Impact of COVID-19 on Long-Term Care in Canada — Dr. Samir Sinha

Alex Maheux:

As the COVID-19 pandemic is rapidly evolving, the circumstances may have changed from the time this podcast was recorded, and may not reflect the current environment.

Hi, and welcome to the CHIP: the Canadian Health Information Podcast. I’m your host, Alex Maheux. This show from the Canadian Institute for Health Information will give you an in-depth look at Canada’s health systems and talk to experts you can trust. If you’re interested in health policy, our health care systems and the work being done to keep Canadians healthy, this podcast is for you.

Today we’re talking with Dr. Samir Sinha, a renowned clinician and international expert in the care of older adults. Dr. Sinha is the Director of Geriatrics at Sinai Health Systems and the University Health Network in Toronto. He has consulted and advised governments and health care organizations around the world and is the architect of the Government of Ontario’s Senior Strategy. Throughout the pandemic, Dr. Sinha has been a strong voice for seniors and long-term care. He has also served as a key adviser to CIHIs most recent report on COVID-19 in long-term care.

Please remember, Dr. Sinha’s views and comments may not necessarily reflect those of the Canadian Institute for Health Information. Let’s get to it.

Hi, Dr. Sinha, welcome to the CHIP, thanks for joining us.

Dr. Samir Sinha:

Thanks for having me.

Alex Maheux:

So, COVID has shone a bright spotlight on long-term care in Canada and exposed many issues in the system. But before diving right into what’s going on right now, I want to take a step back and ask for your impressions of the state of long-term care before the pandemic. Can you give us maybe a brief explanation on some of the existing problems and how they may have played a part in the current health crisis of the pandemic?

Dr. Samir Sinha:

Yeah, thanks, Alex. I think when you start thinking about long-term care, right, I think for many Canadians it was kind of a system that we knew existed. It wasn’t a system that we were particularly thrilled about, but we knew it was there and I think for most of us we thought it was probably doing an adequate job, but I don’t think a lot of us understood kind of what its strengths and its limitations were. So for a lot of Canadians, they don’t appreciate that long-term care is the home for over 200,000 mostly older Canadians who really have no other care options to allow them to stay at home and independent in the community. They might be an individual who is living with dementia that now needs to have, you know, around the clock support and care that their family can’t provide or that they can’t afford to provide for themselves in their own homes.

But it’s one of those forms of care that I think a lot of Canadians may not have appreciated was never instituted as part of our Universal Medicare Program, so it was never part of the Canada Health Act, it’s something that every province and territory has been providing, for example, at its own discretion. But it’s also something that’s been underfunded significantly compared to our other OECD countries, so we spend 30% less on the provision of long-term care in Canada versus what other industrialized nations spend. We spend most of our long-term care dollars on institutionalizing people into care homes versus caring for them in their own homes. And because we spend so much less in general on providing long-term care in Canada, we end up tending to have poor paid staff, poor quality facilities. I mean, it varies province to province and territory to territory, but by and large, we don’t have a well-funded system and that has created challenges in making sure that our facilities can keep pace with the latest design standards and that we can adequately staff these centres with the right amount and the right types of people to provide the important care that needs to occur in them each and every day.

Alex Maheux:

Earlier this year, CIHI released a report on the impact of COVID-19. You were a key adviser for this report. And at a high level, it showed how the pandemic had disproportionately affected Canada’s retirement and long-term care homes. How has the pandemic evolved in long-term care? What have we seen happen throughout the last year?

Dr. Samir Sinha:

I think the last year really kind of exposed for a lot of Canadians how fragile our long-term care system was. Because, for example, in Ontario, prior to the pandemic, 80% of homes were struggling to recruit and retain enough staff just to have normal operations. So, you can imagine that during a pandemic, for example, where you probably need more, not less staff, and you need to have a specific level of nimbleness and resources to really fight a deadly virus, I think what we saw as a theme across the country were that in areas where there was significant community transmission, we saw that homes really weren’t very immune to COVID-19. It was getting in, it was having devastating consequences, and we saw that by what we had seen in terms of the devastation in provinces, especially like Ontario, Quebec, Alberta and B.C. during the first wave, as well as Nova Scotia. And then the second wave was really a story where we saw some provinces do even worse than they did in the first wave, like Ontario, Alberta, B.C. We saw other provinces do far better, like Nova Scotia, where they didn’t have a single outbreak in their second wave, or even provinces like Quebec where the implementation of key measures between their first and second waves, in my view, really helped them actually do a lot better when it came down to their second wave as well.

