

There will need to be a multi-dimensional approach to this transformation – one that recognizes that these places are at the same time homes, care facilities and workplaces. Long-term care homes are also part of the broader health care system and the community.

Residents do not lose their rights upon entering a long-term care home. They have the same rights as everyone else in society, and those rights must be protected and respected. Residents are entitled to receive quality care and deserve to enjoy a quality of life.

We have to care about the workers in long-term care homes. Emotionally intelligent leaders are needed to drive an organizational culture change in order to create respectful and inclusive work environments in which all team members are valued, and where staff experience high levels of satisfaction and take pride in their work because they are empowered and supported to deliver excellent care. These principles are at the foundation of what the Commission recommends, moving forward, in order to protect residents, loved ones and staff.

In the midst of the great turmoil and tragedy caused by COVID-19, there were also many examples of strong leadership and promising practices that helped to prevent or mitigate the spread of the virus in several long-term care homes. These examples not only deserve recognition but also serve as models of innovative approaches that, if implemented, could help safeguard the health of older Ontarians and improve their quality of life.

Strong leadership proved critical in the face of unprecedented challenges in long-term care homes. The Commission found that key components of effective leadership were consistent regardless of the site or source. It also determined that the presence of these components could not necessarily be equated with an absence of COVID-19 outbreaks; instead, they offer insight into how well leaders responded and mobilized their teams in a time of crisis.

The key components, which are explored in greater depth in this report, included establishing practices that supported staff and improved their morale; recognizing the importance of pandemic preparedness; maintaining open and frequent lines of communication with families, staff and residents; and building and leveraging relationships with health partners.

Effective leaders not only drew on experience and expertise during the pandemic but also provided stability through their behaviour in a chaotic and uncertain time. They were nimble, visible and deliberate in their actions. In turn, they gained the trust and commitment of their teams, as well as of the residents and their loved ones. Increased investment by licensees and the Ministry of Long-Term Care in leadership development and crisis management training – for long-term care home Administrators, Directors of Nursing and Personal Care, and Medical Directors – must occur to support the effective management of homes in periods of crisis.

A number of innovative models and health care practices showed their effectiveness and provided hope, reassurance and stability during the pandemic. For example, the Commission heard evidence pointing to the value of having nurse practitioners in long- term-care homes. Whether engaging with homes through Nurse-Led Outreach Teams or as attending nurse practitioners, their distinct skillset and hands-on approach was consistently leveraged during the pandemic, especially when medical leadership was not on site. Nurse practitioners are a valuable resource and should continue to be deployed in long-term care homes across the province as needed.

Other innovative programs to strengthen quality of life and care in long-term care homes include the establishment of mobile community palliative care units; the creation of person-centred care models as a more effective alternative to current institutionalization approaches; and better home design to meet the evolving needs and acuity of long-term care residents.

There is also a need to strengthen home care models – not to replace long-term care but to complement it. The Commission heard that people were at greater risk of infection if they lived in a congregate setting. Accordingly, people were safer in their homes during the pandemic. In its submission to the Commission, the Homecare 2020 group – comprised of Bayshore Healthcare, Saint Elizabeth Health and Victorian Order of Nurses Canada – cited data from Ontario Public Health indicating that the infection rates of home care workers was very low (0.01–0.2 per cent) compared to the infection rate of staff in long-term care homes (30 per cent).

Information shared with the Commission illustrated home care’s cost-effectiveness and use of creative and flexible options that do not take a one-size-fits-all approach. Underlying all of these findings is the fact that most people want to age at home.

These strategies must not be presented as negating the necessity for new and redeveloped beds and facilities. Rather, they are needed as part of a continuum of care that will allow for safe and healthy aging whether at a long-term care home or otherwise.

Conclusion

At the time of writing, Ontario is currently in the third wave of the pandemic. The vaccination program will hopefully protect the residents and staff of long-term care. Nonetheless, given the new variants of COVID-19, it is premature to claim victory. Vigilance is still required.

This Commission was entrusted with the obligation to investigate what happened to cause the excessive sickness and death in long-term care homes and to make recommendations to prevent such a tragedy in the future.

This investigation has also considered the well-accepted conclusion that there will be a significant increase in demand for long-term care in the immediate future. Facility design and overcrowding contributed to the excessive long-term care fatalities that haunt this report. This supply problem must not be allowed to fester further. A new approach to the construction of long-term care facilities is required. The province should adopt the path to solving that problem described above and in more detail in chapter 1. In short, it should embrace a strategy that separates construction from care.

This investigation has shown that long-standing weaknesses in the long-term care sector figured prominently in the death and devastation COVID-19 inflicted on residents, their loved ones and the staff who care for them.

The same can be said for the lack of advance planning for such a crisis. The failure of successive governments to properly plan for a pandemic led to a lack of personal protective equipment, a cumbersome response structure, and slow government reaction time when COVID-19 hit. These issues were compounded by critical and early failures to adhere to the precautionary principle. Precautions with respect to asymptomatic spread, masking guidance and limiting staff working in multiple homes should have been taken sooner. This is also true for interventions in homes.

The homes and regions that acted early and proactively to take precautions fared better throughout the pandemic. Their example demonstrates what could have been done, and what must be done in the future.

As it should have done following the SARS outbreak in 2003, the province must now accept that there will be another pandemic; it is not a matter of if but when. Ontario must resolve to remember the lessons so painfully learned here in order to ensure that its long-term care homes are not doomed to repeat the past.