A. Moser1, P. Pariser2, A. Verma3, F. Razak3, B. Wong4, L. Pus2, S. Feldman1
1. Department of Family and Community Medicine, University of Toronto, Baycrest Health Sciences, Canada; 2. Department of Family and Community Medicine, University of Toronto, Womens College Hospital, University Health Network, Canada; 3. Li Ka Shing Knowledge Institute, St. Michael’s Hospital; Department of Medicine, University of Toronto, Institute of Health Policy, Management and Evaluation, University of Toronto, Canada; 4. Department of Medicine, University of Toronto, Sunnybrook Health Sciences, Canada. Corresponding author: A Moser, Department of Family and Community Medicine, University of Toronto, Baycrest Health Sciences, Canada, firstname.lastname@example.org, 416-785-2500 ext 3499
Jour Nursing Home Res 2020;6:45-46
Published online July 6, 2020, http://dx.doi.org/10.14283/jnhrs.2020.12
The Novel Coronavirus, COVID-19 began circulating among humans in late December 2019. The first cases in Canada were identified in February, with the majority of initial cases linked to travel. By June 5, 2020, there were over 94,000 cases of COVID-19 in Canada with 7652 deaths, with over 75% of deaths being individuals who resided in nursing homes (1, 2). This deadly virus has exposed many opportunities for improvement in the nursing home sector in Canada. We will focus on our experience in the Province of Ontario, Canada.
In Ontario there are 622 Long Term Care Homes (nursing homes) caring for over 70,000 residents. Demographics of those in NH in Ontario are an average age of 85 years, over 90% with cognitive impairment, 64% with diagnosis of dementia, 80% with neurologic disorders, 76% with cardiorespiratory disease, and the majority requiring significant assistance with activities of daily living (3). There are a small number of short stay convalescent or respite beds but these are the minority with the majority of post-acute care and rehab occurs in rehabilitation hospitals or community settings.
The response in Canada was to shutter most businesses, restaurants, work environments keeping only essential services running and some of those in a more limited capacity. There have been numerous directives for the nursing home sector including: limitation of visitors, reduction of group activities, reduction of non-essential services and restrictions on staff working in more than one facility. Some have questioned whether these directives, along with efforts to test residents and staff for COVID-19, were applied quickly or comprehensively enough. There has been a rapid uptake of virtual care by the expansion of approved platforms and provider fee codes for all health care settings including nursing homes. In Ontario this has been a drastic shift as prior to this telemedicine consultation was focused on increased access to specialty care, not primary care.
Despite these drastic measures we have seen outbreaks of COVID-19 in over 20% of the NH in Ontario with over 70% of COVID deaths in Ontario attributed to NH residents (4). There are variations amongst NH in size of outbreaks, ability to contain outbreaks and estimates of mortality. Reasons for these variations have not yet been fully characterized, but may include infection control measures such as hand hygiene, availability, knowledge and use of personal protective equipment (PPE), access to COVID-19 testing, staff rotation amongst multiple facilities and visitor restrictions in addition to variations in resident demographics and chance (5).
There has been an overwhelming response from the health care system and public with work underway to address the immediate needs within the nursing home sector and acknowledgment of the need for longer term solutions. In this report, we focus on the immediate steps that have been or are being implemented to support the LTC homes in Ontario. Many regional programs are emerging to collaborate with LTC homes providing enhanced education, clinical supports and technology.
We are witnessing an explosion in rapidly evolving information related to COVID-19, including webinars through public health agencies, international, national and provincial medical associations, nursing home associations and regional providers. These resources are being curated by many groups to focus their members on most relevant resources for the nursing home setting. It is notable that many resources are being shared freely on sites where access previously was restricted to members only. Nursing homes with COVID-19 outbreaks are in emergency mode, focusing on containment and management of the outbreak. Those homes without COVID-19 are being encouraged to focus on prevention and preparedness strategies. These include such topics as review of staffing models, contingency planning for medical staff, review and refresh infection control practices, PPE supplies, emergency drug supplies, review of advance care planning, COVID-19 management, palliative approaches to care, amongst others.
One example is the formalized education program, ECHO (Extension for Community Healthcare Outcomes). During COVID-19 the ECHO has pivoted to focus specifically on COVID-19 with sessions, for example, on preparing LTC for possible COVID cases, management of COVID-19, best practices for infection control, palliative care and supporting staff. These sessions have been fully booked with over 100 sites joining on each videoconference session.
The compelling challenge to nursing homes has resulted in a response from acute care that has not been seen previously in our health care system. We are seeing new relationships being established between acute care and nursing home sector with a desire to work with nursing homes and understand their specific needs. A call for much needed Personal Protective Equipment (PPE) and specialized Infection Prevention and Control supports has been heard in the province of Ontario. The Ministry of Health has assigned hospitals to support prioritized homes. These teams are being deployed to provide onsite supports for the homes which includes additional testing, staffing, PPE, infection control education and outbreak management.
We are also seeing groups of medical specialists in acute care working with nursing homes providing virtual supports to enhance care in the nursing homes. In the Toronto region, we are witnessing new collaborations and partnerships developed with internal medicine specialists offering to provide 24 hour 7 day a week virtual care with primary care providers in nursing homes. The program has been developed through engagement with attending physicians and medical directors across the region. The specialists signed up for LTC PLUS are working with nursing homes to understand specific needs, support and provide urgent medical specialty consultation and to coordinate rapid follow up that was not easily accessible previously. Additional specialty groups such as geriatric medicine, geriatric psychiatry and palliative care are organizing and offering their support.
Creative solutions are being tested across the sector to increase social engagement for residents in nursing homes. These include such things as virtual care visits with residents and their families, families visiting through windowpanes, signs and letters being sent.
Technology is being rapidly deployed and implemented with increased access and support provided by the Ministry of Health, enabling virtual care visits over an increased number of available platforms. The recurring barrier however is the ability for nursing home staff to facilitate virtual care particularly if experiencing staffing shortages during an outbreak situation. At Baycrest an innovative solution is being trialed with the creation of a new role called a Clinical Liaison. The clinical liaisons are staff who have been re-deployed (e.g. from closed outpatient clinics) and will be working with the clinical care units in a multifaceted way. They will provide assistance with nutrition and hydration at mealtimes, will support virtual visits between residents and families, and will facilitate virtual care with attending physicians and consultants.
In summary, this is an unprecedented time in health care globally and in Canada with a particular focus on nursing homes. Much attention has been paid to the virus’ devastating effects within the sector, but we are also seeing a wide-ranging response to provide immediate supports and develop longer-term solutions. In the post COVID-19 era those of us working in the NH sector are hopeful that the lessons learned will chart a new path forward for the sector. The supports that have come we hope will stay, that NH will not be standalone silos of care but will be integrated in a meaningful and valued way within the health care system.
Conflict of Interest: Dr Moser, Dr Feldman, Dr Wong, Dr Pariser, L Pus have no disclosures to report. Dr Razak, Dr Verma report personal fees from Ontario Health, during the conduct of the study.
2. https://ltccovid.org/wp-content/uploads/2020/05/Mortality-associated-with-COVID-3-May-final-5.pdf. Comas-Herrera A, Zalakaín J, Litwin C, Hsu AT, Lane N and Fernández J-L (2020) Mortality associated with COVID19 outbreaks in care homes: early international evidence. Article in LTCcovid.org, International Long-Term Care Policy Network, CPEC-LSE, 3 May 2020.
3. Canadian Institute for Health Information (2018). Continuing Care Reporting System: Profile of Residents in Continuing Care Facilities 2017–2018. Ottawa: CIHI