So really what you saw was a story where a lot of our long-term care homes really weren’t well-prepared across the country. And if they got a free pass during the first wave, like, say, Manitoba and Saskatchewan, they really showed their limitations and their lack of preparedness by their second wave, and it really speaks to the fact that these are very vulnerable environment. Vulnerable because staffing is precarious, vulnerable because it’s hard to provide excellent care to a population where there are significant mobility limitations — the majority of people are living with cognitive impairments — and in a setting where you have significant and growing staffing challenges as the pandemic raged on, if you will.

I think the only reprieve, really, was that while we saw that doing definitive things actually makes a difference and those provinces that did those things really had a difference in their outcomes. But, you know, thank God that towards the end of the second wave, vaccinations had come along and so that at the start of our third wave now, long-term care ironically has now become one of the safest places to be in Canada because literally we have well over 90% of our long-term care residents across Canada that are now fully vaccinated, and that, I think, has made an enormous difference in terms of at least protecting these homes when other standard measures like staffing or other infection prevention and control measures just were really difficult to implement and maintain in a solid way during the first and second waves.

Alex Maheux:

Mm-hmm. And you mentioned the vaccination is a major reason why we’re able to move forward in the third wave. But what are some of the other learnings that we took from the first two waves? How can we handle things differently moving forward and what’s being done right now to mitigate the risk of cases in deaths and ultimately the toll on families across Canada?

Dr. Samir Sinha:

Let’s start with staffing. Staffing was just such an issue that it became clear that it was not only about having enough staff, but making sure that these staff were well-supported and well-trained, with good wages to start with, with more full-time employment opportunities, with access to adequate things like paid sick leave, for example. These are things that, for example, were quite lacking for the majority of workers across most of our provinces. And I think provinces like BC that basically put everybody in their long-term care system on full-time employment with adequate benefits, I think those things actually made a huge difference. And what you’ve seen in provinces like Ontario, Ontario has announced up to $1.9 billion to hire more staff because it’s not just about treating your staff better and paying them better and giving them benefits, but it’s about having just enough staff to begin with to provide the care that’s actually needed.

So, I think there has been some key recognitions about the challenges of staffing, but I haven’t necessarily seen a sea change where that, you know, the majority of long-term care staff now across Canada are going to be able to get full-time employment opportunities with adequate benefits and appropriate pay and that there will be enough of them being hired to provide that care. But I’m hoping these are the trends that will become more universal over the coming years.

I think the other issue has really been understanding the importance of family presence, for example. Family presence being when you shut out family caregivers and the ability of residents to visit with family and friends, for example, that really created a huge gap not only in care, but it also really affected the social and emotional wellbeing of residents. And we really, I think, took family caregivers for granted and really restricted their access in ways that actually created more harm than good in the grand scheme of things.

And then finally, I think the third area that I think we’ve really learnt a lot about is the quality of the facilities in which we’re providing care and how older facilities with poor ventilation and crowded rooms is just a perfect recipe to be an infection prevention control nightmare, and how even by the second wave we had learnt a lot of these lessons, but not all of them were being applied. And hopefully with the move towards new National Long-Term Care Standards, including the work that CSA will be doing to actually develop, design, and even HVAC and Infection Prevention Control Standards, I think hopefully this will create a new paradigm through which as we look to develop new and modern long-term care homes, we’re going to be taking into account the real physical aspects that not only keep people safe, but actually help them achieve a better quality of life as well.

Alex Maheux:

You mentioned quality of life; I want to bring it back to the report that we released that addressed something that I think wasn’t talked about quite as much. We talked about cases in death related to COVID, but the report also found that the health impacts of non-COVID-related illnesses had in long-term care. For instance, we saw fewer physician visits, fewer hospital transfers during COVID, that in some cases it has some really detrimental effects. Can you talk to us a bit about what you saw and how it affected the overall health of long-term care residents unrelated to COVID?

Dr. Samir Sinha:

I think one of the things that I think a lot of people don’t appreciate is that we’ve had over 14,000 people die in our long-term care homes and they’ve been recorded as deaths due to COVID, if you will. But I think one of the things that we saw through our CIHI report was that there really was a decline in the availability of medical care or the amount of medical care that was being provided in homes, and that had significant knock-on effects when you have less physician visits, for example, you have less expert eyes, for example, that can help determine when someone might benefit from going to a hospital or when someone might just require a bit of additional support so that you could avoid something from becoming a much worse issue overall.

So, while we certainly know how many people died, you know, if you will, of COVID, for example, there are probably a lot of people in many homes who died not of COVID, but with COVID because there are other basic care needs like being hydrated and well fed just were not being adequately met or the other issues that were just becoming neglected, for example. We saw a significant decline in the number of long-term care residents that were being routinely sent to hospital for conditions like congestive heart failure or COPD or pneumonia, things where people would traditionally, if there was more medical support available, would have been identified as people who would have been appropriate for hospital transfers, but that just really wasn’t happening, and I think that probably further compromised the health of a lot of individuals.

Because certainly when you looked at our data from the CIHI report, we were seeing some provinces where there were hardly any cases of COVID, but a significant increase in the number of what we call excess deaths. And if COVID wasn’t killing them, then what was? And I think it was a lack of, if you will, medical care and a lack of that usual support that would keep someone healthy and well. But when you actually go to, you know, hear the stories of what happened in some of these homes, you hear about what we call an absolute collapse or a total collapse of care, where everybody got sick, including the staff and the residents, for example.

When the staff gets sick, they have to be off isolating for up to 14 days each, and so you had homes that really had their staffing devastated. And when they’re caring for individuals who have high needs, who need support at meal time, need other forms of support and care, whose family caregivers can’t necessarily visit because the home is in outbreak, etcetera, etcetera, all of a sudden, you just find people’s basic needs aren’t being met. And when they’re frail, older people whose basic needs aren’t being met, you wonder if that’s why that one home had over 50% of their residents with COVID die. And while in another home, only one in five residents, for example, died.

I think those are the things that, again, the data can help tell us to look further and understand what was the difference here and there, but anecdotally, this is certainly what we were seeing on the ground when you dig into some of the most devastating outbreaks or devastating death tolls that you saw across Canada overall.

Alex Maheux:

Mm-hmm. There’s definitely some very dark situations and stories that lie behind the data that you’re talking about. What’s it like working in the field right now? How are you personally coping with all of this?

Dr. Samir Sinha:

Right now, I think, you know, what my colleagues, what my patients, what their families tell me is that it’s been a horrendous year for those working and living and caring for loved ones in long-term care homes because it’s been an incredibly demoralizing year. There’s been so many people who died, there are so many staff, for example, who got sick, including those who died as well, it’s been incredibly traumatizing, it’s been incredibly demoralizing. But there were incredible points where people did rally together, where there were great acts of kindness and care and that where families and residents talk about, you know, the absolute heroism and the dedication of the staff who stuck with them and stuck through it with them.

But we have to realize that, you know, what happened in our long-term care homes really is, in my view, a national shame. That we really didn’t support those residents and the staff who care for them in the ways we needed to. And so, where people were in some cases it enraged me when people were saying, “Well, it was the staff not doing their job.” And I’m like, “Oh, don’t blame the staff here, the staff were doing the best things that they could, despite a horrible situation.”

I think really what we do need to recognize is, is that staff and residents and families are still traumatized. People are still waiting for homes to be allowed to reopen post-vaccination so that family caregivers can be welcomed back in, visitors can come back in to meet with their loved ones. Residents just want their congregative activities to resume, because that hasn’t happened in most homes. But I think what we do owe it is to recognize that we’re not out of the woods yet, especially as we’re in a third wave. We have an opportunity to not only do a better job about recognizing the vulnerability and do better at promoting the safety and the quality of life for residents, but there’s a lot of work that we have to do over the medium- or long-term to correct a lot of wrongs that we’ve discovered in the system, like out staffing issues, like our lack of recognition for essential family caregivers, and the issues of poor quality facilities that only make infection prevention and control measures that much worse.

Alex Maheux:

Well, and you’ve kind of touched on this, but what comes next after the pandemic, the next phase of COVID-19 is likely to be an endemic, where it’s a cyclical illness like influenza, what can be done to protect seniors, particularly those in long-term care and retirement homes?

Dr. Samir Sinha:

I think the easiest thing that we need to do, first off, is just continue to make sure that those residents in these settings are recognized as those who are most vulnerable to this virus, and therefore those who need to always be prioritized for vaccination. So, there’s already talk about, as you said, as this virus becomes potentially endemic, is making sure that when we have this idea of booster shots coming through and available, that we prioritize long-term care residents to be the first ones to be able to receive this. That we really support staff and family caregivers in these settings to be supported, but that we also make sure that moving forward, we don’t repeat the mistakes of the past where we simply think that closing the doors and shutting out families is actually good policy. I hope we never go back to that again and that we actually have much more thoughtful policies moving forward so that we can always enable and enhance family presence, while appropriately balancing the risks with the benefits and promoting, you know, social and emotional wellbeing of these residents.

Alex Maheux:

How do you feel about how the system is going to be set up for when you’re a senior, I have to ask? And have you thought about what you’re going to do when you get older?

Dr. Samir Sinha:

Yeah, that’s a good question. And I think as a geriatrician who has dedicated my life to caring for older adults, I am deeply worried. I am deeply worried that we haven’t established a system that supports Canadians to age with the dignity and respect that they deserve. We have a grossly underfunded long-term care system when it comes to the provision of home and community care to long-term care. I don’t think that out of this pandemic I’ve seen kind of any jurisdictions say, “Yup, okay, these are all the changes we’re going to make and never again we’ll do this.” Do I think we’re going to get it all to where we need it to be by the time I’m an older person? Well, I hope so. I mean, this is what I’m dedicating my life to doing.

But, you know, I do have a contingency plan where I’m just trying to save up enough money so that I can hire my own personal support worker who can support me if I need their support so I can age in my own apartment for as long as possible. So, you know, I’m being realistic and I think I share the notions of most Canadians, because when you ask every older Canadian where they aspire to end up, very few, if any, ever say they want to end up in a long-term care home. I think every Canadian is desperate to stay healthy and independent for as long as possible in their own homes, but we have to be realistic that not every Canadian will be in that position, that many of us will need the benefits of a good high-quality long-term care system. And so, we owe it to ourselves, our future selves, and to each other now, but also our parents, our grandparents, anybody else we know, that we do need to make significant improvements in the provision of long-term care, and I’m hoping that some of the work that I’m leading, that the work that others are leading as well, will help us get closer to where we need to be sooner rather than later.

Alex Maheux:

Absolutely. And I couldn’t help but notice how often you use the word hope, so I will join you in being hopeful. Thanks so much for joining us, Dr. Sinha, and for helping us understand more about this important topic. And most importantly, for the incredible work that you do.

Dr. Samir Sinha:

Thanks so much for having me, Alex.

Alex Maheux:

Thanks for listening. We hope you enjoyed this episode. Check in next time when we bring you more valuable health perspectives and continue to chip away at health care topics that matter to you.

If you want to learn more about CIHI, visit our website: cihi.ca. That’s C-I-H-I-dot-C-A. If you like what you heard, subscribe where you find your podcasts and leave us a review and give us a follow on social media.

This episode was produced by Jonathan Kuehlein, with research from Amie Chant, Marisa Duncan, Shraddha Sankhe and Ramon Syyap. I’m Alex Maheux, thanks for tuning in to the Canada’s Health Information Podcast. Talk to you next time.

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